Active Healthy
Kids Scotland
Report Card
Detailed Methodolgy
and Findings

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CHILD’S
PLAY
2013?

Summary of Indicators and Grades from the Short Form Card3

Summary of Indicators and Grades from the Short Form Card5

The 2013 Active Healthy Kids Scotland Report Card

7

About the Active Healthy Kids Scotland Report Card 20139

Indicators and Grades

11

A Guide to the Rest of this Long Form Active Healthy Kids
Scotland 2013 Report Card12

Physical Activity and Health Behaviours and Outcomes

		

21
		

25
26

Physical Activity and Health Behaviours and Outcomes
Sedentary Behaviour(Including recreational screen time, TV viewing, gaming, internet use)
The Scottish Intercollegiate Guidelines Network recommends that schoolage children and adolescents should spend no more than 2 hours per
day in recreational screen time, and this is consistent with international
recommendations.

F

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Contents

76% of Scottish 11-15 year olds report more than 2 hours per day of TV
alone. In addition, 77% of boys and 37% of girls report 2 hours per day of
gaming2010 HBSC Scotland Survey.

12

Sedentary Behaviour

13

Physical Activity

14

Active Transportation

15

Active and Outdoor Play

17

Participation in Organised Sport

18

Diet

19

Obesity

Physical Activity

Settings and Influences on Physical Activity and Health21

Family and Peer Influence

22

Community and the Built Environment

24

National Policy, Strategy, and Investment

List of Stakeholder Names and Organisations
References Cited

Abbreviations and Definitions

Among 11-15 year olds, only 19% of boys and 11% of girls2010 HBSC met the
Scottish, UK, and international recommendation of at least 60 minutes per
day of daily physical activity of at least moderate intensity.

F

Active Transportation
Multiple sources of data suggest that just over half of Scottish primary school
children regularly commute actively (walking or cycling) to school, and about
40-50% of those at secondary school regularly commute activelyScottish Health
Survey 2010; National Travel Survey 2012; Hands Up Scotland Survey 2011.

C

Active and Outdoor Play
57% of Scottish children were reported to play outdoors for at least 30
minutes for at least five times in the last week Scottish Health Survey. In the absenceof a recommendation, and given the F grades for sedentary behaviour andoverall physical activity, this is difficult to grade.

INC

Organised Sports Participation
BMI

Body mass index (calculated as weight in kg divided by height inmetres squared)

HBSC		Health Behaviour in School Age Children Survey
ISD		Information and Statistics Division of NHS Scotland

2

MVPA

Moderate-to-vigorous intensity physical activity (activities with anenergy cost at least three times the cost of resting, roughly equivalent
to brisk walking)

NHS

National Health Service

NMES

Non-Milk Extrinsic Sugars

NTS

National Travel Survey

SHS

Scottish Household Survey

SHeS

Scottish Health Survey

SIGN

Scottish Intercollegiate Guidelines Network

INC

Diet
Sugar* intake should not exceed 11% of energy intakeScottish Dietary Target for Children. Sugar intake reached 15% of energy intake in 3-7 year olds, 16% in 8-11
year olds, and 17% in 12-16 year olds, increasing with increasing levels ofdeprivation.Survey of Diet Among Children in Scotland 2010Children and adolescents typically had 2 –3 portions of fruit and vegetables
per day, and only 14% met the ‘5 a day’ recommendationScottish Health Survey 2011.
Fruit and vegetable intake was lowest among more deprived children andadolescentsSurvey of Diet Among Children in Scotland 2010.

D-

Average intake of saturated fat (13%) exceeded the 11% of energy intake
recommended; average total fat intake as was 33% of energy intake which
met the recommendation to not exceed 35% of energy intakeSurveyofDiet AmongChildren in Scotland 2010.

Active Healthy Kids Scotland Report Card

* Non-Milk Extrinsic Sugars
Detailed Methodology and Findings

3

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GUS		Growing Up in Scotland

Participation in sport at least once in the previous week was reported for
69% of 2-15 year oldsScottish Health Survey data aggregated to 2011. In the absence of arecommendation, and given the F grades for sedentary behaviour andphysical activity, this is difficult to grade.

Summary of Indicators and Grades from the Short Form Card

The 2013 Active Healthy Kids Scotland Report Card

Physical Activity and Health Behaviours and Outcomes

Authors and Contributors

Obesity

The 2013 Active Healthy Kids Scotland Report Card
was produced by a working group from the Universityof Strathclyde (Prof John J Reilly), University ofAberdeen (Prof Geraldine McNeill, Dr Smita Dick),and the Children’s Hospital of Eastern Ontario Healthy
Active Living and Obesity Research Institute (Prof MarkS Tremblay).

F-

The working group was advised by a steering group(Dr Julie Armstrong, Glasgow Caledonian University;
Dr Tim Lobstein, International Obesity Task Force,
Members of the Obesity Working Group of the Scottish
School of Public Health Research). A much larger
group of stakeholders provided information on sourcesof Scottish data, and commented on early drafts of theReport Card at a meeting in Glasgow on 4th June 2013,
and as part of an online consultation in June and July
2013. A full list of stakeholders is provided on page 25.

