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Risk-Taking Behavior During Adolescence Charles E. Irwin, Jr., M.D. Department of Pediatrics Division of Adolescent and Young Adult Medicine UCSF Benioff.

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Presentation on theme: "Risk-Taking Behavior During Adolescence Charles E. Irwin, Jr., M.D. Department of Pediatrics Division of Adolescent and Young Adult Medicine UCSF Benioff."— Presentation transcript:

1 Risk-Taking Behavior During Adolescence Charles E. Irwin, Jr., M.D. Department of Pediatrics Division of Adolescent and Young Adult Medicine UCSF Benioff Children’s Hospital University of California, San Francisco March 2014

2 A similar version of this presentation was presented during Grand Rounds at Children’s Hospital Boston in October 2009.

3 Majority of morbidity/mortality during adolescence is preventable Behaviors responsible for leading causes of morbidity/mortality during adulthood in the U.S. are initiated during second decade of life (e.g., smoking, substance use, physical inactivity, sexual behavior, driving, etc.) Co-occurrence of risk behaviors is common Risk Taking – Background

4 Leading Causes of Death in U.S.: Ages 10-19 & Ages 25-44, 2010 Source: National Center for Injury Prevention & Control, WISQARS database, 2012

5 Risk-Taking Behavior Volitional Potential for Negative Outcome Lack of Cognitive Competence regarding Negative Outcomes

6 Risky Behaviors During Adolescence

7 Specific Behaviors & Outcomes Substance Use: Habituation & Trauma Sexual Activity: STI’s & Pregnancy Injury Related Behavior: Trauma & Disability Eating Behaviors: Eating Disorders, Obesity & Chronic Physical & Mental Health Disorders

8 Alcohol Use Among High School Students, 2011 Source: Youth Risk Behavior Surveillance System, 2011

9 Cigarette Use Among High School Students, 2011 Source: Youth Risk Behavior Surveillance System, 2011

10 Other Tobacco Use Among High School Students, 2011 Source: Youth Risk Behavior Surveillance System, 2011

11 Illicit Substance Use Among High School Students, 2011 Source: Youth Risk Behavior Surveillance System, 2011

12 Sexual Activity Among High School Students, 2011 Source: Youth Risk Behavior Surveillance System, 2011

13 Seatbelt and Helmet Use Among High School Students, 2011 Source: Youth Risk Behavior Surveillance System, 2011

14 Driving and Alcohol Use Among High School Students, 2011 Source: Youth Risk Behavior Surveillance System, 2011

15 Health Risk Behaviors - Trends Arrows denote trends in prevalence over past decade Injury-related behaviorTobacco use Unsafe sexual behaviorAlcohol use Inadequate physical activityMarijuana use Poor nutritional habitsPrescription & OTC use Violence

16 Covariation of Behaviors Injury-related Behavior & Substance Use (e.g., Alcohol) Substance Use/Substance Use, Sequence & Developmental Trajectory by Gender Sexual Behavior & Substance Use Eating Behaviors & Other Risk Behaviors Certain Behaviors as Markers (e.g., Sexual Activity, Substance Use, etc.)

17 Single & Multiple Risk-Taking Among 7th- 12th Graders, by Behavior Source: Urban Institute, 2000, analysis of 1995 Add Health data 5% 7% 11% 14%

18 Covariation of Risk Behaviors Among Adolescents (% of Sx, N=1241) Dangerous vehicle users include subjects who reported driving or riding in vehicles when the driver is under the influence of alcohol or other substances. Source: Irwin et. al.. 1998 Sexually Active TobaccoAlcoholMarijuanaDangerous Vehicle Use Sexually Active 100.083.088.074.216.7 Tobacco44.7100.091.766.512.8 Alcohol40.077.8100.057.412.0 Marijuana56.293.895.3100.015.6 Dangerous Vehicle Use 58.082.390.871.9100.0

19 Distribution of Health Risk Behaviors by Race/Ethnicity, 7th-12th Grade Percent Participating # of Risk Behaviors Source: Add Health, 1995

20 Risk Behaviors in Young People with Chronic Conditions Greater rate of risky behaviours in Swiss youth with chronic conditions (n=7548) current smoking 1.32 (1.13, 1.54) illegal drugs1.49 (1.15, 1.92) early sexual debut1.33 (1.03, 1.72) eating disorder 1.44 (1.26, 1.74) antisocial acts 1.48 (1.26, 1.74) attempted suicide2.24 (1.55, 3.24) Youth with chronic conditions were more likely to report multiple simultaneous behaviours Suris et al. Pediatrics 2008

