6-Minute Walk Test Performance in Young Children who are Normal Weight and Overweight

Abstract

PURPOSE

The primary purpose of this study was to investigate 6-minute walk test (6MWT) performance in young children who were normal weight (NW) and overweight (OW).

METHODS

Seventy children, 5-9 years of age, participated in this study. The 6MWT was performed on an indoor walkway. Heart rate (HR), blood pressure (BP), and oxygen saturation (SaO₂) were measured. A self-reported physical activity questionnaire was completed by a parent/guardian. Data were analyzed with independent t tests, ANOVA, correlation analyses, and logistic regression.

RESULTS

The systolic BP values were higher in the children who were OW compared with their NW peers (resting mean 104.1 (8.9) mmHg vs. 97.5 (7.8) mmHg, P < 0.05; post-6WMT: mean 118.4 (10.78) mmHg vs. 109.9 (9.1) mmHg, P < 0.05). The SaO₂ values were lower in the children who were OW compared to their NW counterparts (resting: mean 97.2 (1.1) % vs. 98.0 (1.0) %, P < 0.05; post-6WMT: mean 96.8 (1.0) % vs. 97.7 (1.0) %, P < 0.05).

CONCLUSIONS

The children who were OW had higher systolic BP and lower SaO₂ levels at rest and post-6WMT. More research is needed to determine if these differences contribute to children who are OW having difficulty performing exercise.

INTRODUCTION AND PURPOSE

Childhood obesity is a serious global health threat due to a marked increase in its prevalence. For children 6-11 years, the rate of obesity has quadrupled in the past 3 decades¹ with an estimated 30% of children being overweight (OW) or at risk of being OW.² Childhood obesity is strongly predictive of obesity in adulthood,³ which is associated with astounding health care costs.⁴ The health consequences of childhood obesity can be serious and include pulmonary, orthopedic, gastroenterologic, neurologic, and endocrine problems.⁵,⁶

A decrease in physical activity and a sedentary lifestyle are regarded as the most important factors contributing to the development of childhood obesity.⁷ A combination of social and environmental changes over the past few decades have resulted in less physical activity in children's daily routines. Few children and adolescents get the 60 minutes of moderate to vigorous physical activity per day recommended by the Centers for Disease Control and Prevention (CDC) for healthy growth and development.⁸,⁹ Children who are OW may have impaired cardiopulmonary status that can limit functional capacity and their ability to participate in exercise. In adults, it is well established that increased weight leads to decreased exercise fitness and aerobic capacity.¹⁰ Heart rate (HR) at self-selected walking speeds averages ~70% of age predicted maximal HR in adults who are obese compared to 58% for individuals who are not obese.¹⁰ An increase in walking speed of just 10% can lead to a HR of ~94% age-predicted maximal HR and a rating of perceived exertion (RPE) of ~15 in adults who are obese.¹¹ In adolescent children, Norman et al¹² found that obesity is linked with impairment of cardiorespiratory fitness resulting in decreased exercise tolerance. The Institutes of Medicine reports that approximately 60% of children 5-10 years of age have at least one cardiovascular disease factor and 25% have two or more risk factors.¹³ Furthermore, several studies suggest a link between childhood obesity and cardiovascular disease (CVD) risk factors early in life,¹⁴ and persistent obesity is associated with the development of adverse adult CVD risk profiles.³,¹⁵ The impact of increased weight on exercise capacity in young children in the United States remains to be determined.

The demand for clinical assessment tools to evaluate exercise capacity in children who are OW is increasing. The 6-minute walk test (6MWT) is a simple, practical, reliable, and valid measure of submaximal exercise capacity in healthy children¹⁶,¹⁷ and children with chronic disease or neuromuscular disorders¹⁸,¹⁹,²⁰ or cardiopulmonary disease.¹⁶,²¹ Additionally, the 6MWT is standardized, safe, inexpensive, and requires minimal equipment, training, and time to administer.²² It is also considered as the most relevant walk test that reflects physical activity of daily living as well as cardiopulmonary fitness.¹⁶ Moreover, the validity and reproducibility of the 6MWT in obese adults²³ and children²⁴ has been established and the test can be easily performed by children/adolescents who are obese and do not tolerate maximal exercise.²⁵ Clinically, in addition to the 6-minute walk distance (6MWD), the test provides valuable information on blood pressure (BP), heart rate (HR), and oxygen saturation (SaO₂) levels.

