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Germany’s 2018 report card on physical activity for children and youth

  • Yolanda DemetriouEmail author
  • Jens Bucksch
  • Antje Hebestreit
  • Annegret Schlund
  • Claudia Niessner
  • Steffen C. E. Schmidt
  • Jonas David Finger
  • Michael Mutz
  • Klaus Völker
  • Lutz Vogt
  • Alexander Woll
  • Anne K. Reimers
Review

Abstract

The German Report Card on Physical Activity for Children and Youth 2018 provides a summary and a comprehensive evaluation of physical activity levels and correlated indicators using the Active Healthy Kids Canada grading framework. The Report Card aims to benchmark the national actions promoting physical activity in children and youth in Germany with the overarching goal to raise awareness for the promotion of physical activity. The 2018 German Report Card focuses on adherence to physical activity and sedentary time recommendations identified by an expert panel. Additionally, settings and sources of influence as well as strategies and investments towards physical activity are analyzed. Sources included national surveys, peer-reviewed literature, as well as government and non-government reports. The expert panel assigned grades to the ten Report Card indicators using existing benchmarks. Most children and youth in Germany failed to meet the World Health Organization recommendation for physical activity and engaged in high levels of sedentary behaviours despite favourable conditions within the relevant settings (e. g., schools). Therefore, we assigned poor grades for most behavioural indicators (“overall physical activity”, “sedentary behaviour”, “active play” and “active transportation”) with the exception of “organized sport participation”. It was not possible to assign grades for two indicators—“physical fitness” and “government”—due to insufficient evidence. The fact that no evaluated government policy exists to promote physical activity in children and youth signals a need for further government action to promote physical activity and create environments that support healthy active living among children and youth in Germany.

Keywords

Environment Benchmark Health promotion Experts 

Bewegungszeugnis zur körperlichen Aktivität von Kindern und Jugendlichen in Deutschland 2018

Zusammenfassung

Das deutsche Bewegungszeugnis zur körperlichen Aktivität von Kindern und Jugendlichen 2018 bildet basierend auf dem Rahmenkonzept der Active Healthy Kids Canada eine Zusammenfassung über das Ausmaß der körperlichen Aktivität und des sitzenden Verhaltens von Kindern und Jugendlichen in Deutschland. Ausgewählte Settings und Lebenswelten sowie politische Maßnahmen werden hinsichtlich ihrer Bewegungsfreundlichkeit analysiert. Die Basis für die Evaluation bilden nationale Surveys, wissenschaftlich begutachtete Studien und Berichte aus staatlichen und nichtstaatlichen Organisationen. Die Bewertung dieser Dokumente wurde vom Active-Healthy-Kids-Germany-Expertenteam durchgeführt. Für die zehn Indikatoren des Bewegungszeugnis wurden basierend auf den vorhandenen Benchmarks Schulnoten vergeben. Die Mehrheit der Kinder und Jugendlichen in Deutschland erfüllt nicht die Empfehlungen der Weltgesundheitsorganisation für eine ausreichende körperliche Aktivität und verbringt einen Großteil des Tages mit sitzenden Verhaltensweisen, obwohl zentrale Settings (z. B. Schule) eine bewegungsfreundliche Ausstattung aufweisen. Aus diesem Grund wurden schlechte Noten für die Verhaltensindikatoren („körperliche Aktivität insgesamt“, „sitzendes Verhalten“, „aktives Spielen“ und „aktiver Transport“) mit Ausnahme des „organisierten Sports“ vergeben. Die Indikatoren „physische Fitness“ und „Regierung“ konnten aufgrund mangelnder Evidenz nicht bewertet werden. Bislang existiert keine evaluierte übergreifende politische Maßnahme zur Förderung der körperlichen Aktivität bei Kindern und Jugendlichen in Deutschland. Weitere Maßnahmen zur Förderung körperlicher Aktivität und zur Schaffung von bewegungsfreundlichen Umwelten, die eine gesunde und bewegungsaktive Lebensweise in Deutschland ermöglichen, sind notwendig.

Schlüsselwörter

Umwelt Evaluation Gesundheitsförderung Experten 

Introduction

According to the World Health Organization (WHO), children and adolescents aged 5–17 years should engage in moderate- to vigorous-intensity physical activity (MVPA) for at least 60 min every day (World Health Organization, 2018). In Germany, 90 min of daily MVPA is recommended (Rütten & Pfeifer, 2016). In the analyses of the paper, the WHO recommendations of 60 min were used to allow a comparison between other countries. Recent systematic reviews underpin that children who follow these recommendations are at lower risk of overweight or obesity, type II diabetes mellitus, metabolic syndrome, and other comorbidities than less physically active children (Poitras et al., 2016). Additionally, the regularly active children are more likely to have a higher level of aerobic fitness and are more likely to experience positive mental health (Janssen & LeBlanc, 2010; Okely et al., 2012). Similarly, more time spent on sedentary activities (screen time, video gaming, and television viewing) is associated with unfavourable body composition, higher clustered cardiometabolic risk, unfavourable behavioural conduct, lower fitness and lower self-esteem (Carson et al., 2016). Even though the positive health effects of regular physical activity are well known, national and international surveillance data show that physical activity is the “pill not taken” (Finger, Varnaccia, Borrmann, Lange, & Mensink, 2018; Kalman et al., 2015). This leads to widespread negative health and economic consequences.

In order to guide innovative, comprehensive future interventions as well as strategies and policies involving the individual, families and peer groups, schools, the community and the government, it is important to understand facilitators of and barriers to physical activity and sedentary behaviour across Germany and to evaluate the proportion of children and youth who meet the WHO recommendation and those who fail. Furthermore, it is important to also understand to what extent governmental policies foster physical activity, for example by reconsidering the built environment involving urban planners.

