ARTICLE IN PRESS
Disability and Health Journal
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(2015)
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www.disabilityandhealthjnl.com
Brief Report
The physical activity patterns of adolescents with intellectual disabilities: A descriptive study Ana Queralt, Ph.D.a,*, Anna Vicente-Ortiz, M.Sc.a, and Javier Molina-Garcıa, Ph.D.b b
a Nursing Department, University of Valencia, c/Jaume Roig s/n, Valencia 46010, Spain Department of Teaching of Musical, Visual and Corporal Expression, University of Valencia, Avda. dels Tarongers 4, Valencia 46022, Spain
Abstract Background: Emerging data suggest that adolescents with intellectual disabilities (IDs) have lower physical activity (PA) levels and have a higher incidence of obesity than their peers without IDs. Objective: To examine daily PA patterns (weekdays vs. weekend days) of adolescents with IDs among boys and girls. The contributions of PA at school, including school recesses and physical education time, and PA outside of school were also analyzed. Methods: Participants included forty-nine adolescents with mild to moderate IDs (mean 15.3 years) from the Valencia region (Spain). Adolescents wore a pedometer for seven consecutive days to measure PA objectively and filled in a daily activity log. Mean steps for weekdays, weekend days, and for the different day segments were calculated and compared. Results: This study indicates significant differences in daily PA levels between boys and girls (12,630 and 9599 steps respectively; p ! 0.05). Girls were less active than boys on weekdays (13,872 vs. 9868 steps; p 5 0.016), during school time (7097 vs. 4802 steps; p 5 0.005), and during school recesses (1953 vs. 1147 steps; p 5 0.033). Boys showed higher levels of PA on weekdays compared to weekend days (13,872 vs. 10,188 steps; p 5 0.015) and PA at school represented 50% of the participants’ daily PA in both genders. There were no differences comparing weight status groups (normal vs. overweight/obese) in PA levels either on weekdays or weekend days. Conclusions: These findings provide an empirical basis for interventions to increase PA levels among adolescents with IDs. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Adolescent; Gender; Intellectual disability; Special school; Physical activity
Regular physical activity (PA) has been linked to many health benefits in adolescents1 therefore it is recommended that youth of both genders accumulate at least 60 min per day of moderate intensity PA which corresponds to 11,500 steps.1,2 However, there is little evidence about PA levels among adolescents with intellectual disabilities (IDs).3 Emerging data suggest that adolescents with IDs are insufficiently active and have a higher incidence of obesity than their peers without IDs.3,4 Although most of the available data for youth with IDs are based on objective instruments such as pedometers and accelerometers3 the results usually show daily/weekly total PA levels and do not analyze the contribution of the time spent at school and out of school to PA behavior. The few scientific studies examining gender differences in adolescents with IDs have indicated that girls have lower levels of PA than Conflict of interest: None declared. Funding: This work was partially supported by a grant from the Generalitat Valenciana, Spain (Grant no. GV-2013-087). * Corresponding author. Tel.: þ34 963983143; fax: þ34 963864310. E-mail address: [email protected] (A. Queralt). 1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2015.09.005
boys.5,6 Apart from demographic differences, the literature indicates that PA levels can differ between weekdays and weekend days,7 although the evidence is limited. Therefore, the aim of this study was to examine daily PA patterns (weekdays and weekend days) of adolescents with IDs among boys and girls. In addition, the contributions of PA at school, including school recesses and physical education (PE) time, and PA outside of school were considered in our analysis. Methods Participants The final sample was composed of 35 adolescents (mean age 15.3 6 2.7 years; 62.9% boys). Nine of the participants had Down syndrome. The average body mass index (BMI) was 24.4 6 5.0 kg/m2 (54.3% normoweight). Participants were recruited from a special education school for people with IDs in the Valencian region, Spain. This public school is specific for youth with intellectual disabilities who have special education needs. Inclusion criteria were: an age of 12e20 years, with mild (Intelligence Quotient [IQ] of
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20,000 in order to limit unrealistic data.11 Following current recommendations,12 150 steps were added to the daily number of steps for every minute of reported cycling or swimming. A minimum of 4 entire days of pedometer data were required; fourteen participants were excluded because they did not meet this criteria.