Settings and Influences on Physical Activity and HealthFamily and Peer Influence
48% of adult men and 33% of adult women reported meeting the physicalactivity recommendation of 5 x 30 minutes of moderate-vigorous intensity
physical activity per weekScottish Health Survey 2011.
More than 28% of adults were obese and 64% either overweight or obese in
2011Scottish Health Survey 2011.

DFunding

Only 22% of Scottish adults reported meeting the ‘5 a day’ fruit andvegetable intake recommendation in 2011Scottish Health Survey 2011, fruit andvegetable consumption is lower in the more deprived, and purchasing may
have been declining recentlyLiving Cost and Food Surveys.

Production of this report card was possible
with a Knowledge Exchange Grant fromthe Scottish Universities Insight Institute(www.scottishinsight.ac.uk). The funding
body had no role in the development of the card, or in the content orpresentation of the card. The authors of the card have no conflicts ofinterest to declare.

Community and the Built Environment(Perceived safety, access, and availability of space for physical activity)

77-81% of Scottish adolescents felt that it was ‘always safe for children toplay outside’ and 51% agreed that they ‘always felt safe locally’2010 HBSC Scotland
Survey.

B

Access to the Card, Reproduction of the Card
The 2013 Report Card, in both long-form and short form, is available forreproduction provided the following copyright information is included:

88% of parents of under 5 year olds reported having access to a park or playarea locallyGrowing Up in Scotland and 40-50% of households reported having accessto a park or play area locally.

Information has been provided from The 2013 Active Healthy Kids
Scotland Report Card, with permission from Active Healthy Kids
Scotland (www.activehealthykidsscotland.co.uk)
Please use the following citation:

National Policy, Strategy, and Investment(Including Schools)

Physical activity and health is given great emphasis in national policy,
strategy, and investmentwww,scotland.gov.uk.
Many of the Health Behaviours and Outcomes graded in the first section ofthis card are the focus of national policies, investments and/or targets for
improvement.

The 2013 Active Healthy Kids Scotland Report Card. Glasgow: Active
Healthy Kids Scotland (www.activehealthykidsscotland.co.uk).

B

An academic publication describing the 2013 Active Healthy Kids
Report Card will be submitted to the Journal of Physical Activity &Health in 2013.
Future Cards
The 2013 Active Healthy Kids Scotland Report Card was inspired by
the Active Healthy Kids Canada Report Card, and joins an emerging

4

Active Healthy Kids Scotland Report Card

Detailed Methodology and Findings

5

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77% of parents of 5 year olds agreed or strongly agreed that local outdoor
space was safe for their childrenGrowing Up in Scotland.

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Multiple data sources suggest that levels of obesity among children andadolescents are higher than at any time in our history. Obesity prevalence
among children and adolescents has more than trebled since 1990, andobesity is more common among the more deprivedScottish Health Survey 2011.

international network of Active Healthy Kids Report Cards (www.
activehealthykids.ca).
The 2013 first Scottish card should not also be the last card:
In May 2014 Scottish data will be reported in the context of the otherinternational cards, permitting international comparisons.

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We aim to use the Scottish Report Card, now and in future, to engage
Scottish children and adolescents in physical activity, and in doing so
to improve their health, wellbeing, and academic attainment.

Specifically, we aim to:• critically assess the ‘state of the nation’ for physical activity andhealth among children and adolescents;• identify important gaps in our knowledge;• provide direction as to how to increase physical activity among
Scottish children and adolescents;• present the physical activity and health of Scottish children andadolescents in an international context;• determine whether the problem of low physical activity amongchildren and adolescents is improving.

6

Active Healthy Kids Scotland Report Card

Detailed Methodology and Findings

7

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Active Healthy Kids Scotland was established in 2013 with funding
for a 7 month period to produce this, the first Active Healthy Kids
Scotland Report Card.

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In May 2015 we plan to publish the second Active Healthy Kids
Scotland Report Card. To do so will require further funding, and if
you are interested in providing funding for the production of future
cards, or in joining the team to develop future cards, please contact
Professor John J Reilly (john.j.reilly@strath.ac.uk).

About the Active Healthy Kids Scotland Report Card 2013

About the Active Healthy Kids Scotland Report Card 2013
GradesThis Active Healthy Kids Report Card was inspired by the Canadianexample (www.activehealthykids.ca) which has been publishedannually for the last 9 years.

Common to all report cards are the grades. This first Scottish Report
Card 2013 assigns grades to 10 indicators grouped into 2 categories(see below).