21 Covariation of Behaviors Summary of Covariation of Behaviors High Prevalence Rate Early Age of Onset Gender Specificity Peers/Family Behaviors/Not Isolated

22 Theoretical Models of Risk-Taking Behavior

23 Risk Taking as a Dispositional Trait Risk-Taking Viewed As Deviant & Pathological Poor Self Esteem Inadequate Social Skills Propensity for Unconventionality Problem Behavior Theory

24 Risk Taking as a Dispositional Trait Risk-Taking Viewed As Individual Differences Sensation Seeking Theories Locus of Control

25 Risk Taking as a Dispositional Trait Risk-Taking Viewed As Individual Differences Sensation Seeking Theories Locus of Control

26 Risk-Taking From an Ecological Perspective Microsystems & Mesosystems: Peers & Parents Exosystems: Neighborhoods, Communities, and the Media Macrosystems: The Impact of Culture

27 Biological Models of Risk-Taking Genetics Neuroendocrine & Hormonal Influences Timing of Pubertal Events Brain development/maturation

28 Brain Development Grey matter volume peaks in early adolescence Selective pruning proceeds ‘from back to front’ Greater efficiency of neurotransmission results from myelination Neuromaturation underpins emotional regulation &control

29 Biopsychosocial Model of Risk-Taking Dispositional and ecological Biological development during adolescence Psychosocial significance of puberty Psychosocial development Environmental context

30 Causal Model of Adolescent Risk-Taking Behavior

31 Cognitive Scope  Egocentrism  Future time perspective Self Perceptions  Self-esteem  Body image  Self-reliance  Tolerance  Identity Perceptions of Social Environment Parental:Peer:  Influence  Controls  Supports Personal Values interdependence  Affection  Achievement Biological Maturation Risk Perception  Optimistic bias  Costs  Controllability  Benefits Characteristics of Peer Group  Peer age, values & behavior Risk-Taking Behavior Causal Model of Adolescent Risk-Taking Behavior

32 Biopsychosocial Development

33 A Model of Development Puberty heightens emotional rousability, sensation-seeking, reward orientation Period of heightened vulnerability to risk taking, problems in terms of affect & behaviour Maturation of brain facilitates regulatory competence Early adolescence 10-14 yrs Mid adolescence 15-19 yrs Late adolescence 20-24 yrs Steinberg

34 Brain development now extends into the adolescent years Most of this development occurs in the frontal lobe - Executive functions - Planning - Reasoning - Impulse control Adolescent Brain Development

35

36 Physiological Maturation and Development: Timing Body image Physical abilities Sexuality Hormonal effects

37 Mechanism of Linkages: Biology/Behavior Interface Maturation (Timing): Environmental pressure Early maturing females: Greater risk for problem behavior/brought in by parents with complaints of problem behaviors Late maturing males: Parents and adolescents concerned by lack of development, often viewed as precocious for stage of physical development

38 Precocious Puberty ("Natural Experiment") Literature More behavioral problems More troubled Depressed Aggressive Decreased social competence

39 Association of Psychosocial Events with Physiological Maturation Changes in family interactions Peer relationships and expectations Patterns of intimacy Educational achievements Heterosocial behavior

40

41 Specific Examples of Interface of Timing of Maturation/Development Early Maturing Females More risk/problem behaviors "Endomorphic”: Dissatisfaction with physical development Lower self esteem Less recognition by same sex peers Identity crises

42 Early Maturing Females, cont. Increased needs for independence Social networks/older adolescents Environmental pressure Increase in heterosocial behavior Early sexual debut Specific Examples of Interface of Timing of Maturation/Development

43 Late Maturing Females Less risk/problem behaviors Higher self-esteem More parental/environmental support Delay in initiation of sexual behavior Specific Examples of Interface of Timing of Maturation/Development

44 Early Maturing Males More risk/problem behaviors Early sexual debut Specific Examples of Interface of Timing of Maturation/Development

45 Late Maturing Males Less risk/problem behaviors "Ectomorphic" body type Negative self-concept and body image Social disadvantage Specific Examples of Interface of Timing of Maturation/Development