70e50) to moderate (IQ 50e35) IDs, and an ability to walk at least 10 m without assistance. Students meeting the age criteria were selected and screened by the school nurse; 83 students met the inclusion criteria and their parents or legal representatives were contacted by the school nurse via an information letter in order to obtain informed consent for their child’s participation in this study. Fortynine signed consents were obtained. The study protocol was approved by the Human Research Ethics Committee of the University of Valencia.
Data analysis The mean number of steps for weekdays, weekend days, and for the different segments of the day (at school, outside of school, recesses, and PE) were calculated. Gender differences were also analyzed. Differences between the means were evaluated by unpaired and paired t-tests. Effect sizes were estimated using Cohen’s d. Statistical analyses were conducted using SPSS 19.0 software (SPSS, Chicago, Illinois, USA).
Measurements and procedure Yamax Digiwalker SW-200 pedometers (Yamax, Tokyo, Japan) were used to measure PA. Pedometers are one of the objective instruments which can be used to accurately assess PA patterns for youth with disabilities.9 Before data collection, both parents and adolescents were trained in the use of the pedometers. Participants were instructed to wear the pedometer for 7 consecutive days (Spring 2012), during waking hours except during water-based activities. The school day was segmented into two categories based on Brusseau et al10: at school (8:00e17:00) and outside of school (from 17:00 until the start of school in the morning). Moreover, PA was assessed during PE classes and recesses. There were two active PE classes a week with a length of 60 min, and two school recesses per day. The first recess was 30 min in length during the mid-morning and the second recess was for lunch (60 min). Weight and height were measured to calculate BMI (kg/ m2) using a standard scale (A~ n o-Sayol SL, Barcelona, Spain). BMI percentiles were calculated and this data was used to divide the adolescents into two groups: normalweight and overweight/obese. A daily activity log was used to record the number of steps each participant took, and the school nurse and school teachers helped the students to record their pedometer step counts at different times of the school day: when they arrived at/left school, school recesses, and PE lessons. Outside of school and during weekend days, the activity log was completed by the adolescents with assistance from their parents before bedtime. Unusual step values were checked with the participants and their parents for clarification. Means for the total number of steps per day were calculated, registering counts of more than 20,000 as
Results The descriptive characteristics of the study sample are shown in Table 1. Overall, there were significant differences in daily PA levels (t 5 2.02, p ! 0.05, d 5 3.03; D 5 3031 steps) between boys and girls. Furthermore, as shown in Fig. 1, girls were less active than boys on weekdays (t 5 2.57, p 5 0.016, d 5 1.09; D 5 4004 steps), during school time (t 5 3.07, p 5 0.005, d 5 1.13; D 5 2295 steps), and school recesses (t 5 2.25, p 5 0.033, d 5 0.89; D 5 806 steps). The t-test results indicated that boys showed higher levels of PA on weekdays compared to weekend days (t 5 2.66, p 5 0.015, d 5 0.60; D 5 3684 steps), whereas there were no significant differences in PA levels between weekdays and weekend days for girls. There was no difference between the number of steps counted at school and out of school for either boys or girls. Fig. 2 presents the step counts for each PA segment by weight status. Overall, there were no differences in PA levels when comparing BMI groups, either on weekdays or weekend days. Normal-weight adolescents took an overall higher number of steps than overweight/obese adolescents during the recess periods (t 5 2.55, p 5 0.017, d 5 1.01; D 5 842 steps). Although no differences were observed in PA levels between weekdays and weekend days, either in normal-weight or overweight groups, a
Table 1 Sample characteristics All N Age (years) Weight (kg) Height (m) Body mass index (kg/m2) Physical activity (steps/day) Values are mean 6 SD.