One way to address this knowledge translation is to use the Report Card method developed by Active Healthy Kids Canada (AHKC) (Tremblay et al., 2014b). The Report Card is a vehicle that advocates for children and youths to be more physically active every day, while also providing a surveillance mechanism at both the national and international level. There are ten indicators within the Report Card, to which letter grades are assigned and, thus, provide a comprehensive overview of the “state of the nation” on how children and youths engage in domain-specific physical activity and sedentary behaviour and on how a country is succeeding in providing physical activity opportunities for children and youths. The ten core physical activity indicators of the Report Card belong to four categories: daily behaviours (overall physical activity, organized sport participation, active play, active transportation, sedentary behaviours), individual characteristics (physical fitness), settings and sources of influence (family and peers, school, community and environment) and strategies and investments (government). The German Report Card is a brochure consisting of several pages and it is distributed online and in a printed version in the German and English language. Thus, the grading in the Report Card is based on the German (1–6) and the English (A–F) grading system accordingly.

The world’s first Global Summit on the Physical Activity of Children in Toronto involved 15 countries presenting their Report Cards (Tremblay et al., 2014b). Following the success of this summit, the Active Healthy Kids Global Alliance (AHKGA) was established in 2014. The AHKGA is a network of researchers, health professionals and stakeholders who are working together to advance physical activity in children and youths from around the world. During the second Global Matrix 2.0 in 2016 in Bangkok 38 countries presented their Report Cards (Tremblay et al., 2016). The first German Report Card will be presented at the Global Matrix 3.0 in Adelaide, Australia with 49 countries participating.

The impact of the Report Card on Physical Activity for children and Youth was analyzed in 2014, 10 years after launching the project (Tremblay, Barnes, & Bonne, 2014a). In most countries, the Report Card is distributed based on an electronic and printed version. In Canada, more than 120,000 printed copies and more than 200,000 electronic copies were distributed between 2005 and 2014. The media attention has been very high reaching 150–940 media hits (number of stories or times the content appears). Surveys indicated that the most common uses of the Report Card were to keep up with research in the field; policy or strategy development; program design or delivery changes; education and training; creation of new or strengthened partnerships; and advocacy.

The 2018 German Report Card on Physical Activity evaluates children’s and youths’ levels of physical activity in different domains and the presence and implementation of strategies for promoting physical activity identified by the AHKG expert panel. The Report Card aims to evaluate and benchmark the national physical activity promotion efforts in children and youth in Germany with the overarching purpose to raise awareness for the promotion of physical activity. The Report Card can be used by a number of people including stakeholders from the field of public health, sports and education such as school directors, teachers, parents, coaches, government ministers and others that have an influence on children’s and adolescents’ physical activity levels. The Report Card will be sent via post to relevant stakeholders and can be downloaded online from the Report Card’s webpage https://www.stiftung-gesundarbeiter.de/home.html.

The purpose of this contribution is to summarize the process, development, methods and key findings of Germany’s 2018 Report Card on Physical Activity for Children and Youth. The Report Card is based on the best available recent evidence from German children and adolescents.

Method

The development of Germany’s 2018 Report Card on physical activity for children and youth

The work to develop and produce Germany’s 2018 Report Card on Physical Activity for Children and Youth was initiated and coordinated by the Technical University of Munich (http://www.sportpaedagogik.sg.tum.de/startseite/). The 2018 Report Card was developed by the AHKG research work group (hereinafter simply called AHKG), based on the Canadian model (Colley, Brownrigg, & Tremblay, 2012; Tremblay et al., 2014b) and consisted of 12 researchers from seven universities and two research institutes, who are the authors of this manuscript. The AHKG is a collaboration between German experts in the field of children’s physical activity and health research who have an interest in increasing the overall physical activity levels of young children and youth in Germany. It was established in 2018, providing knowledge and expertise in different areas of physical activity and physical fitness research, related determinants and health research and represents different scientific perspectives and methodological backgrounds. The aim of the AHKG is to provide a ‘state of the nation’ resource by creating Germany’s first Report Card on Physical Activity for Children and Youth. The AHKG identified the existing key data sources on each indicator and met to discuss, interpret and grade the indicators.

Indicators

The AHKG assigned grades to ten indicators that are grouped under the categories daily behaviours, individual characteristics, settings and sources of influence and strategies and investments based on the Global Matrix 3.0 (Fig. 1).
Fig. 1

The ten indicators of Germany’s 2018 Report Card on Physical Activity for Children and Youth

Literature search: data sources

From January to May 2018 the AHKG searched scientific databases (PubMed, SPORTDiscus and SURF) for relevant evidence from nationally representative surveys within Germany. Additionally, existing studies based on the knowledge of the AHKG were included and other key researchers in the field were asked to check whether key studies were missing. Sources included national surveys, peer-reviewed literature, and government and non-government reports. Surveys were included when carried out in the last 10 years. Only studies with a minimum sample size of 500 children and/or adolescents were considered. Exceptions regarding publication year or study sample size were made if no other comparable data existed.

Grades

In May 2018, members of the AHKG agreed on identified studies and datasets for the evaluation process. During a workshop, they appraised available evidence and assigned grades to each of the ten indicators once agreement had been reached through discussion. The grades were assigned by comparing suitable survey data against a relevant evidence-based recommendation, where available, using the grading scheme (Table 1) and benchmark approach from the AHKGA (Table 2) (Barnes et al., 2016; Tremblay et al., 2016). For example, for the indicator overall physical activity, the number of children and adolescents in Germany meeting the WHO recommendation of 60 min MVPA per day was investigated.
Table 1

Global Matrix 3.0 grading rubric (Aubert et al., 2018a)

Grade

Prevalence (%)

Interpretation

A+

94–100

We are succeeding with a large majority of children and youth

A

87–93

A−

80–86

B+

74–79

We are succeeding with well over half of children and youth

B

67–73

B−

60–66

C+

54–59

We are succeeding with about half of children and youth

C

47–53

C−

40–46

D+

34–39

We are succeeding with less than half but some children and youth

D

27–33

D−

20–26

F

<20

We are succeeding with very few children and youth

INC

Incomplete—insufficient or inadequate information to assign a grade

Table 2

Grades and rationales for Germany’s 2018 Report Card

Indicator/definition

Benchmark(s)

Gradea & confidence ratingb

Rationale

Overall physical activity

Any bodily movement produced by skeletal muscles that requires energy expenditure