Active Healthy Kids Report Cards have been influential in a numberof countries (e.g. Canada, the USA, Mexico, South Africa, Kenya),by providing an assessment of the ‘state of the nation’, identifying
knowledge gaps in each country, advocating for improvements in theassessment of the state of the nation (‘public health surveillance’),and suggesting solutions to the problem of low physical activity
among children and adolescents. The knowledge shared by the
Active Healthy Kids Report Cards has helped stakeholders build
better programmes and policies to address low physical activity inother countries, and it is our intention that Scottish Report Cards will
be used for this purpose.

The card grades are based on an assessment of current Scottish data
for each indicator, judged against a benchmark (an evidence-based
recommendation where this is available). Nationally representative
Scottish data were used where possible, as this is a national reportcard. Grades were determined by the percentage of Scottish children
and adolescents meeting the benchmark, using the Active Healthy
Kids Canada Grading System1,2 as follows.

Stages of Work
This first Active Healthy Kids Scotland Report Card is based on six
stages of work.

2. Critical assessment of
the information obtainedby adopting the methods
used for the CanadianCard.1,2

3. Summarising theinformation synthesis
and critique in a form
(The Short Form Card)
accessible to children
and adolescents and theirfamilies, media, national
and local government,
non-governmentalorganisations, health andeducational professionals,
and researchers.

C

We are succeeding with about half of children and adolescents (4059%)

F

We are succeeding with very few children and adolescents (0-19%).

B

We are succeeding with well over half of children and adolescents(60-79%).

D

We are succeeding with less than half of our children andadolescents (20-39%)

INC or were inadequate to assign a grade.

(Incomplete Grade). Where current Scottish data were not available,

Report Card Grades also contain important information, where it isavailable, about trends over time and the presence of inequalities(e.g. by age, gender, ethnicity, or socio-economic deprivation).
Grades are assigned a ‘+’ if trends are improving or if there is nomarked inequality, and assigned a ‘–‘ if they are getting worse or if
there is marked inequality.

4. Describing further
details on the process andmethodology in this, theLong Form Scottish Report
card.

8

5. Comparing the ‘state of
the nation’ in Scotland withthat of the other nationsin the Active Healthy
Kids Network (www.
activehealthykids.ca),
starting in 2014.

6. Identifying partners to
help produce, and help
fund, future Active Healthy
Kids Scotland Report
Cards, from 2015.

Active Healthy Kids Scotland Report Card

The grades provide a robust assessment of the ‘state of the nation’, i.e. how
we are doing as a country in promoting physical activity and health amongchildren and adolescents in Scotland.

Detailed Methodology and Findings

9

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1.Identification andsynthesis of a large
number and wide range ofsources of information on
the physical activity andhealth of Scottish children
and adolescents.

A

We are succeeding with a large majority of children and adolescents(80-100%)

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Inspiration

Indicators and GradesIndicators and Grades

A Guide to the Rest of this Long Form Active Healthy Kids Scotland
2013 Report Card

The 10 health indicators are grouped into 2 categories:
Summary
For each of the 10 health indicators, in the two categories summarised
below, a summary of the process by which sources of data wereidentified, and grades assigned, is given below. For each indicator theformat is as follows:

1 Sedentary Behaviour•

The grade assigned in the 2013 card.

2 Physical Activity•

The appropriate benchmark (evidence-based recommendation),where this is available.

3 Active Transportation•		The Scottish data sources considered, and the rationale for choiceof data used to inform the 2013 card and assign the grade for eachindicator.
•

4 Active and Outdoor Play•		Information considered when assigning the grade, informed by theexpertise of the working group, steering group and stakeholders, andinformed by systematic reviews of the relevant scientific literature
where these were available.

5 Organised Sport Participation

6 DietInformation common to all of the health indicators in the card:•

7 Obesity

Settings and Influences on
Physical Activity and Health

Probability and direction of bias in the measure used for eachindicator (is the actual health behaviour or health outcome better orworse than is suggested by the data used to inform the grade, i.e.
are we likely to be overestimating or underestimating the scale of the
problem in this card?);

Phy

8, 9

1-7

Ph

ys

iou

ic al

r s a nd Outcom

A c t i v it y a n d Htheal

10 National Policy, Strategy, and Investment

10

Active Healthy Kids Scotland Report Card

Are trend data available now,or likely to be available in the
future?;•Are data on inequalities available
now, or likely to be available in
the future?;•

What are the major gaps in our
knowledge in Scotland?;•

Recommendations for improving
the measurement of thatindicator in future;•

Brief recommendations for
improving the grade in future.

es

av

h

9 Community and the Built Environment

& 10

•

Detailed Methodology and Findings

11

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8 Family And Peer Influencethaland Influence
so
ings
t
t
n
Se
i
t
v
y
i
t
and
c
A
l
a
He
sic

Be

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Reasons for including or excluding data.

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Physical Activity and Health Behaviours
and OutcomesPhysical Activity and Health Behaviours and Outcomes

Sedentary Behaviour

How to improve the grade in future•

Few Scottish 11-15 year olds meet the recommendation for screen
time.

•

76% report more than 2 hours per day of TV alone30.