Boys
35 15.26 60.02 1.57 24.44 11,689.13
Girls
22 6 6 6 6 6
2.70 14.14 0.13 4.98 3934.99
14.68 59.04 1.57 23.80 12,629.77
p-value
13 6 6 6 6 6
2.61 15.02 0.14 5.30 3888.27
16.23 61.67 1.55 25.53 9598.81
6 6 6 6 6
2.68 12.94 0.12 4.36 3340.69
e 0.102 0.603 0.671 0.327 0.046
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Fig. 1. Physical activity (step counts) of adolescents with intellectual disabilities by gender. *p < 0.05. **p < 0.01. PE: physical education.
tendency for overweight/obese adolescents accumulating fewer steps at the weekend compared to weekdays was observed (t 5 1.99, p 5 0.073, d 5 0.57; D 5 3074 steps). Discussion The study shows the presence of gender differences in PA levels among adolescents with IDs. Considering the mean daily number of steps, boys could be considered as sufficiently active (more than 11,500 steps a day) based on current recommendations.2 However, the mean number of daily steps for girls was insufficient and was significantly lower than the number taken by boys (9599 vs. 12,630 steps a day). Specifically boys had higher PA levels than girls during weekdays, whereas they were similar during weekend days. Analogous results were found in the study of Brusseau et al,13 where boys and girls accumulated similar step counts during the weekend days (7660 and 7,317, respectively). However, these results are not consistent with those found in other studies performed using samples of young people without IDs10 or with Down Syndrome7 where boys’ PA levels were only higher than girls’ during weekend days.
In our study, the number of steps accumulated during school hours was higher for boys than for girls (7097 vs. 4802 steps a day). More specifically, school breaks contributed significantly to establishing gender differences (1953 vs. 1147 for boys and girls respectively). In accordance with previous studies carried out with samples of young people without IDs,14 girls were less physically active during school recesses. Furthermore, the results of the present study point out that those adolescents who were obese or overweight were also less likely to be involved in any physical activities during recesses. Our results suggest that school breaks are a primary time for engaging in PA in the school setting. In line with previous studies performed with samples of adolescents without IDs,14 the boys and girls in this study showed similar PA levels during PE classes: the mean number of steps per PE lesson (i.e. 60 min) was 1,839, although these data are far from meeting the recommended 2000 steps per 30-min PE lesson.15 The literature shows the relevance of PE in enhancing the daily levels of PA among young people as they can accumulate a significant percentage of PA during classes.10 Therefore it is important to
Fig. 2. Physical activity (step counts) of adolescents with intellectual disabilities by weight status. *p < 0.05. PE: physical education.
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consider PE in school programs when trying to determine ways of increasing PA levels among young people with IDs. Our results suggest that girls with IDs are likely to participate to the same extent as boys in organized and structured activities such as PE lessons. Therefore, it is of utmost importance that schools develop educational interventions for school recesses based on co-educational sport programs that enhance female participation, as well as considering the inclusion of activities aimed at preventing and treating obesity. In accordance with a recent study carried out which objectively assessed the PA levels of a sample of adolescents with Down syndrome,7 there were no differences in PA levels inside or outside the school hours. These results are the opposite of those found in young sample populations without IDs,16 where adolescents were more physically active out of school hours. Authors such as Izquierdo-Gomez et al,7 suggest that this absence of differences may be due to the existence of barriers to leisure-time PA outside the school and that are typical for young people with IDs, such as the lack of appropriate programs or overprotective parents.17,18 Our study with adolescents with IDs found differences in PA levels when comparing weekends with the rest of the week only in boys. As already reported in the literature on young people with IDs,19 boys were less physically active during weekends. On the contrary, girls showed similar low levels of PA during both weekends and weekdays. These results for girls are consistent with those found by Izquierdo-Gomez et al7 in adolescents with IDs, although further research will be required to determine which factors correlate with PA levels during weekend time for each gender. Considering these findings, it is important to design school-based educational interventions in order to convert recreational areas into safe and appropriate places to play, mainly for girls and children with weight problems. Additionally, schools and institutions should also understand that PE classes not only allow young students to have appropriate opportunities for PA during school days, but also promote the acquisition of knowledge and skills which encourage PA outside of school.19 Therefore we recommend that the frequency and intensity of PE classes in the population with IDs should be increased.20 Furthermore, it would be useful to monitor the levels and patterns of PA in people with IDs, using tools such as pedometers. This is where the school nurse, in coordination with other school agents (e.g., PE teachers), plays a pivotal role in assessing PA behavior and in coordinating health programs in order to reduce disparities in PA levels among students with IDs, as well as to help prevent obesity.21,22 There are limitations of this study that should be pointed out. Firstly, our sample came from only one special education school. Therefore, the school context of the adolescents we assessed was not similar to that of other mixed schools or perhaps even to that of other schools for children
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with IDs. Secondly, the present study did not analyze the determinants of PA levels during PE lessons, such as teacher behavior. Finally, an analysis of the environmental variables where PA is undertaken, either in or out of school, was not performed. Future studies using samples with IDs should analyze environmental factors that determine PA behavior.