Percentage of children and youth who meet the Global Recommendations on Physical Activity for Health, which recommend that children and youth accumulate a combined total of at least 60 min of moderate- to vigorous-intensity physical activity on average

D−

**

National data show that across studies only about 20% of girls and boys accumulate at least 60 min of MVPA per day. The percentages of girls and boys fulfilling the World Health Organization recommendations vary slightly between studies and type of measurement (subjective/objective). The recommendation compliance is lower in older compared to younger age groups and among girls compared to boys (Bucksch, Inchley, Hamrik, Finne, & Kolip, 2014; Finger et al., 2018; Helmholtz Zentrum München Deutsches Forschungszentrum für Gesundheit und Umwelt, 2017; Kettner et al., 2013; Konstabel et al., 2014; Manz et al., 2014; Rauner, Jekauc, Mess, Schmidt, & Woll, 2015; Schmidt, Will, Henn, Reimers, & Woll, 2016a; Smith, Berdel, Nowak, Heinrich, & Schulz, 2016; Uhlenbrock, 2011)

Organised sport participation

A subset of physical activity that is structured, goal-oriented, competitive and contest-based

Percentage of children and youth who participate in organized sport and/or physical activity programs

B

***

National data show that a high percentage of children and adolescents are members in sport clubs (about 70%). The membership numbers decrease slightly with rising age and girls are less often members in a sports club in comparison to boys (Burrmann, Seyda, Heim, & Konowalczyk, 2016; Deutscher Olympischer Sportbund, 2017; Grgic, Holzmayer, & Züchner, 2013; Manz, Krug, Schienkiewitz, & Finger, 2016; Manz et al., 2014; Mutz & Burrmann, 2015; Schmidt, Henn, Albrecht, & Woll, 2017; Schmidt, Will, & Woll, 2016b; Uhlenbrock, 2011; Will, Schmidt, & Woll, 2016)

Active play

Active play may involve symbolic activity or games with or without clearly defined rules; the activity may be unstructured/unorganized, social or solitary, but the distinguishing features are a playful context, combined with activity that is significantly above resting metabolic rate. Active play tends to occur sporadically, with frequent rest periods, which makes it difficult to record

Percentage of children and youth who engage in unstructured/unorganized active play for several hours a day. Percentage of children and youth who report being outdoors for several hours a day

D−

*

Less than 25% of children and adolescents play actively for several hours per day. More children than adolescents actively play and slightly more girls than boys engage in active play (Feierabend, Plankenhorn, & Rathgeb, 2017; Schmidt et al., 2017)

Active transportation

Active transportation refers to any form of human-powered transportation—walking, cycling, using a wheelchair, in-line skating or skateboarding

Percentage of children and youth who use active transportation to get to and from places (e. g., school, park, mall, friend’s house)

C−

**

Approximately 40% of the children and adolescents commute actively to school. Girls walk to school more often and boys cycle to school slightly more often (Bundesministerium für Verkehr und digitale Infrastruktur, 2017; Deutsches Institut für Urbanistik gGmbH & Bundesministerium für Verkehr und digitale Infrastruktur, 2014; Reimers, Jekauc, Peterhans, Wagner, & Woll, 2013)

Sedentary behaviours

Any waking behaviour characterized by an energy expenditure of 1–1.5 metabolic equivalents, while in a sitting, reclining or lying posture

Percentage of children and youth who meet the sedentary behaviour guidelines (5- to 17-year-olds: no more than two hours of screen time per day)

D−

*

About 80% of children and adolescents spend more than 2 h/day sedentary, watching TV or using other screen devises. The results range across studies depending on the measurement instrument and the type of behaviour in focus (screen based vs. total sedentary behaviour) (Bucksch et al., 2014; Huber & Köppel, 2017; Konstabel et al., 2014; Manz et al., 2014; Santaliestra-Pasías et al., 2014; Smith et al., 2016)

Physical fitness

Characteristics that permit good performance of a given physical task in a specified physical, social, and psychological environment

Average percentile achieved regarding relative peak oxygen uptake

INC

Summary analyses for endurance performance are planned for the next Report Card. The focus for the current Report Card was placed on the physical activity behaviour

Family and peers

Any member within the family who can control or influence the physical activity opportunities and participation of children and youth in this environment

Percentage of family members (e. g., parents, guardians) who facilitate physical activity and sport opportunities for their children (e. g., volunteering, coaching, driving, paying for membership fees and equipment)

B−

*

In total, 66% of parents are regularly physically active and 60% of the children feel that they receive positive support from their parents and friends to be physically active (Reimers, Jekauc, Mess, Mewes, & Woll, 2012; Reimers, Schmidt, Demetriou, & Woll, in press; Schoeppe, Röbl, Liersch, Krauth, & Walter, 2016)

Percentage of parents who meet the Global Recommendations on Physical Activity for Health, which recommend that adults accumulate at least 150 min of moderate-intensity aerobic physical activity throughout the week or do at least 75 min of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity

Percentage of family members (e. g., parents, guardians) who are physically active with their kids

Percentage of children and youth with friends and peers who encourage and support them to be physically active

Percentage of children and youth who encourage and support their friends and peers to be physically active

School

Any policies, organizational factors (e. g., infrastructure, accountability for policy implementation) or student factors (e. g., physical activity options based on age, gender or ethnicity) in the school environment that can influence the physical activity opportunities and participation of children and youth in this environment

Percentage of schools with active school policies (e. g., daily PE, daily physical activity, recess, “everyone plays” approach, bike racks at school, traffic calming on school property, outdoor time). Percentage of schools where the majority (>80%) of students are taught by a PE specialist

B+

**

In primary schools, only about half of the PE teachers have university qualifications to teach PE, whereas in secondary schools nearly all teachers are professionally educated PE teachers. All schools provide some kind of sports facilities to carry out PE classes, whereas access to swimming pools for PE was lower (ca. 70%). As part of the curriculum, PE is mandatory in all school types independent of students’ class level (Beisenkamp, Müthing, Hallmann, & Klöckner, 2012; Deutscher Olympischer Sportbund, 2006; Süßenbach & Geis, 2014)

Percentage of schools where the majority (>80%) of students are offered the mandated amount of PE (for the given state/territory/region/country)

