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. 2025 Sep 27;114(12):3136–3146. doi: 10.1111/apa.70315

Estimated Prevalence of Compliance With Muscle‐Strengthening Activity Recommendations in Children and Adolescents: A Meta‐Analysis

Antonio García‐Hermoso 1,✉, Jacinto Muñoz‐Pardeza 1, Ignacio Hormazábal‐Aguayo 1,2, Yasmin Ezzatvar 3,4
PMCID: PMC12599618  PMID: 41014026

ABSTRACT

Aim

To estimate the prevalence of meeting the World Health Organization (WHO) guidelines for muscle‐strengthening activities in children and adolescents, specifically engaging in these activities at least 3 days per week, and explore, whenever possible, this prevalence according to sociodemographic and healthy habits factors.

Methods

Four databases were systematically searched for studies published from inception to January 2025. Eligible studies included articles with samples of children and adolescents reporting the prevalence of meeting the muscle‐strengthening activities guidelines.

Results

Twenty‐nine studies comprising 1 273 544 children and adolescents (49.40% girls; mean age: 13.40 years) from 36 countries were included. Estimated prevalence of muscle‐strengthening activities was 38.51% (95% CI, 34.35% to 42.75%), based primarily on studies involving adolescent populations, with limited data available for children aged 6 to 12 years. According to the subgroup analyses, the predictors that favour compliance with the muscle‐strengthening activity guidelines are being a boy, having normal weight, meeting the aerobic physical activity recommendations and receiving high family support for engaging in physical activity.

Conclusion

Only 4 out of 10 children and adolescents meet the WHO muscle‐strengthening activity guidelines. Targeted efforts are needed, particularly for girls and those with lower support or physical activity levels, to improve participation and youth fitness.

Trial Registration

PROSPERO Registration Number: CRD42025648274

Keywords: adherence, muscle strength, physical activity, youth

Summary.

  • Adherence to muscle‐strengthening activities in youth is often overlooked, despite being a key priority in fitness research, with most studies focusing on aerobic exercise.

  • This study provides the first estimate of adherence to World Health Organization muscle‐strengthening guidelines, analysing data from 1.2 million youths across 36 countries.

  • With only 38.51% meeting recommendations, findings highlight key sociodemographic and behavioural factors, guiding targeted interventions to improve adherence.

1. Introduction

Muscle‐strengthening activities and muscular fitness are crucial for children's and adolescents' health, improving muscle mass, strength, weight management and reducing injury risk [1, 2]. Muscle‐strengthening activities are defined as physical exercises that enhance skeletal muscle strength, power, endurance and mass, such as strength training, resistance training and exercises aimed at increasing muscular strength and endurance [3]. Resistance training, in particular, involves the use of various resistive loads (e.g., free weights, body weight) to improve strength, body composition and overall health [3]. Recognising these benefits, the World Health Organization (WHO) has recommended since 2010 that children and adolescents engage in muscle‐strengthening exercises at least three times a week [4].

Despite muscle strength being recognised as a top 10 priority in youth fitness research [5], compliance with muscle‐strengthening activities remains relatively under‐explored. Although numerous studies have investigated aerobic physical activity levels [6, 7], far fewer have specifically addressed prevalence of muscle‐strengthening activities guidelines, making it the ‘forgotten component’ of international recommendations and guidelines. Understanding the prevalence of compliance with muscle‐strengthening recommendations in young populations is critical for informing public health strategies and interventions aimed at promoting physical activity. Additionally, it is essential to analyse the factors associated with meeting these guidelines, as this can help identify barriers and facilitators [8], ultimately guiding more effective promotion efforts. The purpose of this meta‐analysis was to analyse the global prevalence of meeting the muscle‐strengthening recommendations among children and adolescents, as well as to identify factors that may influence compliance.

2. Methods

The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) criteria were followed [9], and our meta‐analysis was registered in The International Prospective Register of Systematic Reviews (ID: CRD42025648274).

The entire process of the systematic review and meta‐analysis was conducted independently by two authors (AGH and YE), with a third author consulted in cases of disagreement (JMP).