46 Late Maturing Males, cont. Less masculine in behavior More identity crises More rebellious and impulsive Expressive and dynamic More parental/environmental support Specific Examples of Interface of Timing of Maturation/Development

47 Clinical Visit General Questions Useful in Assessing the Extent of Risk Behaviors Checklist of Factors for Risk Behaviors Health Risk Behaviors and Their Acute and Chronic Medical Consequences Physical Signs in the Risk Behaviors Screening Laboratory Tests in Risk Behaviors

48 Physical Signs with Risk Behaviors Recreational/ motor vehicle use Skin: Abrasions; Ecchymoses; Lacerations; Musculoskeletal—fractures, sprains (acute and chronic) Sexual activityReproductive skin rash consistent with disease process; Adenopathy; Amenorrhea; Genital lesions; Vaginal/penile discharge; Cervical discharge, edema, friability; Uterine/adnexal tenderness; Enlarged uterus (pregnant) HIV = human immuodeficiency virus, STI = sexually transmitted infections

49 Substance use General: Agitation, anxiety; Decreased general functional status—sleep disturbances, anorexia; Infection with HIV, hepatitis B, other STDs Skin: Multiple bruises; Track marks; Abscesses Central nervous system/mental status: Altered mental status; Decreased short-term memory; Decreased motivation; Decreased fine motor movements; Diminished coordination Head, eyes, ears, nose, oropharynx: Injected conjunctivae; Chronic nasal discharge, nasal mucosal irritation; Recurrent nosebleeds; Leukoplakia, gingival recession, dental caries; Mucosal inflammation (nasal passages, oropharynx); Malodorous breath Breast: Gynecomastia (males) Cardiorespiratory: Tachycardia; Hypertension; Evidence of deconditioning; Chronic cough, recurrent bronchitis Gastrointestinal: Abdominal pain and dyspepsia; Weight loss; Liver tenderness or enlargement Musculoskeletal: Poor muscle tone/strength HIV = human immuodeficiency virus, STI = sexually transmitted infections Physical Signs with Risk Behaviors

50 Screening Laboratory Tests in Risk Behaviors Substance use Substance use screen of urine, serum, gastric contents in acute intoxication, psychiatric symptoms, acute behavior changes Liver function test-ALT, AST, y-glutaryl transpeptidase (alcohol use) Hepatitis B – HbsAg, HbsAb, HbcAg (parental drug use) Human immunodeficiency virus antibody (parenteral drug use) Sexual activity Urine for STI’s (GC, CT) Cultures and vaginal smears for sexual transmitted infection Papanicolaou smear Pregnancy tests RPR (syphilis) Human immunodeficiency virus antibody (HIV) Motor vehicle/ recreational vehicle Substance use screen of urine and blood

51 General Questions Useful in Assessing the Extent of Risk Behaviors

52 Introduction Sometimes young people do things that might be considered risky, or they take chances.

53 General Questions Do you do anything that you would consider risky or dangerous? What kinds of activities do you do? How many of your classmates do things that you consider risky or dangerous? What kinds of activities do they do that you think are risky? How many of your four closest friends would you say do things that are risky or dangerous? What kinds of activities do they do that you think are risky?

54 Questions Using Alcohol Use as an Example Have you ever used alcohol? If yes, how often and how much do you drink? Under what conditions? With whom? When was the last time you had a drink? How many of your classmates drink alcohol? How about your four closest friends? How many of them drink alcohol? Do your parents drink?

55 Questions About Related Behaviors (For each behavior, ask about frequency, intensity and situational context) Have you ever taken any other drugs? Have you ever used alcohol or drugs prior to riding a bicycle or skateboard? Have you ever ridden in a car when the driver had used alcohol or drugs prior to driving? Have you ever driven a car when you had used alcohol or drugs prior to driving? Have you ever had sexual intercourse? (If yes, query about use of substances prior to sexual activity)

56 Anticipatory Guidance (For each behavior – key messages) Avoiding tobacco is very important for your health Smoking/Chewing tobacco becomes a habit that is hard to break Avoiding alcohol and drugs is very important for your health and safety Wear a seatbelt every time you ride in a car Wear a helmet every time you blade/board/ bike/scooter Avoiding sex is the safest way to prevent pregnancy, STI’s &AIDS.