Conclusion In summary, our results suggest that boys with IDs are more physically active than girls with IDs during weekdays and especially during school recesses. PA during school time represents approximately half of the daily PA for both genders. Furthermore, boys were more physically active during weekdays compared to weekends. The results of the current study suggest that the school environment plays a critical role in providing educational interventions to increase PA levels in adolescents with IDs. References 1. World Health Organization. Global Recommendations on Physical Activity for Health. Geneva: Switzerland; 2010. 2. Adams MA, Johnson WD, Tudor-Locke C. Steps/day translation of the moderate-to-vigorous physical activity guideline for children and adolescents. Int J Behav Nutr Phys Act. 2013;10:49. 3. Hinckson EA, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: a systematic review. Res Dev Disabil. 2013;34(1):72e86. 4. Maiano C. Prevalence and risk factors of overweight and obesity among children and adolescents with intellectual disabilities. Obes Rev. 2011;12(3):189e197. 5. Lin JD, Lin PY, Lin LP, Chang YY, Wu SR, Wu JL. Physical activity and its determinants among adolescents with intellectual disabilities. Res Dev Disabil. 2010;31(1):263e269. 6. Whitt-Glover MC, O’Neill KL, Stettler N. Physical activity patterns in children with and without Down syndrome. Dev Neurorehabil. 2006;9(2):158e164. 7. Izquierdo-Gomez R, Martinez-Gomez D, Acha A, et al. Objective assessment of sedentary time and physical activity throughout the week in adolescents with down syndrome. the UP&DOWN study. Res Dev Disabil. 2014;35(2):482e489. 8. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD-10). Geneva: Switzerland; 2010. 9. Beets MW, Combs C, Pitetti KH, Morgan M, Bryan RR, Foley JT. Accuracy of pedometer steps and time for youth with disabilities. Adapt Phys Activ Q. 2007;24(3):228e244. 10. Brusseau TA, Kulinna PH, Tudor-Locke C, Ferry M. Daily physical activity patterns of children living in an American Indian community. J Phys Act Health. 2013;10(1):48e53. 11. Tudor-Locke C, Ham SA, Macera CA, et al. Descriptive epidemiology of pedometer-determined physical activity. Med Sci Sports Exerc. 2004;36(9):1567e1573. 12. Miller R, Brown W, Tudor-Locke C. But what about swimming and cycling? How to ‘‘count’’ non-ambulatory activity when using pedometers to assess physical activity. J Phys Act Health. 2006;3(3): 257e266. 13. Brusseau T, Kulinna P, Tudor-Locke C, van der Mars H, Darst P. Children’s step counts on weekend, physical education, and non-physical education days. J Hum Kinet. 2011;27:123e134.
ARTICLE IN PRESS A. Queralt et al. / Disability and Health Journal 14. Sarkin JA, McKenzie TL, Sallis JF. Gender differences in physical activity during fifth-grade physical education and recess periods. Journal of Teaching in Physical Education. 1997;17:99e106. 15. Pangrazi RP, Beighle A, Sidman CL. Pedometer Power. 67 Lessons for K-12. ERIC; 2003. 16. Silva P, Santos R, Welk G, Mota J. Seasonal differences in physical activity and sedentary patterns: the relevance of the PA context. J Sports Sci Med. 2011;10(1):66e72. 17. Pitetti K, Baynard T, Agiovlasitis S. Children and adolescents with Down syndrome, physical fitness and physical activity. Journal of Sport and Health Science. 2013;2(1):47e57. 18. Haney K, Messiah SE, Arheart KL, et al. Park-based afterschool program to improve cardiovascular health and physical fitness in children with disabilities. Disabil Health J. 2014;7(3):335e342.