•

In addition, 77% of boys and 37% of girls report 2 hours per day of
gaming3.

Recommendation or benchmark
SIGN Guidelines (SIGN www.sign.ac.uk) recommend that school-age children andadolescents should spend no more than 2 hours per day/14 hours per week inrecreational screen time4, largely on the grounds that this would be helpful in obesity
prevention and management. The SIGN recommendation is the same as many otherinternational recommendations.
Main data sources considered
The Health Behaviour in School-Aged Children survey3 provides self-reported
recreational screen time in 11, 13 and 15 year olds. GUS5 has some parent-reported
data for younger children, and some data are available in Scottish dietary surveys.

The majority of Scottish children and adolescents need to make substantial
reductions to their recreational screen time.
Awareness of the importance of reducing sedentary behaviour for health islimited among the public, and among health and educational professionals andpolicymakers. Raising awareness of the importance of screen time, non-screen
sedentary behaviour, and sitting time and sitting fragmentation is an essential first
step.
SIGN Guideline 115 has valuable information on reduction in screen time4.

F

Physical Activity•

Among 11-15 year olds, only 19% of boys and 11% of girls3 met the
Scottish, UK, and international recommendation.

Reasons for choice of data source used to assign the grade

Recommendation or benchmark

Nationally representative data available.
The Scottish Health Survey6 (SHeS) has only recently started to collect screen time
data-this should be useful in future cards.

The UK Health Departments ‘Start Active Stay Active’ report10 recommends that
school-age children and adolescents achieve at least 60 minutes of physicalactivity of at least moderate intensity every day. For pre-school children therecommendation is at least 3 hours of physical activity of any intensity every day.
These recommendations are consistent with international recommendations.

Likely biases in the Scottish data
A systematic review by Lubans et al7 concluded that most self and parent-reported
methods of measuring sedentary behaviour, including screen time, probably havereasonable reliability but are of unknown validity; self- and parent-proxy reports may
underestimate recreational screen time7.
Are trend data available?

Main data sources considered
The SHeS data are parent-reported and assume that all physical activity reported isof at least moderate intensity. This is unrealistic as most physical activity is usually oflight intensity9,11, so that levels of MVPA reported in the SHeS are too high12.
The HBSC uses self-reported measures of MVPA, but provides more realistic
estimates of PA levels, with some evidence of validity relative to a criterion measureof physical activity13, and so these were used in the 2013 card.

Yes, from HBSC, and GUS and SHeS in future.
Are inequality data available?

Validity of GUS data on younger children is unknown.

Yes, from all data sources referred to above.

Reasons for choice of data source used to assign the grade

Major gaps in the Scottish data/How to improve the card in future
There is a lack of accurate data from pre-adolescents.

Nationally representative data available for adolescents. The most valid data wereused, from HBSC 2010.

Data derived from objective measurement of recreational screen time would bedesirable7. Non-screen based sedentary behaviour and total time sedentary areimportant health behaviours8 which have to be measured objectively9, and are notmeasured in Scottish surveillance at present.

SHeS data overestimate MVPA, by 2 hours per day on average in one study of 6-7
year olds.12 Biases in the data used in HBSC are less marked13.

12

Detailed Methodology and Findings

Active Healthy Kids Scotland Report Card

Likely biases in the Scottish data

13

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Recent evidence from adults shows that both the time spent sitting, and the extent towhich sitting time is ‘fragmented’ (characterised by prolonged bouts or interrupted)
influence risk of later heart disease, diabetes, and premature mortality8. Sitting timeand fragmentation probably have to be measured objectively8,9, and these data are
not collected in Scottish surveillance at present.

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F

Major gaps in the Scottish data/How to improve the card in future (cont.)

Are trend data available?

Yes, from all current sources of data.

Yes, from all data sources identified.

Are inequality data available?

Are inequality data available?

Yes, from all current sources of data. However, a review of UK studies9 found thatsocio-economic inequalities in physical activity identified in studies which usedsubjective (self or parent-proxy report) methods were not real. Such inequalities havenot been present in the studies which used objective methods (e.g. accelerometry).

Yes, from all data sources identified.

Major gaps in the Scottish data/How to improve the card in future

Data sources considered active commuting among school age children andadolescents. Data on active commuting to nursery/pre-school were underrepresented.

There was a lack of accurate data for children.
Measuring habitual physical activity objectively in public health surveillance, as insome other countries1,2,14, is essential9.
The 3-hour per day recommendation for pre-school children is relatively new and noassessment of adherence to it has been made to date.
How to improve the grade in future

Active Transportation•

How to improve the data used to inform the card in future
Greater focus on pre-school children.
Greater focus on other forms of commuting transportation, not just the commute to
and from school, in future Scottish surveillance14.
How to improve the grade in future

The majority of Scottish children and adolescents need to increase their levelsof habitual physical activity through behaviours covered elsewhere in this card:
reduced sedentary behaviour; increased active play, active transportation, and sportparticipation; continued policy implementation/more effective policy implementation;
more attention to environmental influences on physical activity.