2.1. Eligibility Criteria

To be eligible for inclusion in the present meta‐analysis, studies had to meet the following criteria: (i) participants: children and adolescents with a mean age between 6 and 18 years old; (ii) outcome: prevalence of compliance with muscle‐strengthening activities guidelines, with a cutoff of three or more sessions per week [4]; and (iii) study design: cohort studies included at least 200 participants and/or used probabilistic‐based sampling [10]. Excluded studies included only populations with a diagnosis of a chronic disease or disabilities and those that presented duplicate data from the same source and year. The study with the higher sample size was chosen when two studies contained duplicate data from the same source and year.

2.2. Information Sources

We searched the PubMed, Web of Science, SportDiscus and Scopus databases for studies published from inception to January 2025. A professional librarian was consulted to ensure the quality of the search strategy.

2.3. Search Strategy

The following search terms were used: ‘muscle‐strengthening’ and ‘prevalence’ and ‘guidelines’ and (‘children’ or ‘adolescents’). Full search strategies for all databases are provided in online‐only supplemental Method S1. Additionally, reference lists of eligible studies were manually reviewed to identify further relevant articles, which were included if deemed appropriate.

2.4. Selection Process

We evaluated the entire text of discovered publications for eligibility after eliminating duplicates and looking over the titles and abstracts of possible studies.

2.5. Data Collection Process and Data Items

The following data were extracted from each study using a Microsoft Excel spreadsheet specifically designed for the present study: (i) study characteristics (i.e., first author's name, publication year, country, sample size and study design); (ii) participants' information (e.g., sex and age); (iii) sociodemographic factors (e.g., area of residence, ponderal status); (iv) physical activity assessment details; and (v) the proportion of participants meeting the muscle‐strengthening activities guidelines.

2.6. Study Risk of Bias Assessment

The assessment of study bias was conducted using the Joanna Briggs Institute (JBI) appraisal checklist for prevalence studies, which is a specialised tool designed for studies reporting prevalence data [11]. This tool comprises nine items that evaluate the methodological quality of a study and the extent to which it addresses potential bias in its design, implementation and analysis. Each item is rated as ‘yes’ (if the criterion is met), ‘no’ (if not met), ‘unclear’ or ‘not applicable’, with corresponding scores of 0 or 1. The overall risk of bias is categorised as ‘low’, ‘moderate’ or ‘high’ based on the total score: 0–3 points indicate high risk, 4–6 points moderate risk and 7–9 points low risk.

2.7. Effect Measures

Prevalence estimates and their 95% confidence intervals (CIs) were calculated based on the total number of children and adolescents in the sample and the number of individuals who met the muscle‐strengthening activity guidelines.

2.8. Synthesis Methods

We used Stata 17.0 (StataCorp LP, College Station, TX) and the metaprop procedure to pool data from multiple studies by applying a random‐effects model that displayed the results as forest plots using the DerSimonian and Laird method [12]. The exact or Clopper–Pearson method [13] was used to establish 95% CIs for prevalence from the selected individual studies, and Freeman–Tukey transformation was used to normalise the results before calculating the pooled prevalence [14]. When prevalence data from different studies were available for the same country, a fixed‐effects analysis was conducted to obtain a combined estimate.

Metaprop tests for intragroup heterogeneity of pooled proportions were calculated using the I 2 statistic and its p‐value.

The Luis Furuya‐Kanamori (LFK) index and the Doi plot were used to evaluate potential small‐study effects due to publication bias [15]. When the values of the LFK index were −1, between −1 and −2, and > −2, they were deemed to represent no, minor and major asymmetry, respectively.

Whenever possible, subgroup analyses were conducted based on age group (children and adolescents), sex, body weight status (underweight, normal weight, overweight and obesity), area of residence (rural or urban), parental support for children's and adolescents' physical activity (high or low) and physical activity (meeting or not meeting aerobic recommendations). Additionally, following these same predictors, we performed a global analysis of the odds ratios (OR) using a random‐effects model based on the DerSimonian and Laird method when logistic regressions were reported.