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19. Dauenhauer BD, Keating XD. The influence of physical education on physical activity levels of urban elementary students. Res Q Exerc Sport. 2011;82(3):512e520. 20. Sit CH, McManus A, McKenzie TL, Lian J. Physical activity levels of children in special schools. Prev Med. 2007;45(6): 424e431. 21. Bryan C, Broussard L, Bellar D. Effective partnership: how school nurses and physical education teachers can combat childhood obesity. NASN Sch Nurse. 2013;28(1):20e23. 22. Wright K, Giger JN, Norris K, Suro Z. Impact of a nurse-directed, coordinated school health program to enhance physical activity behaviors and reduce body mass index among minority children: a parallel-group, randomized control trial. Int J Nurs Stud. 2013;50(6): 727e737.
Disability and Health Journal
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(2015)
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www.disabilityandhealthjnl.com
Brief Report
The physical activity patterns of adolescents with intellectual disabilities: A descriptive study Ana Queralt, Ph.D.a,*, Anna Vicente-Ortiz, M.Sc.a, and Javier Molina-Garcıa, Ph.D.b b
a Nursing Department, University of Valencia, c/Jaume Roig s/n, Valencia 46010, Spain Department of Teaching of Musical, Visual and Corporal Expression, University of Valencia, Avda. dels Tarongers 4, Valencia 46022, Spain
Abstract Background: Emerging data suggest that adolescents with intellectual disabilities (IDs) have lower physical activity (PA) levels and have a higher incidence of obesity than their peers without IDs. Objective: To examine daily PA patterns (weekdays vs. weekend days) of adolescents with IDs among boys and girls. The contributions of PA at school, including school recesses and physical education time, and PA outside of school were also analyzed. Methods: Participants included forty-nine adolescents with mild to moderate IDs (mean 15.3 years) from the Valencia region (Spain). Adolescents wore a pedometer for seven consecutive days to measure PA objectively and filled in a daily activity log. Mean steps for weekdays, weekend days, and for the different day segments were calculated and compared. Results: This study indicates significant differences in daily PA levels between boys and girls (12,630 and 9599 steps respectively; p ! 0.05). Girls were less active than boys on weekdays (13,872 vs. 9868 steps; p 5 0.016), during school time (7097 vs. 4802 steps; p 5 0.005), and during school recesses (1953 vs. 1147 steps; p 5 0.033). Boys showed higher levels of PA on weekdays compared to weekend days (13,872 vs. 10,188 steps; p 5 0.015) and PA at school represented 50% of the participants’ daily PA in both genders. There were no differences comparing weight status groups (normal vs. overweight/obese) in PA levels either on weekdays or weekend days. Conclusions: These findings provide an empirical basis for interventions to increase PA levels among adolescents with IDs. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Adolescent; Gender; Intellectual disability; Special school; Physical activity
Regular physical activity (PA) has been linked to many health benefits in adolescents1 therefore it is recommended that youth of both genders accumulate at least 60 min per day of moderate intensity PA which corresponds to 11,500 steps.1,2 However, there is little evidence about PA levels among adolescents with intellectual disabilities (IDs).3 Emerging data suggest that adolescents with IDs are insufficiently active and have a higher incidence of obesity than their peers without IDs.3,4 Although most of the available data for youth with IDs are based on objective instruments such as pedometers and accelerometers3 the results usually show daily/weekly total PA levels and do not analyze the contribution of the time spent at school and out of school to PA behavior. The few scientific studies examining gender differences in adolescents with IDs have indicated that girls have lower levels of PA than Conflict of interest: None declared. Funding: This work was partially supported by a grant from the Generalitat Valenciana, Spain (Grant no. GV-2013-087). * Corresponding author. Tel.: þ34 963983143; fax: þ34 963864310. E-mail address: [email protected] (A. Queralt). 1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2015.09.005
boys.5,6 Apart from demographic differences, the literature indicates that PA levels can differ between weekdays and weekend days,7 although the evidence is limited. Therefore, the aim of this study was to examine daily PA patterns (weekdays and weekend days) of adolescents with IDs among boys and girls. In addition, the contributions of PA at school, including school recesses and physical education (PE) time, and PA outside of school were considered in our analysis. Methods Participants The final sample was composed of 35 adolescents (mean age 15.3 6 2.7 years; 62.9% boys). Nine of the participants had Down syndrome. The average body mass index (BMI) was 24.4 6 5.0 kg/m2 (54.3% normoweight). Participants were recruited from a special education school for people with IDs in the Valencian region, Spain. This public school is specific for youth with intellectual disabilities who have special education needs. Inclusion criteria were: an age of 12e20 years, with mild (Intelligence Quotient [IQ] of
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20,000 in order to limit unrealistic data.11 Following current recommendations,12 150 steps were added to the daily number of steps for every minute of reported cycling or swimming. A minimum of 4 entire days of pedometer data were required; fourteen participants were excluded because they did not meet this criteria.