Percentage of schools that offer physical activity opportunities (excluding PE) to the majority (>80%) of their students

Percentage of parents who report their children and youth have access to physical activity opportunities at school in addition to PE classes

Percentage of schools with students who have regular access to facilities and equipment that support physical activity (e. g., gymnasium, outdoor playgrounds, sporting fields, multi-purpose space for physical activity, equipment in good condition)

Community and environment

Any policies or organizational factors (e. g., infrastructure, accountability for policy implementation) in the municipal environment that can influence the physical activity opportunities and participation of children and youth in this environment

Percentage of children or parents who perceive their community/municipality is doing a good job at promoting physical activity (e. g., variety, location, cost, quality)

B+

*

Most cities and communities provide good infrastructures facilitating daily physical activity, such as bicycle lanes, inner-city roads with 30 km/h speed limit, public playgrounds, parks and soccer pitches

The majority (75%) of parents state that their children can play outside without supervision (Blinkert, Höfflin, Schmider, & Spiegel, 2015; Kimpel, 2015; Reimers et al., 2012; Reimers et al., 2014)

Percentage of communities/municipalities that report they have policies promoting physical activity

Percentage of communities/municipalities that report they have infrastructure (e. g., sidewalks, trails, paths, bike lanes) specifically geared toward promoting physical activity

Percentage of children or parents who report having facilities, programs, parks and playgrounds available to them in their community

Percentage of children or parents who report living in a safe neighbourhood where they can be physically active

Percentage of children or parents who report having well maintained facilities, parks and playgrounds in their community that are safe to use

Government

Any governmental body with authority to influence physical activity opportunities or participation of children and youth through policy, legislation or regulation

Evidence of leadership in and commitment to providing physical activity opportunities for all children and youth. Allocated funds and resources for the implementation of physical activity promotion strategies and initiatives for all children and youth. Demonstrated progress through the key stages of public policy making (i. e., policy agenda, policy formation, policy implementation, policy evaluation and decisions about the future)

INC

Many interventions exist and have been implemented to promote physical activity in children and adolescents. However, there are very few standardized government policies and their implementation and effectiveness have not been evaluated as yet

aSee also Table 1 for the grading scheme

b“1 Star = substantial concerns”, “2 stars = some concerns” and “3 stars = minimal concerns”

MVPA moderate- to vigorous-intensity physical activity, PE physical education

The country Report Card grades were submitted along with a rationale explaining the given grade and were audited by members of the AHKGA Executive Committee to ensure that the grades were consistent with the benchmarks and grading scheme used by all 49 countries participating in the Global Matrix 3 (https://www.activehealthykids.org/). The audit process led to minor changes of the grades or rationale (Aubert et al., 2018a).

Confidence rating

The AHKG also graded the confidence they had in the data supporting the indicator grades assigned on a 1-, 2‑, and 3‑star (“1 = substantial concerns”, “2 = some concerns” and “3 = minimal concerns”) scale based on the recommendations of the AHKGA. Each confidence rating reflects how representative and robust the data are. The data are rated as representative based on year of data collection (not later than 2008), the reach of the sample (e. g., whether data were collected regionally or across Germany) and sampling frame/procedure (e. g., randomly). The data were rated as robust based on whether they were objective vs. subjective and reliability and validity values of the data. Similar to the grading process, the AHKG reached consensus regarding the confidence rating given to each indicator based on a discussion during the expert workshop.

Results

The average grade of the German Report Card was “C” and Germany was ranked number 17 when compared with the other 48 countries participating in the Global Matrix 3.0 (Aubert et al., 2018a). Table 2 contains the ten indicators, the corresponding grades and the confidence ratings assigned, while Table 3 shows the studies from which the data were drawn to inform the grades. Fig. 2 presents the front cover of the German Report Card.
Table 3

Surveys used to inform each of the grades assigned to each indicator of the 2018 Activity Report Card

Survey

Data assessment method

Age

N

Indicator(s) no.

KiGGS Study Baseline (2003–2006)

MoMo Modul

Nationally representative

Survey specific questionnaire (MoMo-PAQ)

4–17 Years old

14,712 (KiGGS)

4528 (MoMo)

2, 3, 4, 7, 8

KiGGS Wave 1 (2009–2012)

Nationally representative

Survey specific questionnaire (MoMo-PAQ)

Parent report up to 11 years and self-report from the age of 11 years

4–17 Years old

10,063 (KiGGS)

3994 (MoMo)

1, 2, 5

KiGGS Wave 2 (2014–2017)

Nationally representative

Survey specific questionnaire (MoMo-PAQ and accelerometry: Actigraph GT3X+)

4–17 Years old

15,023 (KiGGS)

1

HBSC Study (2013/2014)

Nationally representative

HBSC questionnaire

11-, 13-, and 15-year-olds

5961

1, 2, 5

GINI Study (1995–2015)

Regionally representative (Wesel and Munich)

Accelerometer data (ActiGraph GT3X, hip worn for 7 consecutive days) analyzed with Freedson’s cut-off points

Mean age 15.6 years

1054

1, 5

MAAS Kids-Study (2011)

Regionally representative

Pedometers data (StepWatch 3™ System worn for 7 consecutive days)

School class 1, 3, 5, 9 and 11

1020

1, 2, 3

Bestandserhebung Deutscher Olympischer Sportbund (DOSB)—2017

Nationally representative

Membership data 2016

0–18 Years old

14,198,848

2

Mobility in Germany (2008)

Nationally representative

Survey specific questionnaire

Ca. 25,000 households

4

IDEFICS

Regionally representative

Accelerometer data (ActiGraph GT1M, hip-worn for at least 3 consecutive days) analyzed with Evenson cut-off points

2–10.9 Years old

516

5

Huber and Köppel ( 2017 )

Regionally representative

Survey specific questionnaire

4–20 Years old

4385 (Germany, Luxemburg and Austria)

5

Fit for Pisa Project (2008)

Regionally representative

Survey specific questionnaire

Mean age 11.0 ± 0.6 years

737

7

Elephant Child Health Study (Elefanten-Kindergesundheitsstudie) (2011/2012)