57 Checklist of Factors for Risk Behaviors

58 Biopsychosocial Asynchrony of physiologic/psychosocial development - early vs. late maturation Developmental drives during adolescence – stage of adolescence Attitudes/beliefs – Sense of competence/invulnerability – Lack of awareness of consequences Male gender

59 Socioenvironmental Peer group known to be engaging in problem behaviors Parenting/family style – Authoritarian/permissive vs. Authoritative – Chronic family conflict – Family history of alcoholism/substance abuse – Lack of cohesiveness – Parental/family use of substances, incl. cigarettes & alcohol Life transitions School transitions Ready availability of substances, vehicles

60 Behavioral Lack of skills to resist peer pressure Sensation-seeking drives Personality factors – Depressive symptomatology – Anxiety – Insufficient coping mechanisms – Poor self-esteem

61 Intervention and Prevention Programs: Generalities Focus on developmental needs of adolescents Focus on physiological development/chronologic age similarity and disparity Critical factors in intervention

62 Five Principles of Prevention/Intervention ÊGeneric approach ËSingle behavior as marker ÌDelay onset of behavior – anticipatory guidance ÍProvide alternatives ÎInsulate from most negative outcomes

63 Screening Adolescents for Risky Behavior Behavior? Start? Amount? Frequency? Environment?

64 TOBACCO Amount? How many cigarettes (or snuff) do you usually smoke (or chew) in a day? Frequency? How often do you smoke/chew tobacco? Environment? Do your friends use tobacco? Does anyone in your family or household use tobacco?

65 TOBACCO Behavior? Do you ever smoke cigarettes or cigars, or chew tobacco? Start? How long have you been smoking/chewing? When was the last time you smoked/chewed tobacco? Has a doctor ever told you that you have asthma?

66 TOBACCO KEY MESSAGES Message 1 Avoiding tobacco is very important for your health Message 2 Smoking/Chewing tobacco becomes a habit that is hard to break Message 3 – for teens who smoke/chew only When you decide to stop using tobacco, I can help you and there are resources to help you

67 References Halpern-Felsher BL, Millstein SG, Irwin CE, Jr.: Healthy adolescent psychosocial development. Journal of Adolescent Health, 31(Supp 6): 216 - 225. 2002. Irwin CE, Jr.: The Theoretical Concept of At-Risk Adolescents, Adolescent Medicine: State of the Art Reviews, 1:1 - 14. 1990. Irwin CE, Jr., Burg SJ, Uhler Cart C,: America’s adolescents: Where have we been, where are we going? Journal of Adolescent Health, 31;(Supp 6):91 - 121. 2002. Irwin CE, Jr, Cataldo MF, Matheny AP, Peterson L: Health consequences of behaviors: injury as a model. Pediatrics, 90:798 - 807. 1992. Irwin CE, Jr., Duncan P; Health Futures of Youth II: Pathways to Adolescent Health. Journal of Adolescent Health, 31;(Supp 6): 82 - 89. 2002. Irwin CE, Jr., Halpern-Felsher BL: Commentary on Developmental Sources of Crash Risk in Young Drivers. Injury Prevention 8, Supp II, 21 - 23. 2002. Irwin CE, Jr., Igra V, Eyre SE, Millstein SG: Risk taking behavior in adolescents: the paradigm. In: Jacobson MS, Rees JM, Golden NE, Irwin CE, Jr. (eds.), Adolescent Nutritional Disorders: Prevention & Treatment. The Annals of the New York Academy of Sciences, Vol. 817. New York, NY: The New York Academy of Sciences, pp 1 - 35. 1997. Irwin CE, Jr., Millstein SG: Biopsychosocial correlates of risk-taking behaviors during adolescence. Journal of Adolescent Health Care, 7:82S-96S. 1986. Jessor R. and Jessor SL. Problem behavior and psychological development: A longitudinal study of youth. New York: Academic Press, 1977.

