Just came across an interesting editorial in Lancet Diabetes & Endocrinology via @Dr_Burr and @Skeila on Twitter. The article focuses on physical activity and dietary guidelines, but takes a moment to critique the recent Canadian Society for Exercise Physiology position stand on the risks and benefits of promoting activity in kids (full disclosure: I’m a CSEP member, and have collaborated with/studied under several of the authors of the position stand, although I had nothing to do with the article itself).
Here’s the critique from Lancet Diabetes & Endocrinology (emphasis mine):
Disappointing, then, is the position statement on the benefits and risks of exercise in children that was released by the Canadian Society of Exercise Physiology in August, 2014. Although the society acknowledges the great benefits of physical activity for physical and mental health in children, they strongly suggest that the risks should not be ignored. They advise against promotion of physical activity in children unless information about potential activity limitations is available. Lead author Pat Longmuir (Children’s Hospital of Eastern Ontario Research Institute) said that “[vigorous activity] might precipitate a cardiac arrest due to an unrecognised cardiac condition”. With the substantial gains being made in recent years—reversing the trend of ever-increasing childhood obesity rates—this scaremongering report seems a step in the wrong direction. The only result can be defensive, with schools, sports coaches, or other professionals who should be promoting activity practising caution for fear that any child could have a rare heart condition. The onus should be on parents to tell coaches and schools if their child has a heart condition and whether they are therefore fit to exercise, not on these professionals.
I was surprised that these particular authors would argue that we shouldn’t promote activity unless info about limitations is available, because that seems pretty onerous. And it would probably have a negative impact on physical activity, as the Lancet editorial authors suggest.
So I checked out the position stand, and I think the Lancet may have grossly over-reacted. Here are the most relevant recommendations from the CSEP position stand (emphasis mine):
The experts convened in June 2012 to consider an appropriate approach to promoting increased physical activity in children. They recommended that given the limitations of current evidence, the following question be used for the purpose of determining whether children less than 15 years of age are apparently healthy: “Has your healthcare provider ever told you that your child should not do some types of physical activity?”
Taken together, the goal of these question(s) would be to identify children at increased risk during physical activity without falsely identifying children who are not at risk and to indicate whether a child should be referred to a physician before engaging in increased physical activity. The expert group also recognized that it is typically not feasible to collect background information for unstructured physical activity (e.g., children swimming in a local pool or playing in a local park). Therefore, the use of these questions is recommended only for structured settings and organized programs. Primary healthcare provider-prescribed activity restrictions, conveyed directly from the healthcare provider or by the parent/guardian, must always be respected by the physical activity leader. The need to inquire about healthcare provider-prescribed activity limitations or other relevant information (e.g., allergies, special needs, medical history) is the same for high-intensity and more sedentary pursuits, and regardless of the setting (e.g., competitive, recreational, research)
Parents and professionals should encourage all children to accumulate at least 60 min of physical activity daily.
It is widely recognized that apparently healthy children should perform at least 60 min of daily physical activity that is of at least moderate intensity, and that exceeding 60 min per day offers even greater benefit (Tremblay and Haskell 2012). Vigorous-intensity activity and muscle and bone strengthening activities are recommended at least 3 days per week (CSEP 2012). What may not be recognized is that the same physical activity recommendations apply to children with disabilities or who have conditions that require primary healthcare provider physical activity restrictions. Modifications or restrictions to the frequency, intensity, duration, or type of physical activity permitted can enable physical activity that is appropriate to each child’s condition (Bar-Or and Rowland 2004b).
So they are not proposing that we only allow kids to participate in activity if they have info on their health risk. Instead, the question is meant to simply identify kids who have already been identified as being at high risk. I know this, because I used this specific question as a means of screening participants in a previous study. Here’s how it was worded on the consent form:
Pre-Participation Health Screening
Please answer the questions:
1. Has a doctor ever told you that there are some types of exercise or physical activity that you should not do? (please circle)
Yes / No
2. If you answered yes, please describe the types of exercise or physical activity that you cannot do at this time:
Not surprisingly, almost no one answers yes to these questions (especially among kids who are involved in organized sport). But if there was a reason that someone shouldn’t be exercising, or a specific limitation, it would be helpful to know. In fact, not asking seems almost negligent. The whole reason we used this question in our study was specifically because we wanted a way to identify the kids who were known to be at high risk (which is a reasonable requirement of most research ethics boards), without accidentally screening out a bunch of healthy kids, or subjecting them to unnecessary screening. In other words, this question is meant to avoid the scenario that is described in the Lancet editorial. In my experience, this question is a good way to quickly assess whether a child has any known risk factors for adverse events during exercise, without any real negative consequences.
Obviously I have some inherent biases at play here, so I’m curious to hear what others think. And I realize that this may seem like a pretty minor issue, but since the Lancet literally called people out by name (and accused them of “scaremongering”), I thought it was worth pointing out that they seem to be mistaken.