3. Results

3.1. Study Selection

The electronic search strategy identified 1817 studies. After removing duplicates and screening titles, 42 studies were evaluated for eligibility based on full‐text review. Ultimately, 29 studies were included in the meta‐analysis [8, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43]. The flow diagram illustrates the number of studies excluded at each stage of the systematic review and meta‐analysis (Figure 1). A reference list of excluded articles, along with the reasons for exclusion based on full‐text assessment, is provided in online‐only supplemental Method S2.

FIGURE 1.

FIGURE 1

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PRISMA flow diagram.

3.2. Study Characteristics

The main characteristics of the included studies are described in online‐only supplemental Table S1. The meta‐analysis included 1 273 544 children and adolescents (49.40% girls; mean age: 13.40 years). Studies were conducted in 36 countries.

3.3. Risk of Bias in Studies

The results of the JBI Critical Appraisal Checklist for Prevalence Studies are shown in online‐only supplemental Table S2. Overall, the studies demonstrated a low risk of bias, with a mean score of 8.6 out of 9. The primary criterion that was not met in some studies was the response rate, which was considered adequate if it reached at least 70%. However, several studies either did not report response rate data or failed to achieve the 70% threshold.

3.4. Results of Individual Studies and Synthesis

Figure 2 shows the overall prevalence of muscle‐strengthening activities guidelines in children and adolescents. A total of 497 619 children and adolescents met the muscle‐strengthening activities guidelines. The overall prevalence was 38.51% (95% CI, 34.35% to 42.75%, p < 0.001, I 2 = 99.96%). The LFK index for the Doi plots showed major asymmetry indicating a risk of publication bias (LFK = 5.13) (online‐only supplemental Figure S1).

FIGURE 2.

FIGURE 2

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Forest plot showing the global prevalence and 95% confidence intervals for compliance with muscle‐strengthening activity guidelines among children and adolescents. Squares represent individual studies; their size is proportional to study weight. The diamond at the bottom represents the pooled prevalence estimate. The dashed vertical line indicates the overall mean.

According to sub‐group analyses, the prevalence of meeting the muscle‐strengthening activities guidelines among boys was 50.11% (95% CI, 42.68% to 57.53%, p < 0.001, I 2 = 99.93%), compared to 35.93% among girls (95% CI, 25.66% to 46.89%, p < 0.001, I 2 = 99.97%) (p = 0.036) (online‐only supplemental Figure S2). Regarding weight status, although normal‐weight children reported a higher prevalence of meeting the muscle‐strengthening activity guidelines (37.69%, 95% CI: 19.39% to 58.02%, p < 0.001, I 2 = 99.86%) compared to those who were overweight (28.49%, 95% CI: 12.99% to 47.18%, p < 0.001, I 2 = 99.16%) and those with obesity (22.29%, 95% CI: 9.08% to 39.23%, p < 0.001, I 2 = 98.82%), a significant difference was only observed between normal‐weight children and those with obesity (p = 0.039) (online‐only supplemental Figure S3). Similarly, no differences were found in the prevalence based on living in rural (24.01%, 95% CI, 15.72% to 33.43%, p < 0.001, I 2 = 99.84%) versus urban areas (27.97%, 95% CI, 17.05% to 40.42%, p < 0.001, I 2 = 99.93%) (p = 0.598) (online‐only supplemental Figure S4).

Considering the OR for each predictor (Figure 3), the results show that being a boy (OR = 1.47, 95% CI: 1.21 to 1.78, p < 0.001; I 2 = 96.86%), having normal weight compared to obesity (OR = 1.30, 95% CI: 1.11 to 1.52, p < 0.001; I 2 = 50.24%), meeting the aerobic physical activity recommendations (OR = 3.26, 95% CI: 1.56 to 6.81, p < 0.001; I 2 = 99.59%) and receiving high parental support (OR = 1.47, 95% CI: 1.03 to 2.10, p = 0.029; I 2 = 90.92%) are associated with greater compliance with the guidelines. Conversely, no association was found between having normal weight compared to overweight children and adolescents (OR = 1.05, 95% CI: 0.96 to 1.15, p = 0.280; I 2 = 0%) or the area of residence (OR = 0.97, 95% CI: 0.69 to 1.38, p = 0.880; I 2 = 93.92%).

FIGURE 3.