68 References Millstein SG, Irwin CE, Jr., Adler NE, Cohn LD, Kegeles SM, Dolcini MM: Health-risk behaviors and health concerns among young adolescents. Pediatrics, 89:422 - 428. 1992. Ozer, EM, Irwin CE, Jr.: Adolescent and Young Adult Health: From Basic Health Status to Clinical Interventions. In: Lerner RM, Steinberg, Handbook of Adolescent Psychology, 3 rd Edition. Hoboken, New Jersey. John Wiley & Sons pp. 618-641. 2009 Pirkis JE, Irwin CE, Jr., Brindis C, Patton GC, Sawyer MG. Adolescent Substance Use: Beware of International Comparisons. Journal of Adolescent Health, 33:279 - 286. 2003. Rivara FP, Park MJ, Irwin CE, Jr.: Trends in Adolescent and Young Adult Morbidity and Mortality. In: Di Clemente RJ, Santelli J, & Crosby RA (eds.), Adolescent Health: Understanding and Preventing Risk Behaviors. San Francisco: Jossey-Bass. pp. 7-29. 2009 Sales JA, Irwin CE, Jr.: Theories of Adolescent Risk Taking: The Biopsychosocial Model. In: Di Clemente RJ, Santelli J, & Crosby RA (eds.), Adolescent Health: Understanding and Preventing Risk Behaviors. San Francisco: Jossey- Bass. pp. 31-50. 2009. Steinberg L. Risk taking in Adolescence: New perspectives from the brain and behavioral science. Current Directions in Psychological Science, 16:55-59. 2007 Steinberg L. Risk taking in adolescence: What changes and why? Annals of the New York Academy of Sciences, 101,51-58. 2004 Tschann JM, Adler NE, Irwin CE, Jr. et al. Initiation of substance use in early adolescence: the role of pubertal timing and emotional distress. Health Psychology 12(3): 200-08, 1993. Turner R, Irwin CE, Jr., Millstein SG: Family structure, family processes and experimenting with substances during adolescence. Journal of Research on Adolescence, 1:93 - 106. 1991.

69 Screening for Other Behaviors Alcohol/Drugs Helmet/Seatbelt Use Sexual Behavior Nutrition/Sugared Drinks Nutrition/Fast Food Physical Activity

70 ALCOHOL & DRUGS Behavior? Have you ever drunk alcohol/used drugs? What kind of alcohol/drugs do you use? Start? How long have you been using alcohol/drugs? Amount? How much do you usually drink? How much (quantify for specific drug) do you usually use/take/smoke? Have you ever had 5 or more drinks of alcohol in a row or engaged in binge drinking?

71 ALCOHOL & DRUGS Frequency? How often do you drink/use drugs? Environment? Do any of your friends or family drink alcohol/use drugs? Have you ever been in a car with a driver after he/she was drinking/using drugs? Have you ever driven after drinking/using drugs?

72 ALCOHOL & DRUGS KEY MESSAGES Message 1 Avoiding alcohol and drugs is very important for your health and safety Message 2 Avoid driving a car, riding a bike, skateboarding, swimming, boating, riding a scooter, or doing any activity that is dangerous under the influence of alcohol/drugs or with someone who is under the influence

73 HELMET/SEATBELT Behavior? Do you use a seatbelt when riding in/driving a car? Do you wear a helmet when riding/biking/ skateboarding/blading/using a scooter? Start? Have you ever driven/biked/skateboarded/ bladed/scooted after drinking or using drugs

74 HELMET/SEATBELT Amount? Do you own a helmet? Frequency? How often do you use your seatbelt when riding in a car? How often do you wear your helmet when riding/biking/skateboarding/blading/using a scooter? Environment? Do your friends wear seatbelts? Do your friends wear helmets

75 SEATBELT USE KEY MESSAGES Message 1 Wear a seatbelt every time you ride in a car (for teens 15 ½ and older add: and every time you drive a car)

76 HELMET USE KEY MESSAGES Message 1 Wear a helmet every time you blade/board/ bike/scooter Message 2 If you don’t have a helmet, don’t blade/ board/bike/scooter until you get one

77 SEXUAL BEHAVIOR Behavior? Have you had vaginal sex? Oral sex? Anal sex? Have you had sex with guys, girls, or both? Start? When did you most recently have sex? Do you think you or your partner could be pregnant? Have you ever been pregnant or had a partner who became pregnant? Do you think you or your partner could have a sexually transmitted infection or STI? Have you ever had an STI? Has a partner of yours ever had an STI?

78 SEXUAL BEHAVIOR Amount? Have you had sex with anyone other than your current/most recent partner? When? How many sexual partners have you had? Frequency? How often do you have sex? Environment? Do you use any form of birth control/std prevention when having sex? If yes: What type of birth control/STI prevention do you use? How often do you use (fill in) method of birth control/std prevention? Have you ever felt pressure to have sex? Were you using alcohol/drugs when you had sex?