70e50) to moderate (IQ 50e35) IDs, and an ability to walk at least 10 m without assistance. Students meeting the age criteria were selected and screened by the school nurse; 83 students met the inclusion criteria and their parents or legal representatives were contacted by the school nurse via an information letter in order to obtain informed consent for their child’s participation in this study. Fortynine signed consents were obtained. The study protocol was approved by the Human Research Ethics Committee of the University of Valencia.
Data analysis The mean number of steps for weekdays, weekend days, and for the different segments of the day (at school, outside of school, recesses, and PE) were calculated. Gender differences were also analyzed. Differences between the means were evaluated by unpaired and paired t-tests. Effect sizes were estimated using Cohen’s d. Statistical analyses were conducted using SPSS 19.0 software (SPSS, Chicago, Illinois, USA).
Measurements and procedure Yamax Digiwalker SW-200 pedometers (Yamax, Tokyo, Japan) were used to measure PA. Pedometers are one of the objective instruments which can be used to accurately assess PA patterns for youth with disabilities.9 Before data collection, both parents and adolescents were trained in the use of the pedometers. Participants were instructed to wear the pedometer for 7 consecutive days (Spring 2012), during waking hours except during water-based activities. The school day was segmented into two categories based on Brusseau et al10: at school (8:00e17:00) and outside of school (from 17:00 until the start of school in the morning). Moreover, PA was assessed during PE classes and recesses. There were two active PE classes a week with a length of 60 min, and two school recesses per day. The first recess was 30 min in length during the mid-morning and the second recess was for lunch (60 min). Weight and height were measured to calculate BMI (kg/ m2) using a standard scale (A~ n o-Sayol SL, Barcelona, Spain). BMI percentiles were calculated and this data was used to divide the adolescents into two groups: normalweight and overweight/obese. A daily activity log was used to record the number of steps each participant took, and the school nurse and school teachers helped the students to record their pedometer step counts at different times of the school day: when they arrived at/left school, school recesses, and PE lessons. Outside of school and during weekend days, the activity log was completed by the adolescents with assistance from their parents before bedtime. Unusual step values were checked with the participants and their parents for clarification. Means for the total number of steps per day were calculated, registering counts of more than 20,000 as
Results The descriptive characteristics of the study sample are shown in Table 1. Overall, there were significant differences in daily PA levels (t 5 2.02, p ! 0.05, d 5 3.03; D 5 3031 steps) between boys and girls. Furthermore, as shown in Fig. 1, girls were less active than boys on weekdays (t 5 2.57, p 5 0.016, d 5 1.09; D 5 4004 steps), during school time (t 5 3.07, p 5 0.005, d 5 1.13; D 5 2295 steps), and school recesses (t 5 2.25, p 5 0.033, d 5 0.89; D 5 806 steps). The t-test results indicated that boys showed higher levels of PA on weekdays compared to weekend days (t 5 2.66, p 5 0.015, d 5 0.60; D 5 3684 steps), whereas there were no significant differences in PA levels between weekdays and weekend days for girls. There was no difference between the number of steps counted at school and out of school for either boys or girls. Fig. 2 presents the step counts for each PA segment by weight status. Overall, there were no differences in PA levels when comparing BMI groups, either on weekdays or weekend days. Normal-weight adolescents took an overall higher number of steps than overweight/obese adolescents during the recess periods (t 5 2.55, p 5 0.017, d 5 1.01; D 5 842 steps). Although no differences were observed in PA levels between weekdays and weekend days, either in normal-weight or overweight groups, a
Table 1 Sample characteristics All N Age (years) Weight (kg) Height (m) Body mass index (kg/m2) Physical activity (steps/day) Values are mean 6 SD.