C

Multiple sources of national data suggest that just over half ofScottish primary school children regularly commute actively to school(i.e. walk or cycle), and about 40-50% of those at secondary school
regularly commute actively 3,6,15,16

Active transportation is receiving increasing policy attention (see policy section
below). Cycling is the subject of a specific Scottish government target and strategy18
The Active Healthy Kids Report Card Canada 201314 had a focus on active
transportation and contains many suggestions which should be generalisable to
Scotland.

INC•

Active and Outdoor Play
(INC, incomplete grade – available evidence and lack of a benchmark
insufficient to assign a grade)

Recommendation or benchmark

Recommendation or benchmark
There is no applicable evidence-based recommendation, but systematic reviews
consistently report a number of health benefits to active commuting, in particularincreased overall physical activity.e.g.17
Main data sources considered

There is no specific evidence-based recommendation for time spent in physically
active play and/or play outdoors, but physically active play is important to childhealth and development. Systematic reviews have found that physically active andoutdoor play contribute significantly to overall physical activity levels, particularly to
MVPA, and probably also to the reduction of sedentary behaviour19,20.

Many sources of data are available, as noted above3,6,15,16.

Main data sources considered

Reasons for choice of data source used to assign the gradeThis health indicator concerns participation in physically active play and the use ofoutdoor space for play/physical activity.

Nationally representative data are available.
The data sources identified were remarkably consistent.

The issue of access to outdoor space, and barriers to using it (e.g. perceived safety),is considered as a separate indicator, within the settings/influence domain below.

Data used were self- or parent-reported usual mode of travel to school. Biases
unclear.

The SHeS provides an estimate of participation in outdoor play: 69% of 2-15 year
olds were reported to have played outdoors in the past week in 2011; 57% werereported to have played outdoors for at least 5 occasions lasting at least 30 minutes
in the past week in 2011.

14

Detailed Methodology and Findings

Likely biases in the Scottish data

Active Healthy Kids Scotland Report Card

15

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Major gaps in the Scottish data

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Are trend data available?

Main data sources considered (cont)
The SHS21 provides data on self- and parent-reported active and outdoor play, butdata are presented in aggregated form for 8-21 year olds.GUS5 provides parentreported data on active and outdoor play among younger children, and the HBSC
20103 provides data for adolescents. Both the GUS and HBSC data show thatphysically active play and time outdoors are highly seasonal.

INC
•
		

Organised Sport Participation
Participation in sport at least once in the previous week wasreported for 69% of 2-15 year olds6. In the absence of arecommendation, and given the F grades for sedentary behaviour andphysical activity, this is difficult to grade.

Recommendation or benchmark

Nationally representative data are available.
Multiple data sources are available, but assigning a grade is problematic in theabsence of a specific recommendation for physically active or outdoor play.
Likely biases in the Scottish data
A high degree of seasonality in these behaviours means that care must be taken inassigning a grade where data are collected in summer or winter. SHeS data are freeof this bias. Biases in self- or parent-report of outdoor play are unclear.
Are trend data available?

There is no specific evidence-based recommendation for participation in organised
sports and physical activities, but these behaviours have great potential to improve
the F grades for sedentary behaviour and overall physical activity presented in thisreport card.
Main data sources considered
SHeS data were used.
SHS21 collects sports participation data every two years, but presents it aggregatedfor 8-21 year olds.
Sportscotland collects data on participation in sessions organised by Active Schools
Co-ordinators.

Yes, with all current data sources noted above.
Are inequality data available?
Yes, but note that some apparent socio-economic disparities derived from self orparent report of child physical activity are spurious and not confirmed by objective
measures9.
Major gaps in the Scottish data
Objective measurement of frequency, intensity, and duration of physically active andoutdoor play would be helpful.

Reasons for choice of data source used to assign the grade
Nationally representative data available.

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Reasons for choice of data source used to assign the grade

Only 1 source of data was available for grading, from the SHeS6 , because SHS
information included adult data.
Likely biases in the Scottish data
Biases in self- and parent-reported participation in organised sports and physicalactivity are unclear.

How to improve the data used to inform the card in future
Are trend data available?
Should be available in future from SHeS and possibly SHS.
Are inequality data available?

How to improve the grade in future

Should be available in future.

Improving the F grades for sedentary behaviour and overall physical activity in thiscard will require greater emphasis on promotion of physically active and outdoor play,
and greater use of outdoor space among older children and adolescents.

Major gaps in the Scottish data and how to improve the data used to inform thecard in future.

