**7. Alternative clues and cues**

Apart from evidence from the SR, there are clues and cues from alternative approaches involving lifestyle, PA groupings, and behavioral change that could be applicable to children and adolescents who are identified as inactive or sedentary. The first alternative clue is derived from trying to answer the following inter-related questions: How does SB develop? Do children and adolescents through poor choices, or limited choices, or no choices, or a lack of opportunities, or by not being opportune just stop undertaking PA? How influential is lifestyle and how much control do children and adolescents have over it? Certainly, in terms of the definition of SB, there is little or no PA to speak of, but was this always the case for children and adolescents currently identified as inactive and sedentary? Whilhite's [9] recommendation of extended longitudinal studies would be a valuable cue to answer the questions of SB development or lifestyles that would need to examine a range of SB options between the two extremes of a child who is sedentary at the age of five and still sedentary at 15 and a child who is highly active at five who becomes sedentary at 15. This would require 10-year longitudinal studies which are not exactly *de rigueur* in many fields of research! It would also require a substantial and longevous sample. An alternative cue would be to track the lifestyle history of adolescents who are currently sedentary potentially through the use of the 24-hour movement-based terminology pie-chart ([4]; see **Figure 1**) to see what factors were instrumental in them becoming sedentary. What may become evident is a range of cluster patterns such as those proposed by de Mello [7] will develop as children grow into adolescents. A related cue would be whether children and adolescents remain in the same cluster pattern or are there changes as they grow up? It would be expected that there will be a continuum of patterns based on increasing or decreasing levels of PA, and many of the other factors identified in all four SRs will be influential especially as behavioral change occurs, but how this impacts individual children and adolescents remains an open question.

#### *Changing Sedentary Behavior in Children and Adolescents: Understanding Research… DOI: http://dx.doi.org/10.5772/intechopen.114253*

A second alternative clue develops from the inclusion of energy expenditure in the SBRN definitions identified earlier for those individuals who are inactive and sedentary. In this instance, the cue is related to a more comprehensive approach to the SB already proposed with the use of the 24-hour pie chart and the nutritional component of energy from the calories-in calories-out approach of Chaput and Sharma [20] who, in relation to obesity, provide some valuable cues that are pertinent in the role that food, nutrition, and energy expenditure play in impacting IA and SB. Given the lack of calories-out EE from inactive and sedentary children and adolescents, it is the calories-in approach that has more relevancy especially where there is an overlap between those children and adolescents who are inactive-obese and sedentary-obese. The calories-in proposal is that "a substantial proportion of the variance in the contribution of exercise on body weight can be explained by the positive effects of exercise on the ingestive behavior in individuals in whom overeating is primarily driven by stress, depression, poor self-esteem, or unrestorative sleep, all of which can be improved with regular exercise" (p. 1768). Whether sedentariness alone or in some combination with obesity includes these primary drivers of the ingestive behavior as a cue for SB change is for future analysis and will possibly relate to only certain clusters of children and adolescents who are inactive and sedentary [7].

Another alternative clue relates the understanding of behavioral change. Forming and changing behavior requires challenging values and beliefs, and changes in intentions which relate to how ready individuals are in the pre-contemplative and contemplative stages of readiness [21] are also relevant in this context and were examined by De Mello et al. [7]. My colleague and I [22] examined attitudes which are theoretically linked to changing behavior through intentions in the theory of planned behavior [23]. Using a CATPA [24] scale, we took an alternative view to attitudes by looking at profiles of eight participatory reasons to become more active and can be closely related to de Mello et al.'s [7] clusters. The eight participatory reasons were social growth, health and fitness, vertigo, ascetic cathartic, fitness, esthetic, and aerobic and provide a broad array of reasoning to participate in PA either as a singular antecedent or in one of a number of combinations that can reach 15,625 permutations! This approach avoided the pitfalls of traditional applications of the survey, which aggregate the reasons into one score, and by doing so, we were able to look at ways that the groups of adolescents created their attitudes as a profile of participatory reasons that factor into an attitude toward completing a PA with the expectation that this would be valuable in terms of changing behaviors. The cue is finding the PA that fits each child's reasoning profile or finding the most prevalent profiles and what PA to target. In reality, this is the foundational basis of developmental sports options on Saturday mornings across America where children try different PAs and where there tend to be more misses than hits! The reasoning for this alternative cue is that many traditional approaches to behavioral change for children and adolescents who are obese and overweight are not specific enough especially when, as Janiszewski [25] indicated, BMI does not reflect lifestyle. Indeed, evidence [24] from nine profiles cross-tabulated from two composite variables of EIPA and WSFit indicated that the 29 individuals who reported being obese were identified within five of the nine PA profiles (see **Table 3**). Another question asked the participants: Do you consider yourself underweight, normal weight, or overweight? These results show variation across the various levels of perceived weight status. This leads to another cue for further research which is whether inactive and sedentary children and adolescents perceive themselves actually as inactive and sedentary? This will have influence in how to approach them to initiate behavioral change especially if they do not perceive a need to change what they consider to be acceptable behavior.