Boys
35 15.26 60.02 1.57 24.44 11,689.13
Girls
22 6 6 6 6 6
2.70 14.14 0.13 4.98 3934.99
14.68 59.04 1.57 23.80 12,629.77
p-value
13 6 6 6 6 6
2.61 15.02 0.14 5.30 3888.27
16.23 61.67 1.55 25.53 9598.81
6 6 6 6 6
2.68 12.94 0.12 4.36 3340.69
e 0.102 0.603 0.671 0.327 0.046
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Fig. 1. Physical activity (step counts) of adolescents with intellectual disabilities by gender. *p < 0.05. **p < 0.01. PE: physical education.
tendency for overweight/obese adolescents accumulating fewer steps at the weekend compared to weekdays was observed (t 5 1.99, p 5 0.073, d 5 0.57; D 5 3074 steps). Discussion The study shows the presence of gender differences in PA levels among adolescents with IDs. Considering the mean daily number of steps, boys could be considered as sufficiently active (more than 11,500 steps a day) based on current recommendations.2 However, the mean number of daily steps for girls was insufficient and was significantly lower than the number taken by boys (9599 vs. 12,630 steps a day). Specifically boys had higher PA levels than girls during weekdays, whereas they were similar during weekend days. Analogous results were found in the study of Brusseau et al,13 where boys and girls accumulated similar step counts during the weekend days (7660 and 7,317, respectively). However, these results are not consistent with those found in other studies performed using samples of young people without IDs10 or with Down Syndrome7 where boys’ PA levels were only higher than girls’ during weekend days.
In our study, the number of steps accumulated during school hours was higher for boys than for girls (7097 vs. 4802 steps a day). More specifically, school breaks contributed significantly to establishing gender differences (1953 vs. 1147 for boys and girls respectively). In accordance with previous studies carried out with samples of young people without IDs,14 girls were less physically active during school recesses. Furthermore, the results of the present study point out that those adolescents who were obese or overweight were also less likely to be involved in any physical activities during recesses. Our results suggest that school breaks are a primary time for engaging in PA in the school setting. In line with previous studies performed with samples of adolescents without IDs,14 the boys and girls in this study showed similar PA levels during PE classes: the mean number of steps per PE lesson (i.e. 60 min) was 1,839, although these data are far from meeting the recommended 2000 steps per 30-min PE lesson.15 The literature shows the relevance of PE in enhancing the daily levels of PA among young people as they can accumulate a significant percentage of PA during classes.10 Therefore it is important to
Fig. 2. Physical activity (step counts) of adolescents with intellectual disabilities by weight status. *p < 0.05. PE: physical education.