FIGURE 3

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Forest plot showing odds ratios (OR) and 95% confidence intervals for predictors of compliance to muscle‐strengthening activity guidelines among children and adolescents. Squares represent individual studies, with size proportional to study weight in the analysis. Diamonds represent the pooled effect estimate for each predictor. Horizontal lines indicate 95% confidence intervals. The dashed vertical line represents the null effect (OR = 1.0).

Finally, a worldwide map illustrating the geographic prevalence of muscle‐strengthening activities guidelines is provided in Figure 4.

FIGURE 4.

FIGURE 4

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World map showing the prevalence of compliance with muscle‐strengthening activity guidelines among children and adolescents in the 36 countries included. Countries are shaded according to prevalence percentage, with darker colours representing higher compliance. Countries with no available data are shown in grey.

4. Discussion

Our findings reveal the estimated prevalence of compliance with muscle‐strengthening activity guidelines among children and adolescents, based on data from over 1 million participants across 36 countries. With a prevalence of 38.51%, the results indicate that a significant proportion of youth do not meet the recommended levels of muscle‐strengthening activity. Compliance was higher among boys, those with normal weight, those meeting the aerobic physical activity recommendations and those receiving high family support for engaging in physical activity. This low compliance is particularly concerning given its crucial role in the comprehensive health and development of children and adolescents [30, 44]. However, the high heterogeneity (I 2 = 99.96%) reflects variability in study design, populations and measurement methods, requiring cautious interpretation. Additionally, the absence of a standardised measure further complicates comparisons, and the predominance of data from high‐income countries, along with the limited evidence available for children aged 6 to 12 years, limits the generalisability of the findings. Moreover, this lack of evidence may stem from methodological challenges in younger populations. Self‐reported measures are less reliable at younger ages due to cognitive and recall limitations, which increase the risk of misclassification [45].

Traditionally, epidemiological prevalence studies on physical activity compliance have focused primarily on the aerobic component, often overlooking muscle‐strengthening activities. In this regard, Guthold et al. [7] and Hallal et al. [6] reported that more than 80% of adolescents worldwide fail to meet aerobic physical activity guidelines. On the other hand, a meta‐analysis assessing combined compliance to both aerobic and muscle‐strengthening recommendations found a comparable prevalence of 19.70% [46], suggesting that strength‐based exercises are often underemphasised in youth physical activity promotion [46]. The present meta‐analysis shows that only 4 to 10 children and adolescents meet the recommended levels of muscle‐strengthening activity, reporting higher values than the aforementioned studies. In this regard, it is important to highlight that studies typically report lower prevalence rates for adherence to aerobic activity recommendations compared to muscle‐strengthening activities. Therefore, aerobic guidelines largely determine the level of adherence to physical activity guidelines [42]. For example, in a representative sample of Dutch adolescents, the prevalence of aerobic and muscle‐strengthening activities was 37.10% and 84.20%, respectively [17]. Similar results were reported across all years of the Youth Risk Behaviour Survey, where muscle‐strengthening activity compliance was higher than aerobic activity adherence among US adolescents [24, 25].

In addition to the global analysis, we conducted a country‐specific analysis to determine the prevalence across the 36 countries included in the studies. Overall, we observed considerable heterogeneity between countries, with prevalence ranging from 84.20% [17] in the Netherlands to 2.30% in Romania [42]. Despite the large differences observed, the results should be interpreted with caution, mainly due to differences in how muscle‐strengthening activities were queried, since the validity of the muscle‐strengthening activities item is currently unclear. However, the study published by Bennie et al. [42], using the European Health Interview Survey across 28 countries, found significant cross‐country differences despite using the same question. These authors suggest that wealth disparities may influence muscle‐strengthening activity participation, with richer countries benefiting from better access and cultural factors that encourage engagement.

