SPECIAL POPULATIONS

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Making a Strong Case for Prioritizing Muscular

Fitness in Youth Physical Activity Guidelines
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Avery D. Faigenbaum, EdD, FACSM;1 James P. MacDonald, MD, FACSM;2

Andrea Stracciolini, MD, FAAP, FACSM;3 and Tamara Rial Rebullido, PhD 4

physical activity could yield billions of

Abstract dollars in medical cost savings and have
Although evidence indicates that muscular fitness is foundational for ongo- far-reaching positive effects on adult-
ing participation in active play, exercise and sport, current national and hood earnings (3,4).
international youth physical activity guidelines underplay the critical impor- Despite the well-established benefits
tance of strength-building activities during this developmental phase of life. of physical activity, global levels of
In view of troubling trends in muscular fitness in today's youth, specific youth physical inactivity remain high
recommendations to address neuromuscular deficiencies are required. An (5,6). Data from 1.6 million students aged
understanding of the multidimensional development of youth physical inac- 11 to 17 years from 146 countries re-
tivity and the importance of muscular fitness are needed to have the most vealed that more than 80% were insuffi-
significant impact on youth physical activity at the population level. The ciently active (5). These findings are
mounting evidence of the detrimental effects of physical inactivity on youth consistent with the 2018 Global Matrix
warrant a review of existing physical activity recommendations and guide- 3.0 Physical Activity Report Card con-
lines. The proposed pediatric activity pyramid recognizes the shared impor- firming very high levels of physical in-
tance of strength, skill, and aerobic activities required for the successful activity among youth in the 5- to
implementation of sustainable youth physical activity interventions. 17-year age range (6). Despite ongoing
efforts over the past few decades to ad-
dress this phenomenon, participation in
Introduction physical activity among children and adolescents remains per-
Since the publication of the landmark report on physical sistently low in the context of school, home, and community
activity and health by the United States Surgeon General in settings. Since the decline in physical activity appears to emerge
1996, regular participation in physical activity has increasingly very early in life (7), and physical activity behavior tends to
been recognized as a passport to good health and well-being track from childhood to adolescence (8), the current and future
(1). It is widely recognized that all types of physical activity — health of many contemporary youth is compromised. Invest-
from active transportation to competitive sport — can improve ment at all levels is needed to combat physical inactivity in chil-
the physical and mental health of participants (2). Regular dren and adolescents and encourage uptake and maintenance
physical activity can reduce the risk of noncommunicable dis- of physical activity throughout the life course.
eases, including heart disease, diabetes, and some types of cancer, Public health guidelines constitute a key information resource
and can help to prevent hypertension, overweight, and obesity for parents, policymakers, and health care professionals. It is
(2). Physical activity also offers social and economic benefits. important to regularly assess the efficacy and practicality of
It has been estimated that even modest increases in youth these guidelines to guide policy development and goal setting
for physical activity promotion. The most common recom-
mendation in these documents is that all youth accumulate
1
Department of Health and Exercise Science, The College of New Jersey, at least 60 min of moderate to vigorous physical activity daily
Ewing, NJ; 2Division of Sports Medicine, Nationwide Children’s Hospital, (MVPA), with the majority of the daily discretionary activity
Ohio State University College of Medicine, Columbus, OH; 3Division of classified as aerobic (9,10). Although evidence indicates that
Sports Medicine, Department of Orthopaedics, Boston Children’s Hospital,
Harvard Medical School, Boston, MA; and 4Tamara Rial Exercise & Women’s
muscular fitness activities are foundational for ongoing partic-
Health, Newtown, PA. ipation in active play, exercise, and sport (11–13), current na-
tional and international youth physical activity guidelines
Address for correspondence: Avery D. Faigenbaum, EdD, FACSM, FNSCA, underplay the critical importance of strength-building activi-
Department of Health and Exercise Science, The College of New Jersey, ties throughout childhood and adolescence (9,10). To this
2000 Pennington Road, Ewing, NJ, 08628; Email: faigenba@tcnj.edu.
1537-890X/1912/530–536
point, global declines in youth MVPA have coincided with
Current Sports Medicine Reports temporal declines in measures of muscular fitness in children
Copyright © 2020 by the American College of Sports Medicine and adolescents (14–17).