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consider PE in school programs when trying to determine ways of increasing PA levels among young people with IDs. Our results suggest that girls with IDs are likely to participate to the same extent as boys in organized and structured activities such as PE lessons. Therefore, it is of utmost importance that schools develop educational interventions for school recesses based on co-educational sport programs that enhance female participation, as well as considering the inclusion of activities aimed at preventing and treating obesity. In accordance with a recent study carried out which objectively assessed the PA levels of a sample of adolescents with Down syndrome,7 there were no differences in PA levels inside or outside the school hours. These results are the opposite of those found in young sample populations without IDs,16 where adolescents were more physically active out of school hours. Authors such as Izquierdo-Gomez et al,7 suggest that this absence of differences may be due to the existence of barriers to leisure-time PA outside the school and that are typical for young people with IDs, such as the lack of appropriate programs or overprotective parents.17,18 Our study with adolescents with IDs found differences in PA levels when comparing weekends with the rest of the week only in boys. As already reported in the literature on young people with IDs,19 boys were less physically active during weekends. On the contrary, girls showed similar low levels of PA during both weekends and weekdays. These results for girls are consistent with those found by Izquierdo-Gomez et al7 in adolescents with IDs, although further research will be required to determine which factors correlate with PA levels during weekend time for each gender. Considering these findings, it is important to design school-based educational interventions in order to convert recreational areas into safe and appropriate places to play, mainly for girls and children with weight problems. Additionally, schools and institutions should also understand that PE classes not only allow young students to have appropriate opportunities for PA during school days, but also promote the acquisition of knowledge and skills which encourage PA outside of school.19 Therefore we recommend that the frequency and intensity of PE classes in the population with IDs should be increased.20 Furthermore, it would be useful to monitor the levels and patterns of PA in people with IDs, using tools such as pedometers. This is where the school nurse, in coordination with other school agents (e.g., PE teachers), plays a pivotal role in assessing PA behavior and in coordinating health programs in order to reduce disparities in PA levels among students with IDs, as well as to help prevent obesity.21,22 There are limitations of this study that should be pointed out. Firstly, our sample came from only one special education school. Therefore, the school context of the adolescents we assessed was not similar to that of other mixed schools or perhaps even to that of other schools for children
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with IDs. Secondly, the present study did not analyze the determinants of PA levels during PE lessons, such as teacher behavior. Finally, an analysis of the environmental variables where PA is undertaken, either in or out of school, was not performed. Future studies using samples with IDs should analyze environmental factors that determine PA behavior.
Conclusion In summary, our results suggest that boys with IDs are more physically active than girls with IDs during weekdays and especially during school recesses. PA during school time represents approximately half of the daily PA for both genders. Furthermore, boys were more physically active during weekdays compared to weekends. The results of the current study suggest that the school environment plays a critical role in providing educational interventions to increase PA levels in adolescents with IDs. References 1. World Health Organization. Global Recommendations on Physical Activity for Health. Geneva: Switzerland; 2010. 2. Adams MA, Johnson WD, Tudor-Locke C. Steps/day translation of the moderate-to-vigorous physical activity guideline for children and adolescents. Int J Behav Nutr Phys Act. 2013;10:49. 3. Hinckson EA, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: a systematic review. Res Dev Disabil. 2013;34(1):72e86. 4. Maiano C. Prevalence and risk factors of overweight and obesity among children and adolescents with intellectual disabilities. Obes Rev. 2011;12(3):189e197. 5. Lin JD, Lin PY, Lin LP, Chang YY, Wu SR, Wu JL. Physical activity and its determinants among adolescents with intellectual disabilities. Res Dev Disabil. 2010;31(1):263e269. 6. Whitt-Glover MC, O’Neill KL, Stettler N. Physical activity patterns in children with and without Down syndrome. Dev Neurorehabil. 2006;9(2):158e164. 7. Izquierdo-Gomez R, Martinez-Gomez D, Acha A, et al. Objective assessment of sedentary time and physical activity throughout the week in adolescents with down syndrome. the UP&DOWN study. Res Dev Disabil. 2014;35(2):482e489. 8. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD-10). Geneva: Switzerland; 2010. 9. Beets MW, Combs C, Pitetti KH, Morgan M, Bryan RR, Foley JT. Accuracy of pedometer steps and time for youth with disabilities. Adapt Phys Activ Q. 2007;24(3):228e244. 10. Brusseau TA, Kulinna PH, Tudor-Locke C, Ferry M. Daily physical activity patterns of children living in an American Indian community. J Phys Act Health. 2013;10(1):48e53. 11. Tudor-Locke C, Ham SA, Macera CA, et al. Descriptive epidemiology of pedometer-determined physical activity. Med Sci Sports Exerc. 2004;36(9):1567e1573. 12. Miller R, Brown W, Tudor-Locke C. But what about swimming and cycling? How to ‘‘count’’ non-ambulatory activity when using pedometers to assess physical activity. J Phys Act Health. 2006;3(3): 257e266. 13. Brusseau T, Kulinna P, Tudor-Locke C, van der Mars H, Darst P. Children’s step counts on weekend, physical education, and non-physical education days. J Hum Kinet. 2011;27:123e134.
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