Nationally representative

Survey specific questionnaire

School class 2 and 3

4691

8

Cooperation between Sports Clubs and Schools (Kooperation Sportverein und Ganztagsschule) (2012/2013)

Regionally representative

Survey specific questionnaire

1573 Sport clubs

8

Space for Child ’s Play (Raum für Kinderspiel) (2015)

Regionally representative

Survey specific questionnaire

5003 Parents

9

GINI The German Infant Study on the Influence of Nutrition Intervention, KiGGS German National Health Interview and Examination Survey for Children and Adolescents (Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland), MoMo Motor Module Study (Motorik-Modul-Studie), HBSC Health Behaviour in School-Aged Children, MAAS Münster Everyday Activity Studies (Münster Alltags Aktivitäts Studien) IDEFICS identification and prevention of dietary- and lifestyle-induced health effects in children and infants

Fig. 2

Germany’s 2018 Report Card cover (https://www.activehealthykids.org/germany/)

Daily behaviours

For the category of daily behaviours, all indicators could be graded with a degree of confidence ranging between one and three stars based on a combination of the availability of a recommendation and the benchmark of the proportion of children and adolescents meeting the guideline. Overall physical activity was assigned a D− and the key health behaviours active play and sedentary behaviour were also graded with a D−. Active transportation received a C− and organised sport participation a B.

Overall physical activity

The grade D− was assigned to overall physical activity and was based on several surveys in Germany. Self-report data from the population-based German National Health Interview and Examination Survey for Children and Adolescents (Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland, KiGGS) Wave 1 (2009–2012) and the in-depth German Motor Module Study (Motorik-Modul-Studie, MoMo) showed that in the ages between 4 and 17 years 29.4% of boys and 25.4% of girls met the WHO recommendations of 60 min MVPA per day. In the age group of 14- to 17-year-olds only 15% of boys and 8% of girls met the WHO recommendations (Manz et al., 2014). In the KiGGS Wave 2 (2014–2017) 22.4% of girls and 29.4% of boys between 3 and 17 years met the WHO recommendations (Finger et al., 2018). The data obtained for 11–15 year olds from the national German Health Behaviour in School-Aged Children (HBSC) survey (2013/14) based on a questionnaire are somewhat lower: 12% of girls and 19.1% of boys are physically active in a moderate to vigorous intensity for 60 min or more per day. The differences between girls and boys are significant and MVPA levels decreased with increasing age with 8.8% of 15-year-old girls and 16.1% of 15-year-old boys reaching the recommendations (Bucksch, Finne, Glücks, & Kolip, 2012; Bucksch et al., 2014; Sudeck, Bucksch, & Finne, 2016).

Accelerometer data regarding the overall physical activity levels were assessed in the regional (South-East) GINI (The German Infant Study on the Influence of Nutrition Intervention) (1995–2015) study and showed that 17% of girls and 25% of boys accumulated 60 min or more of MVPA (Helmholtz Zentrum München Deutsches Forschungszentrum für Gesundheit und Umwelt, 2017; Smith et al., 2016). The difference between girls and boys was statistically significant. In the regional (North Germany) identification and prevention of dietary- and lifestyle-induced health effects in children and infants (IDEFICS) study (2007/2008 and 2010/2011), physical activity data were also assessed with accelerometers and showed that less girls met the WHO recommendations (14%) compared to boys (33.3%) (Konstabel et al., 2014). Finally, the regional (North-West Germany) Münster Everyday Activity Studies (MAAS Kids Study; 2005–2008) measured physical activity using pedometers and showed that on average girls in the first grade (around 7 years old) exhibit 55.7 min MVPA per day and in grade 11 (about 17 years old) 48.1 min per day. Boys are physically active for around 10 min longer per day than girls (Uhlenbrock, 2011).

Summing up the findings of the different studies, national data show that only about 20% of girls and boys accumulate at least 60 min of MVPA per day. The percentages of girls and boys meeting the WHO recommendations vary slightly between study populations and type of measurement (self-report/device based). Recommendation compliance is lower in older compared to younger age groups and among girls compared to boys. A confidence rating of two stars was given to this indicator as there were some concerns regarding the robustness of the data, since no national accelerometer based data on physical activity levels have been available up to now.

Organised sport participation

The grade B was given to the indicator of organised sport participation. Data from the KiGGS and MoMo Study Wave 1 showed that in the age between 7–10 years 64.6% of girls and 73.5% of boys are physically active in sports clubs. In the age between 11 and 13 years 60.3% of girls and 65.9% of boys are active and in 14- to 17-year-old adolescents 49.4% of girls and 61.9% of boys are active in sports clubs (Manz et al., 2014; Schmidt et al., 2017; Schmidt et al., 2016b). Socio-economic status plays a central role regarding membership in sports clubs. Overall in the age between 6–17 years 48.6% of children and adolescents with a low social status, 62.3% with a middle socio-economic and 76.6% with a high socio-economic status are members in sports clubs (Will et al., 2016). Data from the German Olympic Sports Confederation (Deutscher Olympischer Sportbund, DOSB), which is the non-governmental umbrella organization of German sport associations, showed that 61% of girls and 80.9% of boys in the age between 7 and 14 years are members in sports clubs. In the ages between 15 and 18, 46.8% of girls and 65% of boys are members in sports clubs (Deutscher Olympischer Sportbund, 2017). Similar percentages were confirmed in many other studies (Burrmann et al., 2016; Grgic et al., 2013; Mutz & Burrmann, 2015; Uhlenbrock, 2011). To conclude, national data show that—compared to other European countries—a remarkable percentage of children and adolescents are members in sports clubs (approximately 70%) (Breuer, Feiler, Llopis-Goig, & Elmose-Østerlund, 2017). The membership decreases slightly with rising age and girls are less often members in a sports club in comparison to boys (Schmidt et al., 2017). The AHKG assigned this indicator with three stars as the data are representative and robust, since the surveys are based on national representative samples and come to similar results regarding children’s and adolescents’ organised sport participation.