Childhood obesity is associated with lifelong health concerns, which are a financial burden to the individual as well as to the health care system.⁴ Some of these consequences may be preventable by early identification and treatment. Given the health consequences of being OW and the increasing number of children and adolescents who are OW, a strong investment in the prevention of childhood obesity is needed. Previous work by Morinder et al²⁴ demonstrated the reproducibility of the 6MWT in children and adolescents (8–16 years) who were obese. To date, there are limited data on the effect of being OW on 6MWT performance in young children (< 9 years of age). Additionally, OW is defined clinically as body mass index (BMI) ≥ 85th percentile and < 95th percentile with obesity classified as ≥ 95th percentile.²⁶,²⁷ While literature exists on 6MWT performance in children who are obese,²⁴,²⁸ little is known about children who are categorized as OW. Therefore, the main purpose of this study was to evaluate 6MWT performance of young children who are normal weight (NW) and OW. A secondary purpose of the study was to determine the relationships between BMI, 6MWT performance and physical activity level in young children. Performance on the 6MWT included the distance walked and cardiovascular responses. The main hypotheses were: (1) Children who are OW would have a decreased 6MWD compared to children who are NW. (2) At rest, children who are OW would demonstrate higher systolic BP (SBP) and higher diastolic BP (DBP) compared to children who are NW. (3) Post 6MWT, children who are OW will demonstrate altered response to HR, BP, and SaO₂ levels when compared to children who are NW. (4) Children who are OW will have higher odds of being classified in the pre-hypertensive/hypertensive category as compared to children who are NW. (5) A strong and significant relationship will be observed between BMI and each of the following variables: measures of 6MWT performance and physical activity level.

METHODS

Subjects

This was a cross sectional study in which 70, 5-9 year old, elementary school children participated. Participants were recruited from 2 elementary schools (28 children from one school and 42 children from another school district) via convenience sampling. Fliers explaining the study were distributed to students in K-3rd grade with an invitation to participate. This study was approved by the Institutional Review Board at The Sage Colleges. Each child provided assent and the parent/guardian provided written consent for the child to participate in the study. Convenience sampling was used. Overweight/obesity was determined using body mass index (BMI). Based on the international BMI cut-off points for children, participants with a BMI of < 85th percentile were classified as NW and participants with a BMI of ≥ 85th percentile were classified as OW.²⁷

Materials and Procedure

Height and weight without shoes were measured using a stadiometer (Health o meter Professional Dial Scale, Sunbeam Products, Inc, Bridgeview, IL) to calculate the BMI for each child. The BMI was calculated using CDC's BMI Percentile Calculator for Child and Teen.²⁶ The 6MWT was performed indoors along a flat, straight walkway in accordance with the American Thoracic Society (ATS) guidelines.²⁹ The walking course lengths measured 18 m and 20 m in the two different school settings. The length of the corridor was marked every 3 m with a brightly colored tape. Cones were placed at either end of the walking course to indicate the beginning and end points. Additionally, the starting line, which marked the beginning and end of each lap, was marked on the floor using brightly colored tape. Instructions and demonstrations were given to each child. Participants were informed that the purpose of the test was to find out how far they could walk in 6 minutes and were instructed to walk the longest distance possible at their own pace during the allotted time. Hopping, skipping, running, and jumping were not allowed during the test. Only the standardized phrases for encouragement (eg, ‘keep going’, ‘you are doing well’) and announcement of time remaining were given to the participants. Before and immediately following the test, the participant's HR, BP, SaO₂, and RPE were recorded. Heart rate and SaO₂ were recorded using a finger pulse oximeter (Smiths Medical PM, Inc., Waukesha, WI). Manual HR readings using the radial pulse were initially taken in a subset of children. The HR readings taken manually corresponded with those obtained by the oximeter; all subsequent HR measurements were obtained with the oximeter. Blood pressure was recorded with an aneroid sphygmomanometer per guidelines stated by Frese et al.³⁰ Participants were tested either individually or in the presence of one other. Caution was taken to avoid peer influence by staggering the tests so that participants did not compete with each other. When two participants were tested in an overlapping fashion, two examiners were present to administer the test. The BP measurements were obtained by the same examiner for all participants to ensure reliability. Participants were not allowed to talk during the test except to express desire to stop the test per standard instructions. Prior to obtaining the resting HR, BP, and SaO₂ levels, participants were seated while receiving instructions on the test and RPE. Serial measurements were not obtained to ensure a true resting state; pre-exercise measurements were recorded as resting values. For RPE, each child was asked to rate the level of perceived exertion using the OMNI scale of perceived exertion.³¹,³² All testers who administered the 6MWT were trained to use the standard protocol. We used the age- and sex-specific BP reference standard of children to define prehypertension and hypertension.³³ Both SBP and DBP values < 90th percentile were defined as normal BP; SBP and/or DBP ≥ 90th percentile and < 95th percentile were defined as prehypertension; and SBP and/or DBP ≥ 95th percentile were defined as hypertension.³³