530 Volume 19  Number 12  December 2020 Muscular Fitness in Youth

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 It is time to reconsider the complexity and multifaceted na-
ture of physical inactivity in youth and upgrade generic physical
activity guidelines that fail to address the specific needs and
abilities of this population. While it is unlikely that one strategy
will be the answer, the current approach for promoting physical
activity in children and adolescents is suboptimal, demonstra-
bly lacking in effect. The global rise of noncommunicable dis-
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eases in youth further supports the critical need to review and
revise youth physical activity guidelines that are consistent with
the unique needs, abilities, and interests of children and adoles-
CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 03/03/2024
cents. We argue for prioritizing muscular fitness in youth phys-
ical activity guidelines and propose a new conceptual model for
promoting MVPA in children and adolescents. For ease of dis-
cussion, the term youth refers to children and adolescents col-
lectively, and muscular fitness is defined as a global term that
represents muscular strength, muscular power, and local mus-
cular endurance.
What Are Physical Activity Guidelines for Youth?
Alhough it is unclear whether public health recommendations,
in isolation, increase participation in MVPA, global efforts to es-
tablish national and international guidelines to increase physical
activity at all levels across the life span are supported by key World
Health Organization (WHO) publications (2,9,18). Common
youth physical activity recommendations in these documents
include accumulating at least 60 min of MVPA daily, with
the majority of the MVPA being aerobic (9). The WHO also
recommends muscle- and bone-strengthening activities at least
3 d·wk−1 (9). Other international physical activity guidelines from
the European Union (19) and the Nordic countries (Iceland,
Norway, and Sweden) (20) are consistent with WHO guide-
lines that call for the accumulation of at least 60 min of MVPA
daily in forms that are developmentally appropriate, enjoyable,
and involve a variety of activities. The updated WHO Global
Recommendations on Physical Activity in Youth, Adults, and
Older Adults are expected to be published in 2020 (21).
International youth physical activity guidelines sparked the
development of national physical activity recommendations.
Information presented in the Table outlines 24 national youth
physical activity guidelines published since 2010 (the year the
WHO global recommendations were released). Some national
reports stem from evidence-based frameworks regarding the
dose-response to physical activity and are high-profile docu-
ments, whereas others focus on the public health promotion
of physical activity and exist only on national language web sites.
National guidelines provide specific guidance on physical activity
amounts and modalities for different age groups and may serve
to inform key stakeholders involved with primary prevention
and health promotion.
National youth physical activity guidelines recommend at
least 60 min of MVPA daily with a primary focus on aerobic ex-
ercise and a secondary focus on muscle- and bone-strengthening
activities (10). Austria, France, Philippines, and Uruguay ad-
vise that youth older than 12 years perform strength exercises
(24,28,36,45), and guidelines from South Africa and Switzerland
suggest that strength-building activities should be limited to body
weight exercises until adolescence (39,41).
Youth physical activity guidelines from New Zealand and
the United States encourage children to participate in un-
structured strength-building activities, such as jumping and
climbing, but state that children do not need “formal muscle
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strengthening” programs (34,44). Although the vast majority
of national PA guidelines understate the critical importance
enhancing muscular fitness early in life, recent youth physical
activity guidelines from the United Kingdom recommend
MVPA in all forms to develop muscular fitness, movement
skills, and bone strength (43).
Given the impact of national physical activity guidelines
on policy development and program implementation, it is im-
portant to monitor and iteratively evaluate the influence and
relevance of these recommendations for increasing youth
MVPA. Although efforts have been made to refine and clarify
national guidelines with evidence of improved quality, basic
public health recommendations from 2005 for “school age”
youth to accumulate 60 min or more of MVPA daily remain
much the same today (46). The increasing prevalence of youth
physical inactivity calls for a paradigm change that both recognizes
and emphasizes the appropriate physical needs of modern-day
children and adolescents to effectively impact youth physical
activity worldwide.
Why Prioritize Muscular Fitness Development?
Recent epidemiological reports indicate that today's youth
are not as active as they should be and the decline and disinter-
est in MVPA increases steadily after 6 years of age (5–7). No
child is immune from contemporary lifestyles that often con-
sist of noneducational screen time, sedentary recreational pur-
suits, and limited exposure to physical activities that enhance
muscular fitness. There is an urgent need to address physical
inactivity during childhood and adolescence before youth
become resistant to exercise interventions later in life. This
approach emphasizes the importance of recognizing the mul-
tidimensional development of youth physical inactivity and
promoting strength-building activities for all youth regardless
of physical ability or body size.
As illustrated in Figure 1, low levels of muscular fitness neg-
atively impact physical, psychosocial, emotional, and behav-
ioral factors that drive physical inactivity in youth. Since a
certain amount of force-production and force-attenuation is
needed to move proficiently on the playground as well as the
sports field, weaker youth who lack confidence and compe-
tence in their physical abilities (i.e., physical illiteracy) may
avoid nonessential MVPA to guard against embarrassment,
humiliation, and failure (47). Moreover, inactive youth may
be less willing to experience and tolerate sensations associated
with MVPA due to a feeling of vulnerability or discomfort
(i.e., kinesiophobia) (48). These MVPA fear-avoidance factors
may lead to an increase in unhealthy behaviors and conse-
quent risk of injury and illness.
While low levels of muscular strength and power are well-
recognized risk factors for functional disability and mortality
in older adults (49), it appears that youth also are vulnerable
to the inevitable consequences of dynapenia (48,50). The term
dynapenia is defined as an identifiable and treatable condition
in youth characterized by low levels of muscular strength and
power not caused by neurologic or muscular disease (48,51).
Pediatric dynapenia has been found to be associated with car-
diometabolic risk (52), all-cause disability later in life (53),
and major cause of premature death (54). Since muscular fit-
ness phenotypes appear to track from childhood to young
adulthood (55), youth who are not exposed to progressively
challenging strength-building activities early in life may be less
Current Sports Medicine Reports 531
 Table.
National Physical Activity Guidelines for children and adolescents since 2010*.
Year F I T Primary Mode Other Modes
Argentina (22) 2013 Daily MV ≥60 min Aerobic Strength
Australia (23) 2019 Daily MV ≥60 min Aerobic Strength
≥60 min
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Austria (24) 2012 Daily MV Aerobic Strength, flexibility, skills