Active play

The grade D− was given to the indicator active play. Data from the MoMo Study showed that boys spend 68.1 and girls 55.9 min per week in unorganised sport activity. Girls and boys report playing outside on average on 4 days per week (Schmidt et al., 2017). The German Childhood, Internet, Media (Kindheit, Internet, Medien, KIM) Study showed that in 2016 49% of children played outside “almost everyday” (Feierabend et al., 2017). Overall, less than 25% of children and adolescents play actively for several hours per day. More children than adolescents actively play and slightly more girls than boys engage in active play. The AHKG graded this indicator with one star as substantial concerns exist regarding the representativeness and the robustness of the available data. Additionally, the studies in Germany do not assess precisely the entire spectrum of active play and only refer to specific aspects of it.

Active transport

The grade C− was given to the indicator active transport. Based on the data of the MoMo Study, 22.1% of girls and 16.8% of boys walk to school and 20.6% of girls and 23.8% of boys cycle to school. Girls walk to school more often and boys cycle to school slightly more often (Reimers et al., 2013). Based on data from the German Federal Ministry for Transport and Digital Infrastructure (Bundesministerium für Verkehr und digitale Infrastruktur), 17% of students cycle and 26% walk to school and back home. In the ages between 7 and 10 years, 35% of students walk and 11% use a bicycle. In the age group of 11–13 years, 23% walk and 14% cycle to school. Finally, in the age group 14–17 years, 22% walk and 21% cycle to school (Bundesministerium für Verkehr und digitale Infrastruktur, 2017; Deutsches Institut für Urbanistik gGmbH & Bundesministerium für Verkehr und digitale Infrastruktur, 2014). Overall, approximately 40% of children and adolescents actively commute to school and back home. The AHKG assigned this indicator with two stars indicating some concerns regarding the representativeness of the data as only active transport to school was observed.

Sedentary behaviours

The grade D− was given to the indicator sedentary behaviours. Sedentary behaviours are characterized by an energy expenditure of 1–1.5 metabolic equivalents, while in a sitting, reclining or lying posture (Table 2). In research, studies assessing sedentary time either assessed the overall time spent sedentary or explicitly measured screen related pursuits such as watching TV, playing video games or using the PC during recreational time. The German recommendations regarding sedentary behaviour state that 6‑ to 11-year-olds should gather no more than 60 min of recreational screen time per day and adolescents aged 12–18 years no more than 2 h per day (Rütten & Pfeifer, 2016). Based on accelerometer data of the IDEFICS study, boys and girls spend on average 5 h and 40 min in a sedentary position per day. A total of 12.4% and 8.1% of boys and girls, respectively, exhibit more than 2 h of screen time during weekdays and 28.8 and 22.1% of boys and girls during weekends (Konstabel et al., 2014; Santaliestra-Pasías et al., 2014). In the GINI study, accelerometer data showed that the children and adolescents spend roughly two thirds of their waking time in a sedentary position (Smith et al., 2016). Self-report data from the HBSC study in Germany show that 60.4% of boys and 55.6% of girls spend more than 2 h per day watching TV (Bucksch et al., 2014). Even higher values are reported in the KiGGS Wave 1 study where 72.3% of boys and 57.8% of girls reported spending more than 2 h per day with electronic media use (Manz et al., 2014). Based on self-report data, Huber and Köppel (2017) showed that the average sitting time of children and adolescents is 10.58 h (standard deviation [SD] = 2.68) per weekday and 7.52 h (SD = 2.20) per weekend day, which means that 71% of the time spent awake on working days and 54% on weekend days is sedentary. Additionally, the authors confirmed that school-related sitting is dominant. To conclude, about 40% of children and adolescents spend more than 2 h per day watching TV or using other screen devises. When considering the overall amount of time spent sedentary, it is shown that children and adolescents spend about 70% of their waking time in a sedentary position. The results range across studies depending on the measurement instrument (self-report or device-based) and the type of behaviour in focus (screen-based/total sedentary behaviour) (Bucksch et al., 2014; Konstabel et al., 2014). Different studies showed that screen time cannot be used as a proxy for overall sedentary time (Klitsie et al., 2013). The confidence rating the AHKG assigned to this indicator was one star indicating substantial concerns regarding the robustness of the data, since the measurement instruments used to assess sedentary time were not specifically designed for this aim and usually only screen time was considered and not the overall sedentary time.

Individual characteristics

Physical fitness

The grade INC was given to the indicator physical fitness. Although there are many studies assessing children’s and youth’s physical fitness in Germany (Albrecht et al., 2016; Golle, Muehlbauer, Wick, & Granacher, 2015; Krug, Jekauc, Poethko-Muller, Woll, & Schlaud, 2012; Spengler, Rabel, Kuritz, & Mess, 2017), no overall data aggregation and analysis has been carried out according to the AHKGA benchmarks. The current research landscape is characterised by inconsistent and at times contradictory results. Therefore, initiatives trying to make these data comparable are planned and will be integrated in the next Report Card (Albrecht, Schlenker, Woll, & Bös, 2014).

Settings and sources of influence

For the category settings and sources of influence, good grades ranging between B− regarding the indicator family and peers and B+ for the indicators school and community and environment were assigned. Nevertheless, the degree of confidence while assigning these grades was comparatively low.

Family and peers

The grade B− was given to the indicator family and peers. Maternal and paternal weekly sport participation was assessed through child reports and it was shown that 66% of parents are regularly physically active (Schoeppe et al., 2016). Furthermore, 60% of children feel that they receive positive support from their parents and friends to be physically active (Reimers et al., 2012). The B− grade for Family and Peer Influence on Physical Activity Behaviours and Outcomes indicates that German children and adolescents develop in an environment that is favourable to physical activity and health. Data on peer influence on physical activity and sedentary behaviour were not available and, as such, could not be used to inform the grade. The confidence rating the AHKG assigned to this indicator was one star indicating substantial concerns regarding the representativeness and robustness of the data. There were only two studies to inform the grade and they provided data regarding only very specific aspects of the indicator.