Physical activity level in our participants was assessed using a self-reported physical activity questionnaire completed by a parent/guardian (Appendix 1). We designed this questionnaire by incorporating questions that related to physical activity requirements specified for this age group based on expert committee recommendations.³⁴ Items 1, 2, 5, and 6 on the questionnaire were included to calculate a score that reflects physical activity. Items 3 and 4 were included to calculate a score that reflects screen time.

Data Analysis

Descriptive statistics were calculated for each variable. To assess differences in measures of 6MWT performance such as resting and post 6MWT HR, SBP, DBP, SaO₂ between young children who were NW and OW, independent t tests were used. A 3 way ANOVA (gender × age × BMI group) was used to assess differences in 6MWD. For the 6MWD, participants were classified in the following age groups: 5-6 years, 7-8 years, and 9 years. Additionally, a 2-way repeated measures ANOVA (time × BMI group) was used to assess the difference between resting and post 6MWT values for SBP, DBP, and SaO₂ levels. We conducted a binary logistic regression analysis to examine the association between BMI (NW/OW) and SBP categories (no hypertension/prehypertension). Pearson correlation coefficients were calculated to examine the relationship between BMI and following variables: measures of 6MWT performance and physical activity level. Despite detailed instructions and using the pictorial OMNI scale for RPE, we found RPE reported by these young children to be unreliable, regardless of the BMI group (NW or OW), with many children reporting higher values for pre-6MWT than post-6WMT. Therefore, we did not use this variable for further analysis. All analyses performed were 2-tailed with P values <.05 indicating statistical significance. Statistical analyses were performed using the Statistical Package for Social Sciences for Windows, version 19.0 (SPSS Inc, Chicago, Illinois).

RESULTS

Descriptive characteristics of the participants are presented in Table 1. The sample consisted of 64.8% white, 24.2% black, 9.2% Hispanic, and 1.8% other ethnic groups. Analyses between the NW and OW groups of children showed that resting and post-6MWT SBP were significantly higher in children who were OW (Table 2). The resting and post-6MWT SaO₂ levels were found to be significantly lower in children who were OW compared to the NW counterparts (Table 2). For the 6MWD, separate analyses conducted for each gender revealed no significant differences between the NW and OW groups for both boys (NW: mean 516.7(65.6) m, OW: mean 530.4 (83.6) m) and girls (NW: mean 529.8 (54.8) m, OW: mean 539.8 (39.6) m). Additionally, when 6MWD data were analyzed for each age group, no significant differences were noted between children who were NW and OW (5-6 years-NW: mean 536.7(61.9) m, OW: mean 491.0 (54.9) m; 7-8 years-NW: mean 539.9 (57.8) m, OW: mean 539.1 (50.7) m; 9 years-NW: mean 541.7 (73.6) m, OW: mean 578.6 (23.0) m). Repeated measures analysis for SBP, DBP, and SaO₂ levels revealed no significant interaction between group and time. Logistic regression analysis revealed that the odds that a child who was OW would fall within a prehypertensive category was 12 times that of a child who was NW (OR: 12.6; P = 0.02).

Table 1.