#### **Table 3.**

*Distribution of adolescents with obesity in profiles of physical activity1 .*

An alternative clue that aligns to the SBRN [4] definitions of IA and SB requires magnitude coding [26] of PA completed for the magnitude of effort using MET codes from the CEEY [5] and to determine effort and time involvement of each PA. In [22, 27], we used 10-minute increments from 0 to 60, and this was a reaction to YRBS, and most PA guidelines being solely concerned with meeting the 60-minute threshold. For many children and adolescents who are inactive or sedentary, this is a high bar, but many of them see this as continuous rather than cumulative and often fail to account for walking as a physical activity. The cue, having determined effort in METS for PA and involvement in time, is the development of a multiplicative composite variable effortinvolvement [EIPA] which can be interpreted in relation to the SBRN definitions with scores for an inactive adolescent being between 16 and 29 and for sedentary adolescent being less than or equal to 15. Obviously, more direct measures of PA and energy expenditure can be generated from various personal electronic devices, but in large samples, this may not be possible in which case determining EIPA can be calculated and a valuable alternative especially when PA is undertaken in group sessions of a fixed time.

Currently, there a few alternative clues from the opportunities and organizations within the community that would provide cues for the PA to become a regular and maintained behavior. This final alternative clue is based on the need to have greater emphasis on opportunity/organization approaches to PA that can mobilize those who are inactive and sedentary. As part of getting children and adolescents to continue with physical activity that they had learned in their school PE curriculum, I developed and continue to advocate for an out-of-the-gym door approach as a cue to getting children to continue the PA [28]. In **Figure 2**, the doors through which they pass are replete with personal participation processes such as intentions to try [29], and participation advocacy such as community awareness of opportunities via a community resource guide that they learn either directly or indirectly in PE and are key to continuance. However, without a clear understanding of the opportunity/organizational pyramid and how to use it in the community, children and adolescents can slip past the pyramid and into the world of inactivity. The opportunity/organizational pyramid provides many options about how to complete or perform PA. Toward the top of the pyramid are some traditional organizational opportunities in various forms of sports that are not remotely plausible for those who are inactive and sedentary, but the biggest sections in terms of their opportunities are at the base of the pyramid and are recreational opportunities in unstructured and structured participation that have individual, home, and small group options for nearly all PAs and importantly for everybody. This model fits

*Changing Sedentary Behavior in Children and Adolescents: Understanding Research… DOI: http://dx.doi.org/10.5772/intechopen.114253*


#### **Figure 2.**

*Opportunity-organizational participation within the gym doors and beyond approach to establishing physical activity participation from school physical education.*

with the National PE Standards [30], and the overarching goal of pursuing a lifetime of healthful physical activity. Unfortunately, YRBS 2021 [15] indicates that 53.2% of adolescents have no PE classes in an average week in schools which raises the question: Where and when are they going learn these lifetime skills? One cue would be to move many of the lifetime PA benchmarks into lower grades, especially as high school PE is being waived not only for sports team participation, but also for marching band which does have a walking component! Another cue would be for physical educators to provide not only a broad and balanced set of PA opportunities but more importantly teach children and adolescents how to undertake these PAs in all of the options in the opportunity/organizational pyramid that are not traditionally taught in PE. The lack of opportunities came into full focus during the COVID-19 lockdown when my PEHE teaching internship students had to develop online PE classes only to find that many children did not have access to or own a small ball, such as a tennis ball, in their home. A final cue is that physical educators must prepare all students to create their own opportunities and take them as soon as PE classes are over. The moment you walk out of the gym door, you are in an unstructured participation setting be it in your home or surrounding milieu, and the best of all, you are moving quite literally from SB to IA.