School

The grade B+ was given to the indicator school. As part of the curriculum, physical education is mandatory in all school types independent of students’ class level. In primary schools, only about half (49%) of the physical education teachers have university qualifications to teach physical education, whereas in secondary schools nearly all teachers (89%–98% depending on school type) are professionally educated physical education teachers. All schools provide some kind of sports facilities to carry out physical education classes, whereas access to swimming pools for physical education was lower (ca. 70%). Despite the fact that swimming education is mandatory in the German curriculum, this lack of swimming facilities results in the following numbers: 20% of all primary students and between 46% and 21%—depending on school type—of all secondary school students do not receive swimming lessons in physical education (Deutscher Olympischer Sportbund, 2006). In all, 17.9% of sport clubs provide physical activity opportunities for children during school hours and thus collaborate with schools (Süßenbach & Geis, 2014). Altogether 60% of students state that they receive a lot of information regarding health in school, 20% state that they receive medium amount of information and 20% state that they do not get any information (Beisenkamp et al., 2012). The confidence rating the AHKG assigned to this indicator was two stars as the results are robust and representative for Germany. Nevertheless, the main study source to inform the grade is based on 2006 and therefore has some limitations regarding the representativeness of today’s situation in German schools.

Community and environment

The grade B+ was given to the indicator community and environment. Most cities and communities in Germany provide good infrastructures facilitating daily physical activity, such as bicycle lanes, inner-city roads with 30 km/h speed limit, public playgrounds, parks and soccer pitches. The majority (75%) of parents state that their children may play outside without supervision (Blinkert et al., 2015). In a similar way, Kimpel (2015) showed that 78% of children play outside without supervision and 50% of children live in a neighbourhood that facilitates active play outside. Additionally, it was shown that the distance to the next sport facilities was on average 1.26 km and to the next swimming pool 4.12 km (Reimers et al., 2014). The confidence rating the AHKG assigned to this indicator was one star as the results are mostly based on regional studies in Germany and not all benchmarks of this indicator were addressed in the surveys to inform the grade.

The B+ grade for the indicator community and the environment suggests that children and youth from Germany have high levels of perceived safety as well as access to and availability of space for physical activity. Given the seemingly favourable environment for physical activity, future research should identify reasons and underlying mechanisms of low levels of physical activity and of high levels of recreational screen time.

Strategies and investment

The indicator strategies and investments referring to national policy was given an “inconclusive”. Many interventions exist and have been implemented to promote physical activity in children and youth in Germany. However, there are very few standardized government policies and their implementation and effectiveness have not been evaluated as yet.

The grade INC was given to the indicator government. Many interventions at the national, regional and local level exist and have been implemented to promote physical activity in children and youth. There are also several policies such as INFORM, the German recommendations for physical activity (Rütten & Pfeifer, 2016), “National Health Targets—Grow up Healthy” and “National Cycling Plan 2020, joining forces to evolve cycling”. However, grading this indicator was difficult due to a lack of independent evaluation of these strategies and the policies that are currently in place. Thus, the authors do not know how successful such policies are in terms of promoting physical activity participation among children and youth. To close this knowledge gap, the Joint Programming Initiative on a Healthy Diet for a Healthy Life (JPI HDHL) established the Policy Evaluation Network (PEN), starting in 2019. PEN’s vision is to provide Europe with tools to identify, evaluate and benchmark policies designed to directly or indirectly address physical inactivity, sedentary behaviour and unhealthy diets. PEN will examine content, implementation and impact of lifestyle policies across Europe and thus facilitate grading this indicator accordingly.

Discussion

Germany’s 2018 Report Card on Physical Activity for Children and Youth is the first of its kind for Germany. The AHKG assigned good grades for Germany for most indicators relating to setting and sources of influence. Nevertheless, most children and youth in Germany failed to meet the WHO recommendation for physical activity and engaged in high levels of sedentary behaviours despite favourable conditions within relevant settings (Bucksch et al., 2014; Finger et al., 2018; Schmidt et al., 2017). Therefore, we assigned poor grades for most behavioural indicators with the exception of organized sport participation. For the indicators physical fitness and government we assigned an incomplete grade due to the lacking overall analysis of the existing data and policies.

Based on an international comparison with 48 countries, Germany reached rank 17. Overall, in countries with very high human development indexes, such as Germany, the Netherlands and England, lower behavioural grades and higher source of influence grades were observed. In contrast, higher behavioural grades and lower source of influence grades were generally observed in the low and medium human development index countries such as Nepal and Zimbabwe. This may be associated with low automobile dependency and minimal opportunities as well as access to screen-based recreational sedentary pursuits such as television, computer and internet time (Aubert et al., 2018a).

The aim of Germany’s 2018 Report Card on Physical Activity for Children and Youth is to inform a broad audience including stakeholders from the field of public health, sports and education such as school directors, teachers, parents, coaches and government ministers about the state of the nation regarding physical activity and sedentary behaviours of children and adolescents. Only based on adequate information can transport programmes and adequate policies be developed to enhance the levels of physical activity in children and adolescents.

Strengths and limitations

Germany’s 2018 Report Card has a number of strengths: It is the only report of its kind available for Germany that includes an overall assessment of multiple types of physical activity behaviours, determinants, settings and governmental conditions among children and adolescents. The Report Card initiative is driven by a strong AHKG that comprised a number of experts in the field of children’s and adolescents’ physical activity, fitness and health from Germany. The 2018 grades are based on the most suitable data and provide a national snapshot of how young Germans are faring with regard to their physical activity levels. Furthermore, it is a useful resource that can be used by a number of people, including public health stakeholders such as teachers, parents and others that have an influence on children’s and adolescents’ physical activity levels. It can also be used to inform the development of interventions, policies and research projects, as well as to guide research funding priorities. Furthermore, it provides the possibility for a comparison with the other 48 countries worldwide participating in the Global Matrix 3.0. This comparison can lead to a better understanding of the strengths and weaknesses of Germany as a nation in promoting physical activity (Aubert et al., 2018a, 2018b).

Despite these strengths, some limitations should be highlighted. The German Report Card is a review that constitutes the combined insights and knowledgebase of the AHKG. Thus, the grading is markedly influenced by the participants’ scientific knowledge and experience. Additionally, there may be some publication bias, since studies with favourable results are more often published and the AHKG did not have access to all unpublished data in Germany.