Participant Demographics and Anthropometric Data

	Group	Mean (SD)	P
Age (years)	NW	7.2 (1.2) T	0.764
		7.2 (1.3) G
		7.1 (1.2) B
	OW	7.3 (1.9) T
		7.3 (1.1) G
		7.4 (1.3) B
Sex	NW	26 G; 15 B
	OW	14 G; 15 B
Weight (kg)	NW	24.7 (4.8) T	<0.001*
		25.1 (4.0) G
		24.6 (6.4) B
	OW	34.9 (9.9) T
		33.3 (4.7) G
		36.0 (14.0) B
Height (cm)	NW	124.0 (8.8) T	0.017*
		123.0 (10.0) G
		125.5 (8.8) B
	OW	129.3 (9.0) T
		125.5 (10.1) G
		131.0 (9.1) B
Body Mass Index (percentile)	NW	55.5 (21.7) T	<0.001*
		57.2 (20.5) G
		51.7 (24.8) B
	OW	92.6 (3.28) T
		93.3 (3.92) G
		92.3 (3.87) B

^*Significant difference between NW and OW groups at P < 0.05 NW = normal weight (n = 41); OW = overweight (n = 29), T = total sample, G = Girls, B = Boys

Table 2.

Summary of Comparisons Between the Normal Weight and Overweight Groups

	Group	Mean (SD)	P
6MWD (m)	NW	525.4 (58.1)	0.899
	OW	535.2 (63.6)
Resting HR (bpm)	NW	87.1 (12.7)	0.743
	OW	88.2 (12.7)
Resting SBP (mmHg)	NW	97.5 (7.8)	0.002*
	OW	104.1 (8.9)
Resting DBP (mmHg)	NW	63.0 (6.4)	0.099
	OW	65.9 (7.6)
Resting SaO2 (%)	NW	98.0 (1.0)	0.028*
	OW	97.2 (1.1)
Post-6WMT HR (bpm)	NW	116.7 (15.7)	0.574
	OW	118.9 (15.9)
Post-6WMT SBP (mmHg)	NW	109.9 (9.1)	0.001*
	OW	118.4 (10.7)
Post-6WMT DBP (mmHg)	NW	62.7 (7.7)	0.137
	OW	65.7 (8.6)
Post-6WMT SaO2 (%)	NW	97.7 (1.0)	0.002*
	OW	96.8 (1.0)
Physical activity score	NW	13.1 (2.5)	0.159
	OW	12.1 (1.9)
Screen time score	NW	4.2 (1.5)	0.198
	OW	4.8 (1.6)

^*Significant difference between the 2 groups at P < 0.05. For the 6MWD, the P value for the 3 way ANOVA (gender × age × BMI group) is reported. For other measures, an independent t test was conducted

NW = normal weight; OW = overweight; 6MWD = 6-minute walk distance; HR = heart rate; SBP = systolic blood pressure; DBP = diastolic blood pressure; SaO₂ = oxygen saturation

Low to moderate relationships were noted between BMI and the following variables: resting SBP (r = 0.49; P < 0.01), resting DBP (r = 0.37; P < 0.01), post-6WMT SBP (r = 0.61; P < 0.01), and post-6WMT DBP (r = 0.38; P < 0.01). Correlation analysis to examine the relationship between physical activity level and measures of 6MWT performance showed physical activity scores to be significantly related only to post-6WMT SBP (r = −0.31; P < 0.01).

DISCUSSION

The current study examined differences in 6MWT performance between young children classified as OW and NW. Main findings suggest that the two groups are different in their resting and post 6MWT values for SBP and SaO₂ levels. Body mass index did not influence 6MWD as noted by the lack of difference between the two groups and the poor relationship between the two variables.

In the current study, the mean 6MWD for children who were NW was 534.2 m. This corresponds well with reference values (518.5 m) reported recently in children from the United States, ages 7 to 11 years.³⁵ Similar to several previous studies,³⁵,³⁶ we did not detect any significant differences in 6MWD based on sex. Additionally, when 6MWD data were examined separately for each age group and gender, no differences were noted between the NW and OW groups. Likewise, Klepper and Muir³⁵ did not identify any significant relationships between BMI and 6MWD in their sample. This is contrary to some of the findings reported in older children in other countries, which have shown a lower 6MWD in children who are OW compared to their NW counterparts.²⁴ The increased body mass in people who are OW demands more energy that can limit the distance covered.³⁷,³⁸ The findings from the only study conducted in the US correspond with our results. Importantly, discrepancies in reported differences in 6MWD between children who are OW and NW may be attributed to cultural differences among countries. An evaluation of physical activity level and BMI in children living in 3 different countries found that American children were less active and heavier than children elsewhere.³⁹ Klepper and Muir³⁵ suggest that reference values for performance on the 6MWT developed for children residing in one country may not be applicable to those in other countries, with lower 6MWD values reported for children residing in the United States.