79 SEXUAL BEHAVIOR KEY MESSAGES Message 1 Avoiding sex is the safest way to prevent pregnancy and sexually transmitted infections or HIV/AIDS Message 2 If you choose to have sex, be responsible: – Use a condom every time you have sex – If you don’t have a condom, don’t have sex – To ensure you don’t get pregnant or get your partner pregnant, and as a backup to a condom, use another form of birth control such as oral contraceptives or Depo Provera – If you have unprotected intercourse, you may obtain emergency contraception

80 NUTRITION, SUGARED DRINKS Behavior? Do you drink regular soda/other sweetened beverages/juice? (examples below) – Regular soda: Coke, Pepsi, Mountain Dew, 7-up, Sprite, etc. (not diet soda) – Other sweetened beverages: lemonade, Hawaiian Punch, Nestea, Kool-aid, Tampico, Horchata, Sunny-D, etc. – Juice: all juices, even 100% fruit juices including apple, orange, grape, cranberry, etc.

81 NUTRITION, SUGARED DRINKS Amount? When you do drink a regular soda/other sweetened beverage/ juice, how much do you have? (one cup = 8 oz, 1 can = 12 oz, 1 glass = 12-16 oz, 1 bottle from vending machine = 20 oz) Frequency? How many regular sodas/other sweetened beverages/juices do you drink per day/week? Environment? Are there sodas/sweetened beverages/juice at home? Where else do you get soda/sweetened beverages/juice? (school, corner store, mall, day care/after school program, etc.)

82 NUTRITION, FAST FOOD Behavior? Do you ever have fast food? (include going out, drive through and take-home from McDonald’s, Burger King, In and Out, Wendy’s, etc.) Amount? When you have fast food, what do you normally order?

83 NUTRITION, FAST FOOD Frequency? How many times per day/week do you have fast food? Environment? Do you get fast food with your family/friends? Do they serve fast food at school? Do you go out for lunch (open campus)?

84 NUTRITION KEY MESSAGES Sugared Beverages Message 1 Cutting down on soda, sugared beverages and juice is important for weight control and health Additional Message Drink water and low fat milk (2%, 1% or fat free) most of the time (have diet soda, if you must)

85 NUTRITION KEY MESSAGES Fast Food Message 1 Limit fast food to no more than once a week Additional Message When you do have fast food, order a smaller sized meal (like a hamburger instead of a double cheeseburger) and drink water instead of soda, or diet soda if you must

86 PHYSICAL ACTIVITY Behavior? What activities or sports do you like to play/do? (include organized sports such as soccer and basketball, in addition to unstructured activities like walking to school and dancing) Amount? Do you do any of those activities or sports for at least 20 minutes until you are breathing heavy and breaking a sweat?

87 PHYSICAL ACTIVITY Frequency? How many times per week do you play/practice/do these activities or sports for at least 20 minutes? Environment? Do you do any activities or sports with your family/friends? Is your neighborhood safe to go outside and play? Do you have a stationary bike or treadmill at home? Do you have PE class at school? Is there a neighborhood recreation center where you can go (for example, YMCA, Boys and Girls club, etc)?

88 PHYSICAL ACTIVITY SEDENTARY ACTIVITIES Behavior? Do you watch TV or movies, play video games, or use the computer for fun (such as games, email, instant messaging)? Amount? How many hours per day are you spending in front of the TV, video, computer screen? Frequency? Are you doing this every day? Mostly on weekends? During vacation? (to estimate average daily screen time)

89 PHYSICAL ACTIVITY SEDENTARY ACTIVITIES Environment? Do you have a TV in your room? Are you eating while watching TV? Do you have a VCR/DVD player at home? Can you use it for an exercise video, like Tae Bo? If you have a treadmill/exercise bike, can you put it in front of the TV so that you can walk/bike while watching?

90 PHYSICAL ACTIVITY KEY MESSAGES Physical and Sedentary Activities Message 1 Find an activity/sport that you like and do it every day (goal is 60 minutes total per day) Additional Messages Cut down on TV, computer and video time (this does not count homework) Remove the TV from the bedroom Don’t eat in front of the TV

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