Parents, carers, health and educational professionals, and policy makers should
continue to be informed of the many and varied benefits of active play, and thefact that there are benefits of play which are distinct from those which arise fromorganised sports and activities.
Parents, carers and education policy makers and professionals should be awarethat not all injuries can be prevented, and most injuries which arise from active playmight be considered acceptable because they are usually unintentional and usuallyminor.10,14

Separate presentation of the child and adolescent data collected in the SHS would
be helpful.
The grade in this card was based simply on reported participation. More research
evidence on the contribution of sport and organised activities to overall MVPA andsedentary behaviour, and health outcomes (e.g. obesity) would be helpful in order todevelop a recommendation upon which a grade would be based in future cards.
How to improve the grade in future

Policies and practices which act as barriers to physically active and outdoor playshould be examined in the light of the F grades for sedentary behaviour and physicalactivity in this report card.

Coaches, teachers, and parents should consider the extent to which organised
sports and physical activities might involve more MVPA, without compromising skill
development.

16

Detailed Methodology and Findings

Active Healthy Kids Scotland Report Card17

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Click here to go to contents pageThe existence of a specific evidence-based recommendation would be helpful, but
this requires better evidence both on the accurate measurement of physically active
and outdoor play, and on the health and other benefits of physically active andoutdoor play.

How to improve the grade in future (cont)

Are trend data available?

More research evidence on how to increase participation in sport and organised
activities, and how to increase MVPA in these activities, would be helpful in order toaddress the F grades for overall physical activity and sedentary behaviour containedin this report.

Yes from SHeS. Trend data should be available from future Scottish dietary surveys.

Particular attention should be paid to sub-groups of the population characterised by
low participation/high dropout.

D-

Diet

Yes. Dietary intakes of NMES and fruit and vegetables are strongly socially patterned(less healthy intakes in children and adolescents from more deprived families).
Major gaps in the Scottish data and how to improve the data used to inform thecard in future
Current Scottish dietary data are adequate for public health surveillance and toassign a grade in this report card. Surveillance of the intakes of foods or drinks
suggested as being particularly ‘obesogenic’ from systematic reviews4,24,25 such as
sugar-sweetened beverages, would be useful.
How to improve the grade in future
Improving the diet of Scottish children and adolescents is a major policy priority for
the Scottish government – See section on National Policy, Strategy, and Investment.

•

Sugar* intake should not exceed 11% of energy intake23 . Sugar
intake reached 15% of energy intake in 3-7 year olds, 16% in 8-11
year olds, and 17% in 12-16 year olds, increasing with increasinglevels of deprivation22.

•

Children and adolescents typically had 2 –3 portions of fruitand vegetables per day, and only 14% met the ‘5 a day’recommendationScottish Health Survey 2011. Fruit and vegetable intake waslowest among more deprived children and adolescentsSurvey of Diet AmongChildren in Scotland 2010.

F-

Average intake of saturated fat (13%) exceeded the 11% of energy
intake recommended; average total fat intake as was 33% of energy
intake which met the recommendation to not exceed 35% of energy
intake22.

•

Multiple data sources suggest that levels of obesity among Scottish
children and adolescents are higher than at any time in our history.

•

Obesity prevalence among children and adolescents has more thantrebled since 1990, and obesity is more common among the moredeprived6.

•

21% of all children and adolescents had high waist circumference (ator above the 98th centile), and 31% of adolescent girls had high waist
circumference22.

•* Non-Milk Extrinsic Sugars
Recommendation or benchmark

Main data sources considered
Survey of Diet Among Children in Scotland 2010.22; SHeS6 .
Reasons for choice of data source used to assign the grade
Nationally representative data are available using accepted dietary assessment
methods.

Recommendation or benchmark
There is no specific evidence-based recommendation for the expected prevalence ofobesity, but there is an evidence based recommendation4 that prevalence estimatesshould be based on the measured body weight and height and interpreted using the
BMI for age and sex, expressed relative to reference data from the UK in 1990 (bydefinition this sets ‘expected’ prevalence of obesity at 5% in 1990 and overweight,
including obesity, at 15% in 1990).
Data sources considered

Likely biases in the Scottish data
As with all dietary data, biases in the assessment of dietary intake are likely, andthese data may underestimate the intake of NMES and fat.

SHeS6 ; GUS5 ; routinely collected Scottish NHS data collated by Information andStatistics Division26; Survey of Diet Among Scottish Children 201022
Reasons for choice of data source used to assign the grade

Since some recommendations are expressed in terms of % of dietary energy intake,adherence to one recommendation can affect another, e.g. adherence to the total fat
intake recommendation may have been achieved on average by a high NMES intake.

Nationally representative data available with measured weight and height used to
calculate BMI.

18

Detailed Methodology and Findings

Active Healthy Kids Scotland Report Card

19

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Click here to go to contents pageThe Scottish Dietary Targets23 provide evidence-based recommendations for theintake of NMES, fruit and vegetables, saturated fat, and total fat.

Obesity

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Relevant stakeholders should: examine the barriers to participation in organised sportand physical activity; consider how to reduce the dropout rate from organised sportand physical activity.

Are inequality data available?

Likely biases in the Scottish data
Systematic reviews4,27 have shown that BMI and waist circumference provide
conservative estimates of the prevalence of obesity (excessive fatness). Both havea moderately high false negative rate (many children and adolescents who areexcessively fat have an apparently healthy BMI). Scottish surveillance data are
therefore underestimates of the scale of the problem.