Several other reasons may help explain the lack of 6MWD differences in the current study. Factors such as motivation, attitude towards physical activity, and musculoskeletal pain may affect 6MWD. These factors were excluded from the scope of this study. We also did not examine other factors that may influence the 6MWT performance including variations in the time of day the test was administered, choice of footwear, motivation, and attitudes toward physical activity. Another factor that could play a role is the length of the corridor. According to ATS, a long corridor results in fewer turns, which might lead to increased 6MWD.²⁹ Although the ATS guidelines for adults recommend a 30 m straight track,²⁹ a multicenter study conducted by Weiss et al⁴⁰ found that there was no significant difference in 6MWD among straight tracks ranging from 15-50 m. The walkways used in our study measured 18 and 20 m. In the present study, both the NW and OW groups performed the 6MWT in an identical length hallway so these differences should not have favored either group. Due to a variety of constraints involved with testing in a school setting, the test could not be performed with each student individually or with confirmation that participants began the test at a true resting state. Occasionally, testing was performed in pairs and despite instructions this could have led to children matching pace to peers.

It should be noted that we evaluated children who were in OW or obese categories defined by CDC, and only 7 of our children fell in the obese category. The participants in the studies performed by Morinder et al²⁴ were in the obese category with an average BMI value of >30 kg/m² compared to the average BMI of 20.5 kg/m² in the current study. This may have also led to smaller differences noted in our study between the two groups of children. Also, the post hoc analysis revealed that the power for 6MWD was 15% (overall post hoc power for this study ranged between 15-90% for various variables). Therefore, we may not have had large enough sample size and between group differences to detect any significant differences for this measure. Additionally, the observed changes in HR (rest vs. post 6MWT) in the current study were modest. This may indicate that the 6MWT used in the current study may not have been challenging enough to evaluate exercise capacity. Furthermore, the smaller differences in BMI between the 2 groups may not be detected by a submaximal test such as the 6MWT. Also, though BMI is regarded as one of the most common indicators of OW and obesity, it is not without limitations and is not an accurate measure of total body fat mass.⁴¹ This may have had an impact on our findings. Consideration needs to be made for the age difference between the studies that report differences in 6MWD based on BMI²⁴ and the current study. In younger children being OW may be related more to diet as opposed to activity level and may not necessarily translate to reductions in exercise capacity at this age. Literature on physical activity and obesity is variable and the causal relationship between physical activity, obesity and exercise capacity may be disputable. This age group may not lend itself well to reliably detect differences on a 6MWT. Though careful instructions were provided, there could have been a lack of understanding of the instructions. Little is known about the concurrent validity of the 6MWT and other laboratory based measures of exercise capacity in this age group. Therefore, further research to evaluate the usefulness of 6MWT in young children is needed.

One of the main findings was the increased levels of resting and post-6MWT values for systolic SBP in young children who were OW compared to their NW counterparts. Furthermore, our results suggest that the odds that a child who is OW would fall within a prehypertensive category is 12 times that of a child who is NW. These differences in young children are clinically relevant. Our findings correspond with a recent study conducted on Chinese children (3-6 years) that showed a significant positive correlation between sex- and BMI-adjusted waist circumference and systolic BP.⁴² The exact mechanism that leads to hypertension in children and adults who are OW is not known. Studies support various mechanisms that include sympathetic nervous system imbalance, impairment of the physiological mechanism of pressure natriuresis, hyperinsulinemia, and early vascular changes.⁴³,⁴⁴ Links between obesity and the development of hypertension are also associated with leptin and other neuropeptides.⁴³ Regardless of the mechanism, the elevated BP is a concern as cardiac risk factors track from childhood to adulthood.⁴⁵ Furthermore, cardiac risk factors during adolescence predict the development of subclinical cardiovascular disease,⁴⁶ coronary heart disease,⁴⁷ and mortality in adulthood.⁴⁸ Therefore, improving the cardiac risk factor profile of young children has long-term implications.⁴⁹

Another interesting finding of the current study was that children who were OW had lower resting and post-6WMT SaO₂ levels compared to their NW counterparts. These values were well within normal limits but warrant attention and further long term investigation as these differences early in childhood may lead to potential health concerns later in life. It is well understood that in individuals who are OW, the inspiratory muscles are faced with a greater load, which increases the work of the inspiratory muscles.⁵⁰ This additional elastic load must be overcome during each inspiratory muscle action, whether at rest or during exercise.⁵¹,⁵² The functional consequences of the increased demand in children who are OW could lead to lower SaO₂ levels due to potential exercise hypoxia. It should be noted that the post 6MWT differences in SBP and SaO₂ levels between the two groups may be due to the disparity seen in the groups at rest and not necessarily due to the responses during the 6MWT performance. We did not perform other cardiopulmonary measures that may provide additional insight. Future research to examine these differences between children who are NW and OW using additional cardiopulmonary measures is needed.