The observed sex differences are also consistent with prior research, which indicates that boys are generally more likely to engage in resistance training activities than girls [47]. This difference is influenced by various factors, including motivations, societal norms and opportunities for participation. For example, boys and men often have different motivations for engaging in muscle‐strengthening activities, such as a desire for increased muscle size and strength, competition and social recognition. In contrast, girls and women are more motivated by body toning and attractiveness [48]. Beyond individual motivation, it is important to consider broader sociocultural influences that may shape gender norms and expectations around physical activity. Cultural attitudes toward strength training, gender‐role stereotypes and differential access to opportunities (e.g., through school or sports programmes) may partially explain the lower participation rates among girls. For example, studies in adolescents report that boys are more often motivated by competition, challenge and social recognition, while girls face more barriers such as lack of time or interest in structured exercise, often influenced by societal norms and self‐efficacy beliefs [49]. These disparities also reflect deeper structural inequalities; for instance, girls frequently report more perceived barriers to physical activity, indicating issues in access, infrastructure and supportive environments [50]. This pattern also aligns with findings that meeting aerobic physical activity recommendations is linked to better adherence to muscle‐strengthening guidelines, a noteworthy point given that girls are generally less active than boys across all age groups [51].

Additionally, parental support appears to be a key predictor of compliance to muscle‐strengthening activities. Several studies indicate that parental support significantly promotes youth exercise compliance through mechanisms such as encouragement, logistical support, co‐participation and fostering self‐efficacy, with positive effects observed across various contexts and populations [52, 53]. In the same way, other studies indicate that when parents meet with strength recommendations [22, 39], it serves as a predictor of compliance among children and adolescents. This aligns with the idea that young people engage in specific types of physical activities because they are exposed to their parents' activity patterns through role modelling, observational learning and the transmission of attitudes and values [54].

Another predictive variable for compliance to muscle‐strengthening activities appears to be BMI, specifically having a normal weight compared to obesity. Previous studies have highlighted that adolescents with obesity often experience greater difficulty engaging in physical activities due to several barriers [55]. For example, factors contributing to lower physical activity levels in obese and overweight youth include individual factors (e.g., low motivation, psychological vulnerability), interpersonal factors (e.g., lack of family support) and environmental constraints (e.g., insufficient policy support, inadequate built environment) [56]. Although obesity was analysed as a predictor of lower compliance with muscle‐strengthening activities, it is important to consider the relationship as potentially bidirectional [57]. Indeed, low engagement in muscle‐strengthening activities may contribute to obesity development or maintenance in adolescents [44], reinforcing a self‐perpetuating cycle of inactivity and excess weight that warrants further longitudinal investigation.

It is not surprising that only 4 out of 10 children and adolescents meet the muscle‐strengthening activity guidelines, mainly due to the myths associated with strength training in young people, which have been thoroughly dispelled by scientific evidence [58]. Decades of research have shown that muscle‐strengthening activities are safe and effective for improving muscle mass, strength, supporting healthy weight maintenance, enhancing sports skills and reducing the risk of sports injuries [1]. Another contributing factor is the confusion surrounding what activities actually count as meeting muscle‐strengthening activity. While some may perceive meeting muscle‐strengthening activity as requiring costly equipment, specialised facilities and expert personnel, this is not the case for basic exercises like bodyweight training, which can be done easily once adolescents are properly instructed [1]. Interventions targeting this form of meeting muscle‐strengthening activity in settings where adolescents already spend time, such as schools, have shown promise in increasing participation [59]. Furthermore, family and societal involvement is crucial [39]. In many countries, access to gyms remains a significant barrier to muscle‐strengthening activity [60], except when accompanied by an adult. This highlights the importance of family support and raising awareness within society to provide children and adolescents with more opportunities to engage in muscle‐strengthening activities. Finally, although this study did not evaluate physiological responses to training, it is important to note that age‐related differences in musculoskeletal development may require tailoring the structure and intensity of muscle‐strengthening activities, especially in younger populations [61].