Yes, from SHeS and GUS data, and from routinely collected health service data
(ISD). Very large sample available with routinely collected data from ISD and this has
advantages in terms of identifying trends and disparities by age, gender, ethnicity28,29.

D-

Family and Peer Influence•

48% of adult men and 33% of adult women reported meeting thephysical activity recommendation of 5x 30 minutes of moderatevigorous intensity physical activity per week6.

•More than 28% of adults were obese and 64% either overweight orobese in 20116.

•

Only 22% of Scottish adults reported meeting the ‘5 a day’ fruit andvegetable intake recommendation in 2011Scottish Health Survey 2011, fruit andvegetable consumption is lower in the more deprived, and purchasing
may have been declining recently30.

Are inequality data available ?
Yes, from the data sources referred to above.
Child and adolescent obesity are more common among more deprived families.
Major gaps in the Scottish data and how to improve the data used to informthe card in future.
Current Scottish surveillance using BMI is adequate.
Future addition of body fatness measures, in addition to the measurement of proxies
for body fatness, could overcome the problem of the moderate false negative rate of
BMI and waist circumference.
How to improve the grade in future
Obesity among children and young people is a major focus of Scottish government
policy (see policy section below). Obesity prevalence may be levelling off amongchildren and adolescents in Scotland, as in other western countries.
Scottish evidence-based recommendations on the prevention and management ofobesity among children and adolescents are available in the relevant SIGN guideline.4

Recommendation or benchmark
There is no specific recommendation for the family environment and peer influence,but recommendations (above) are available for physical activity levels of adults, andfor fruit and vegetable consumption. Obesity in Scottish adults is at its highest levelin our history.

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Are trend data available?

Settings and Influences on Physical Activity and Health

Main data sources considered
SHeS data 2011 on obesity, self-reported physical activity, and fruit and vegetableconsumption6.
Living Costs and Food Survey30 on purchasing of fruit and vegetables.
Reasons for choice of data source used to assign the grade
Nationally representative data are available.

Dietary data are self-reported and prone to biases which may underestimate thescale of non-adherence to dietary and nutrient recommendations and targets.
Obesity assessment using BMI provides a conservative estimate of obesity
prevalence-as in children- there is a high false negative rate, particularly high inwomen.31
Adult physical activity levels are self reported and may be susceptible to bias (actuallevels of physical activity may be even lower than reported).
Are trend data available?
Yes- from the data sources used.
Are inequality data available?
Yes-from the data sources used.
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Active Healthy Kids Scotland Report Card

Detailed Methodology and Findings

21

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Likely biases in the Scottish data

Major gaps in the Scottish data and how to improve the data used to inform thecard in future

Data on other indicators of the family environment, and of peer influence, would be
helpful. More specific data on parental modelling of physical activity and support forphysical activity would be useful: there are some Scottish data from GUS5 and morecomprehensive data of this kind is included in surveillance in Canada.14

Data on access to places for physical activity, and availability of facilities for physicalactivity are available from the SHS21, GUS5, and HBSC3.
Reasons for choice of data source used to assign the grade
Nationally representative data are available
Likely biases in the Scottish data

How to improve the grade in future

Biases in self reports of perceived safety, access to and availability of spaces andfacilities of physical activity are unclear.

Scottish children and adolescents grow up in a family environment which isunfavourable for physical activity and health, and which encourages inequalities inhealth.

Are trend data available?

Improvements in adult physical activity, diet, and obesity are all major Scottish
government policy targets (See section on National Policy, Strategy, and Investment).
There is a good deal of scope for families to support physical activity and reduce
sedentary behaviour in transportation, play, and organised sports and activities.
A systematic review concluded that family-based approaches to improving physicalactivity and health of children are promising32, but there is currently little evidence on
how best to use a family approach to increase child physical activity and reduce childsedentary behaviour.

Yes, from the data sources referred to above
Are inequality data available?
Yes, from the data sources referred to above.
Major gaps in the Scottish data and how to improve the data used to inform thecard in future
The Active Healthy Kids Canada Report Card14 is able to draw on survey data on
the satisfaction which families perceive in relation to local, provincial, and national
government policy and practice in relation to the promotion of physical activity.
Information of this kind would be useful in Scotland.
How to improve the grade in future

B

Community and the Built Environment•

This indicator refers to perceived safety, access, and availability ofspaces and opportunities for physical activity, not the behaviour ofactual use of outdoor space and physically active play, which is dealt
with above.

•

77-81% of Scottish adolescents felt that it was ‘always safe forchildren to play outside’ and 51% agreed that they ‘always felt safe
locally’.3•

77% of parents of 5 year olds agreed or strongly agreed that local
outdoor space was safe for their children.5•

88% of parents of under 5 year olds reported having access to apark or play area locally5 and 40-50% of households reported having
access to a park or play area locally.