The current study did not detect any differences in pre-6MWT and post-6MWT HR between the two groups. There is conflicting evidence about this parameter in the literature. Morinder et al²⁴ found that overall 6MWD and exercise HR were significantly lower in children and adolescents (8–16 years) who were obese compared to children who were NW. Contrary to these results, another study reported higher resting HR in children (mean age 12.9 years) who were OW than children who were NW.⁵³ In contrast, no differences in HR were found between adult participants who were obese and lean.²³ The reason for these inconsistencies is uncertain, but motivation and attitude towards physical activity may affect 6MWD, and consequently, HR.

Low levels of activity and fitness are a major public health problem in many countries. Of concern is that children and adolescents spend extended periods of time being sedentary in and outside of school.⁵⁴ Physical inactivity is an established determinant of cardiac risk factors in children and adolescents (9-15 years).⁵⁵ However, whether patterns of sedentary behavior independently impact cardiac risk factors in young children is not completely known. The findings from the current study suggest a weak relationship between physical activity scores and post-6MWT SBP. A recent study by Maggio et al⁵⁶ shows that physical activity level and aerobic fitness were lower in children who were obese compared with controls who were NW. Future research needs to focus on the link between physical activity level and CVD risk profiles in young children. These research endeavors are important since many lifestyle habits, including physical activity, are established during childhood and adolescence.

LIMITATIONS

Some limitations of this study were the small sample size (post hoc power ranged from 15%-90% for various measures used) and number of participants in the obese category. Of the total 29 children who were classified in the OW category, only 7 were obese. This may have also led to smaller differences noted in our study between the two groups of children. As mentioned earlier, we also did not examine other factors that may have influenced the performance on the 6MWT, including variations in the time of day the test was administered, choice of footwear, motivation, and attitudes toward the physical activity. The physical activity questionnaire used in the current study has not been standardized and was used as a self-reported measure. This may explain the lack of significant and strong relationships noted between measures of 6MWT performance and physical activity level.

In summary, this study provides new data for clinical practice and adds to the limited research on 6MWT performance in young children who are OW residing in the United States. The differences noted in BP are important because hypertension in childhood has been shown to be linked to hypertension later in life.⁵⁷ Additional research is needed to further understand differences in cardiorespiratory fitness in children who are OW. This information is vital to allow physical therapists to design exercises that match the child's interests and physical abilities and to allow safe and successful participation in those activities. In the long term, this may promote an expanded role of physical therapists in community public health. Given the health and economic burden of childhood obesity over an individual's lifetime, this is important to physical therapist practice.

Appendix 1 Physical Activity Questionnaire

On a typical day:

• 1. How much time does your child spend in playing indoors in your house (or the house of a friend, neighbor or relative)?

  • □ 0-10 min
  • □ 11-30 min
  • □ 30-60 min
  • □ >60 min

• 2. How much time does your child spend playing outdoors (park, recreation area, playground, etc) in non school and non sports activities?

  • □ 0-10 min
  • □ 11-30 min
  • □ 30-60 min
  • □ >60 min

• 3. How much time does your child spend watching TV/DVD?

  • □ 0-30 min
  • □ 31-60 min
  • □ 61-90 min
  • □ 91-120 min
  • □ ≤120 min

• 4. How much time does your child spend playing video games or on the computer?

  • □ 0-30 min
  • □ 31-60 min
  • □ 61-90 min
  • □ 91-120 min
  • □ >120 min

In a typical week:

• 5. How much time does your child spend in physical education classes at school?

  • □ 0-10 min
  • □ 11-30 min
  • □ 30-60 min
  • □ >60 min

• 6. How much time does your child spend in playing recreational sports?

  • □ 0-10 min
  • □ 11-30 min
  • □ 30-60 min
  • □ >60 min

Please identify the sports activities: _________________________