Table 3.

Key considerations for exercise interventions in pediatric obesity management

No	Consideration	Action	Example
1	Identify pediatric contraindications to exercise.	Determine whether signs and symptoms contraindicate participation in an exercise intervention or whether the design or implementation of the exercise intervention should be modified based on identified red flags.	• Early morning stiffness and polyarticular pain identified on objective assessment. Further work-up should exclude juvenile idiopathic arthritis. Adaption to exercise intervention will be required to manage fatigue and joint pain. •Unilateral limp, reduced range of motion at hip and/or unilateral knee pain identified on objective assessment. Further work-up should exclude slipped capital femoral epiphysis (SCFE) and exercise intervention should be withheld until SCFE is excluded. • Neuromotor delay and increased tone noted during objective assessment. Further work-up should exclude neurological disease or developmental disorder. Adaption of exercise intervention will be needed to address any motor asymmetry, muscle spasm, or muscle weakness. • Fracture history should be noted, including mechanism of injury and if concerned further work-up to assess bone health and exclude osteopenia or other condition. Adaption to exercise intervention might include specific bone building exercises or avoidance of certain movements or contact sports that might increase risk of fracture.
2	Treatment planning of exercise intervention based on objective findings of clinical assessment.	Modify or adapt exercise intervention in line with baseline fitness and underlying health complications or impairments.	• Knee pain may require initial intervention using non-weight-bearing exercise or specific physical therapy intervention.                • • Hypertension may necessitate paced increase in intensity and avoidance of exercises that precipitate valsalva maneuver. • Urinary incontinence may require specific physical therapy intervention addressing pelvic floor function, avoidance of high-impact activities, management with sanitary products, or onward referral.
3	Facilitate buy-in and understanding regarding the aim of the exercise intervention.	Explain how a tailored exercise intervention can address the strengths and impairments of the child identified during the clinical assessment phase.	Explain the benefit of increasing fitness for enhancing the activities and tasks the child is already good at and for improving confidence, insulin sensitivity, blood pressure, and body composition.
4	Planning of exercise intervention based on developmental, socioeconomic, and cultural context.	Design exercise intervention appropriate to child’s age, developmental stage, socioeconomic situation, and cultural considerations.	Child may not possess optimal fundamental motor skills needed for joining in with peers, may not be able to afford to join a gym/sports, or may be discouraged to exercise if female. Incorporation of training for fundamental motor skill will be required as part of exercise intervention.
5	Planning of exercise intervention around child’s preferences and social support available.	Optimize engagement with and adherence to exercise intervention by incorporating activities the child finds enjoyable and those for which support exists from family members, peers, teachers, or friends.	If child is nervous about team-based games/exercise, focus should be on active play and increasing levels of fun by letting the child suggest activities/games. Encourage parents/siblings/peers to support and play with child.
6	Consider body image, self-efficacy, confidence, and skin chafing.	Optimize adherence to the exercise intervention by addressing negative body image, low self-efficacy, or low moto-r-confidence if present. Address skin chafing if present.	Incorporate activities to optimize posture, balance, and confidence in movement. Encourage child/adolescents to wear comfortable clothing and underwear (e.g. cotton sports bra) that support movement. Advise on use of talcum powder and petroleum jelly if appropriate.
7	Address fear of falls if present.	Assess whether and how child can get up independently if they fall or are playing on the floor.	Teach backward chaining* to encourage independence and confidence around getting up from floor.
8	Use goal setting to plan child-centered exercise intervention.	Plan specific, measurable, achievable, realistic, and time-based goals with the child and parent/s to build physical function and physical fitness. Consider family’s usual routine and aims of the child.	Child may first aim to walk to school without discomfort, meeting peers/siblings for outdoor play or improve ball skills followed by participating more in physical education class, learning to ride a bicycle, and joining organized sports or activities. Family aims to play/conduct the prescribed games/activities for 30 mins. with the child twice per week (Wed and Sat) in addition to bringing to supervised exercise session twice per week (Mon and Fri).
9	Reduce sedentary time.	Assess the time child spends using screens for entertainment, sitting throughout the day, and number of movement breaks.	Educate family and child about importance of breaking up and reducing sedentary time where possible.
10	Use FITT-VP.	Use baseline assessment and fitness level to determine the frequency, intensity, time, type, volume, and progression of the exercise intervention.	If the child has severe obesity, low aerobic fitness, low musculoskeletal fitness, low activity levels, and high sedentary time, commence exercise intervention with shorter bouts of low intensity preferred activity 2–3 times per week, aiming to build up time, intensity, and variety of exercise.
11	Decide on metrics/outcomes to evaluate exercise intervention.	Consider the length of intervention and what health outcomes can realistically change within that time. Ensure family are aware of these in addition to planned impact on body composition.	Aim of intervention might be to walk to school without pain or fatigue, to reduce blood pressure, to increase strength of quadriceps, to improve standing balance, or to reduce musculoskeletal pain with more intense activity/exercise.

*Backward-chaining breaks a particular movement task down into steps. In the case of falls, the patient starts learning the task of getting up from the floor back up into standing or sitting on a chair. The patient starts in the most stable position and only progresses to more unstable positions (on knees, sitting, or lying on floor) as they are able