This grade is higher than some others, suggesting that perceived safety of access tofacilities may not be major barriers to physical activity. Nonetheless, improvements inperceived safety, access, and facilities may well produce improvements in physicalactivity and/or sedentary behaviour.
Issues such as perceived safety, access, and availability are the target of somenational policy effort, and this is dealt with below.
More research is needed in order to understand why families appear to perceive
reasonable levels of safety and access to facilities for physical activity but levels ofphysical activity are very low and levels of sedentary behaviour very high.

Recommendation or benchmark
There is no specific evidence-based recommendation, but perceived safety, accessto and availability of spaces and opportunities for physical activity are probably
important influences on overall physical activity14.
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Active Healthy Kids Scotland Report Card

Detailed Methodology and Findings

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Perceived safety data are collected by the HBSC3 , SHeS6, and GUS.5

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Current surveillance data are adequate to assess the family environment in which
Scottish children and adolescents grow up, as represented by adult physical activity,
adult diet, and adult obesity. All three environmental indicators are unfavourable tochild physical activity and health.

Main data sources consideredB

National Policy, Strategy, and Investment(Including School Policy and Investment)
Physical activity and health in childhood and adolescence is the focus
of many national policies in Scotland. Many of the Health Behaviours
and Outcomes in the 2013 report card are the subject of national
policies, investments, and or/targets.

Context
Scottish government policy on child and adolescent physical activity and health isexpressed in several national outcomes and purpose targets including: our children
should have the best start in life; improving the life chances of children and young
people at risk; we should live longer healthier lives; we should tackle the significant
health inequalities which exist in Scotland; increased use of public and active
transport; increased physical activitywww.scotland.gov.uk.

Are inequality data available?
No policy is specifically designed to address socio-economic, ethnic or rural/urban
disparities, though gender disparities are considered, and reducing inequality is
increasingly being regarded as central to health policy.
Major gaps in the Scottish data and how to improve the data used to inform thecard in future
No policy mentions reducing sedentary behaviour.
How to improve the grade in future
More evaluation evidence (process, outcome, economic) would be useful.

Data sources considered
National Physical Activity Strategy
Youth Sport Strategy
Physical Education, Physical Activity and Sport in Schools

Active Healthy Kids Scotland Report Card – List of Stakeholders

Active Schools Programme

24

Detailed Methodology and Findings

Hungry for Success
Schools (Health Promotion and Nutrition Act)
Obesity Route Map
HEAT 3 Targets
Good Places and Better Health
Scottish Planning Policy
Scotland’s National Food and Drink Policy 2009
Healthy Living Award
Healthy Living Programme
Beyond the School Gate
Take Life On
Responsible Marketing of Food and Drink
Reasons for choice of data source used to assign the grade
All national level policies currently operational were eligible for inclusion: local policies
could not be included because of time constraints.
Likely biases in the Scottish data

Active Healthy Kids Scotland Report Card25

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Implementation of some policies could not be ascertained; evaluation has not been
carried out for most policies

Name
Organisation
Julie Armstrong
Glasgow Caledonian University
Emma Broadhurst Fife Council
Kate Campbell
Sustrans Scotland
Michael Craig
NHS Health Scotland
Stuart Forsyth
University of Strathclyde
Jillian Galloway
NHS
Andrew Gasiorowski NHS ISD
Mary Goad
British Heart Foundation National Centre for Physical Activity
and HealthAdrienne Hughes
University of Strathclyde
Jo Inchley
University of St Andrews
Flora Jackson
NHS Health Scotland
Ann-Marie Knowles University of Strathclyde
Benny Lawrie
Youth Sport Trust
Judith Mabelis
ScotCen Social Research
Donald MacLeod
Education Scotland
Diane McGrath
British Heart Foundation
Ruth McQuillan
University of Edinburgh
Victoria Milne
Scottish Government
Gillian Purdon
Food Standards Agency in Scotland
Julie Ramsay
Scottish Government
David Rowe
University of Strathclyde
Naveed Sattar
University of Glasgow
Kathryn Sharp
NHS GGC
Laura Stewart
NHS Tayside
Bruce Whyte
Glasgow Centre for Population HealthDebbie Willett
Play Scotland
Simon Williams
University of Glamorgan
David Williamson
sportscotland
Rachael WoodNHS ISD

Paths for All
Active Girls

Click here to go to contents pageThe number of policies has increased in the last decade and a several new policies
are underway or in preparation, e.g. Supporting Healthy Choices (a voluntary
framework for food businesses).

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Are trend data available?

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Uijtdewilligen L, Nauta J, Singh AM, van Mechelen W, Twisk JWR, vander Horst K, Chinapaw MJM. Determinants of physical activity andsedentary behaviour in young people: a review and quality synthesisof prospective studies. Br J Sports Med 2011; 45: 896-905.

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King AC, Parkinson KN, Adamson AJ, Murray L, Besson H, Reilly JJ,
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