Several notable strengths of this study should be highlighted. We pooled data from over 1 million participants and provided an estimated prevalence of compliance with muscle‐strengthening activity guidelines in children and adolescents, primarily from adolescent samples and high‐income countries. Given that most included studies are representative, the findings offer broader research generalisability in similar contexts. However, it is important to acknowledge several limitations. The first and possibly most significant is the variability in the questions used to determine the prevalence of adherence to muscle‐strengthening activity recommendations. As previously mentioned, there is no validated questionnaire for this purpose, and all measures relied on self‐reported data, which may introduce recall bias and social desirability bias. Second, the high heterogeneity observed (I 2 = 99.95%) indicates substantial variability across studies, likely due to differences in study design and population characteristics, requiring careful interpretation of the results. However, it is important to note that I 2 is not an absolute measure of heterogeneity, especially in meta‐analyses of prevalence, where high values are commonly observed. Some authors argue that I 2 can be biased and may not be a direct indicator of meaningful heterogeneity [62]. Despite attempts to explore sources of heterogeneity, the extreme variability limits the reliability of the pooled estimates and confidence intervals. Third, it is essential to interpret the subgroup analysis results carefully, as limited studies provide data based on these sociodemographic and individual factors, potentially influencing the findings. Notably, for the analysis of residential area and weight status, few of the 28 included studies reported relevant data. Moreover, there was a lack of studies analysing differences by sex, socioeconomic status, or ethnicity, which may impact the generalisability of the results. Fourth, most studies included in this review were conducted in high‐income countries, such as Australia, the United States, Canada, South Korea and various European regions like Germany. As a result, the findings may have limited generalisability to countries with different socioeconomic characteristics, particularly low‐income nations, and there is also a potential risk of publication bias. Finally, another important aspect is that all studies focus exclusively on adolescent populations, with only two studies including data on children aged 6 to 12 years [23, 38]. Notably, these studies reported even lower prevalence rates compared to adolescents. Therefore, more studies are needed to address the 6‐ to 12‐year‐old age group and to ensure better representation of diverse populations.

Raising awareness about the importance of muscle‐strengthening activities, engaging families and designing targeted interventions for girls and youth with obesity is recommended. Emphasising the importance of muscle‐strengthening exercises in schools, along with education on how to perform them effectively and safely, is crucial. Importantly, these exercises can be promoted without the need for expensive equipment, making them accessible and feasible in various settings.

5. Conclusions

Our meta‐analysis indicates that estimated compliance to muscle‐strengthening activities recommendations among children and adolescents is low, with only 4 out of 10 meeting the guidelines. Higher compliance was observed among boys, individuals with normal weight, those who met aerobic physical activity guidelines and those who received strong family support for physical activity. It is important to note the limited data available on children aged 6 to 12 years and on populations from middle‐ and low‐income countries, underscoring the need for further research in these groups.

Author Contributions

A.G.‐H. and Y.E. conceived the study, drafted the analysis plan and manuscript, and conducted the statistical analyses. I.H.‐A. and J.M.‐P. reviewed the analysis plan, provided input, and contributed to drafting the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of authorship.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: General characteristics of the included studies.

Table S2: Results of the Joanna Briggs Institute (JBI) Appraisal Checklist for studies reporting prevalence data.

Figure S1: Doi plot for global prevalence of muscle‐strengthening activities in children and adolescents.

Figure S2: Prevalence of muscle‐strengthening activities among boys and girls.

Figure S3: Prevalence of muscle‐strengthening activities among children and adolescents with normal weight, overweight or obesity.

Figure S4: Prevalence of muscle‐strengthening activities among children and adolescents living in rural and urban areas.

APA-114-3136-s001.docx (837.4KB, docx)

Funding: The authors received no specific funding for this work.

Data Availability Statement

The data supporting the findings of this review are available upon request from the corresponding author. The data were not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1: General characteristics of the included studies.

Table S2: Results of the Joanna Briggs Institute (JBI) Appraisal Checklist for studies reporting prevalence data.

Figure S1: Doi plot for global prevalence of muscle‐strengthening activities in children and adolescents.

Figure S2: Prevalence of muscle‐strengthening activities among boys and girls.

Figure S3: Prevalence of muscle‐strengthening activities among children and adolescents with normal weight, overweight or obesity.

Figure S4: Prevalence of muscle‐strengthening activities among children and adolescents living in rural and urban areas.

APA-114-3136-s001.docx (837.4KB, docx)

Data Availability Statement

The data supporting the findings of this review are available upon request from the corresponding author. The data were not publicly available due to privacy or ethical restrictions.

Articles from Acta Paediatrica (Oslo, Norway : 1992) are provided here courtesy of Wiley

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