The Report Card points to possible methodological problems related to both self-reported and device-based measures of physical activity. Self-reported measures are influenced by limited memory of the intensity and the amount of physical activity in children or their parents. In terms of the interpretation of accelerometer measures, the choice of cut-points is crucial and accelerometers tend to underestimate physical activity levels (Gába, Dygrýn, Mitáš, Jakubec, & Frömel, 2016; Hansen et al., 2014). Sedentary behaviours are often measured based on data regarding screen time. Other sources of sedentary time are often not taken into account. Thus, the time spent in sedentary activities might be underestimated at the time (Klitsie et al., 2013). In comparison to adults, children’s physical activity is not carried out during a fixed period of time but it is much rather an accumulation of short activity bouts over the entire day that might last only a couple of seconds each. This changing behaviour is very difficult to capture and is still a challenge for future research (Rowlands, Pilgrim, & Eston, 2008).

The definitions and benchmarks used to determine the grade of each indicator need to be regularly updated according to the current body of evidence. Overall, more research is needed to clarify the relevant influencing factors for each indicator and to specifically describe the independent influence of each factor in relation to others. For example, the indicator family and peers is estimated based on the percentage of family members who facilitate physical activity and sport opportunities for their children, the percentage of parents who meet the Global Recommendations on Physical Activity for Health and several other factors. Nevertheless, it remains unclear whether children with parents who facilitate physical activity will be more active or whether children with parents who are themselves physically active will be more active or if both of these factors are equally important in order to promote children’s and youth’s physical activity levels. This is an important step in order to precisely define the grade for each indicator based on the current state of research in each country. In a similar way, the indicator active play is difficult to capture and further studies are needed to define what influences active play and how it can be adequately measured and thus promoted in intervention programmes. The wording “play” used to assess the data regarding this indicator might not be adequate to capture this indicator in adolescents.

Socio-economic status and sex/gender are two important variables that influence physical activity levels and sedentary behaviour in children and adolescents and are often a source of inequality. These factors are not yet systematically taken into account when preparing the results of the Report Card. For example, regarding the indicator family and peers, it has not been taken into account up to now whether children and adolescents receive the same opportunities to participate in physical activity independent of their socio-economic status (Mutz & Albrecht, 2017). In future studies, this should be examined in more detail and it should also be an overreaching government strategy to assure that all children and adolescents, independent of their socio-economic status or sex/gender, have the chance to receive the same opportunities in engaging in physical activity.

Conclusions

This Report Card is a vehicle to promote physical activity and reduce sedentary behaviour in children and adolescents. During the Global Matrix 3.0 the Report Cards of 49 countries worldwide will be presented and the grades given to each indicator.

The proportion of children and youth from Germany meeting the WHO recommended levels of physical activity and spending less than 2 h daily on screen time is low, even though the settings and sources of influence are favourable in promoting physical activity levels and reducing sedentary behaviour levels. Despite high membership rates in sports clubs in Germany, this alone does not appear to lead to sufficiently high physical activity levels and low levels of sedentary behaviour. The fact that there is no overall evaluated government policy to promote physical activity in children and youth underpins the need for further actions from a government perspective that facilitate physical activity and reduce sedentary behaviour and create environments that support healthy active living among children and youth in Germany. This indicates an implementation gap between the settings and sources of influence level and the individual level that needs to be bridged to increase physical activity and reduce sedentary time. Future issues of the Report Card will be useful in assessing whether this favourable policy and community/built environment have the desired impact on important health behaviours and health outcomes for children and adolescents in Germany. The Australian Report Card asked the question: “So what is holding Australian children and youth back?”. This question also needs to be answered for the German children and youth.

The conduct and the results of the German Report Card showed that more research is needed in the future in order to inform the grades of the Report Card with a high confidence rating. Regarding the indicator fitness, a systematic analysis of all studies measuring children’s and adolescents’ fitness is needed to provide a grade for this indicator and, thus, an international comparison. Finally, to what extent existing German public policies impact on physical activity—directly or indirectly—will be investigated within PEN. A policy audit of the national policies will be developed and provided for future benchmarking activities. This is a crucial element in order to achieve a cultural shift and conscious actions to ensure that a high percentage of children and young people in Germany develop the level of physical activity required to establish a healthy and active lifestyle.

Notes

Acknowledgements

Funding for Germany’s 2018 Report Card on Physical Activity for Children and Youth was provided by a grant from the Schwenninger Krankenkasse (https://www.die-schwenninger.de/), Health Worker Foundation (Stiftung Die Gesundarbeiter) and the SDK Foundation. The funding body had no role in the content of the Report Card and in the current manuscript. The media strategy for the dissemination of the Report Card was conducted in collaboration with the Schwenninger Krankenkasse. We thank Fabienne Hofmann and Frank Hauger from the Schwenninger Krankenkasse for making the AHKG Workshop as well as the print and dissemination of the Report Card possible.

Compliance with ethical guidelines

Conflict of interest

Y. Demetriou, J. Bucksch, A. Hebestreit, A. Schlund, C. Niessner, S.C. E. Schmidt, J.D. Finger, M. Mutz, K. Völker, L. Vogt, A. Woll and A.K. Reimers declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Copyright information

© Springer-Verlag GmbH Deutschland, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Sport and Health SciencesTechnical University of Munich, Uptown Munich Campus DMunichGermany
  2. 2.Faculty of Natural and Human SciencesHeidelberg University of EducationHeidelbergGermany
  3. 3.Leibniz Institute for Prevention Research and Epidemiology—BIPSBremenGermany
  4. 4.Institute for Sports and Sport ScienceKarlsruhe Institute of TechnologyKarlsruheGermany
  5. 5.Department of Epidemiology and Health MonitoringRobert Koch InstituteBerlinGermany
  6. 6.Department of Sports ScienceJustus-Liebig-Universität GießenGießenGermany
  7. 7.Institute of Sports ScienceGoethe University FrankfurtFrankfurtGermany
  8. 8.Institute of Sports ScienceUniversität MünsterMünsterGermany
  9. 9.Institute of Human Movement Science and Health, Faculty of Behavioral and Social SciencesChemnitz University of TechnologyChemnitzGermany

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