Canada (25) 2016 Daily MV ≥60 min Aerobic Strength
Chile (26) 2017 Daily MV ≥60–90 min Aerobic Strength, flexibility
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China (27) 2017 Daily MV ≥60 min Aerobic Strength

France (28) 2018 Daily MV ≥60 min Aerobic Strength, flexibility
Germany (29) 2016 Daily MV ≥90 min Aerobic Strength
Italy (30) 2018 Daily MV ≥60 min Aerobic Strength
Malaysia (31) 2017 Daily MV ≥60 min Aerobic Strength
Mexico (32) 2015 Daily MV ≥60 min Aerobic Strength
Netherlands (33) 2017 Daily MV ≥60 min Aerobic Strength
New Zealand (34) 2012 Daily MV ≥60 min Aerobic Strength, flexibility
Paraguay (35) 2014 Daily MV ≥60 min Aerobic Strength
Philippines (36) 2010 Daily MV ≥60 min Aerobic Strength, flexibility
Qatar (37) 2014 Daily MV 60 min Aerobic Strength
Singapore (38) 2013 Daily MV ≥60 min Aerobic Strength
South Africa (39) 2013 Daily MV ≥60 min Aerobic Strength
Spain (40) 2015 Daily MV ≥60 min Aerobic Strength
Switzerland (41) 2012 Daily MV ≥60 min Aerobic Strength, flexibility, agility
Turkey (42) 2014 Daily MV ≥60 min Aerobic Strength
UK (43) 2019 Daily MV ≥60 min† All forms‡
USA (44) 2018 Daily MV ≥60 min Aerobic Strength
Uruguay (45) 2017 Daily MV ≥60 min Aerobic Strength
*Adapted from Parrish et al (10).
†An average of at least 60 min MVPA per day across the week.
‡A variety of physical activities including those that develop movement skills and muscle strength.
F, frequency; I, intensity; T, time; MV, moderate-vigorous.

likely to acquire the desired skills and behaviors that support
ongoing participation in MVPA (48,56,57).
Research findings show that regular participation in youth
resistance training has a positive impact on fundamental move-
ment skills (e.g., jumping, throwing, and running) (57), and
a positive association between muscular fitness and physical ac-
tivity (particularly vigorous physical activity) in children and
adolescents has been reported (56). Notably, researchers identi-
fied a motor proficiency barrier for meeting physical activity
guidelines in children (58). Almost 90% of children with
low actual motor competence did not meet the public health
recommendations of at least 60 min of MVPA daily (58).
Meta-analytic findings provide additional support for a mod-
erate to large positive relationship between motor competence
and physical fitness from early childhood to early adulthood
(59). Collectively, these findings underscore a potential synergis-
tic adaptation whereby integrative physical activity interventions
can complement naturally occurring adaptations throughout
childhood and adolescence (60,61). Since fundamental movement
skills are the basic building blocks for more advanced, complex
movements, there is an opportunity to develop a basal level of
muscular fitness early in life in order to provide a strong foun-
dation for ongoing participation in a variety of physical activ-
ities. Indeed, meta-analytic findings underscore the importance
of developing a foundation of muscular strength before per-
forming more advanced power training activities (62).
Despite outdated concerns and misperceptions associated
with youth resistance training, a compelling body of evidence
indicates that regular participation in a well-designed resistance
training program can offer observable health and fitness value
for children and adolescents (12,13,63). A high level of muscu-
lar fitness in children and adolescents is associated with future
health benefits (e.g., lower insulin resistance, higher bone min-
eral density) (63) and the most effective youth injury-reducing
and performance-enhancing programs include strength-building
activities (64–66). Notwithstanding the potential benefits of
aerobic exercise, without integrative exercise interventions
that target neuromuscular deficits early in life, contemporary
youth may be unable to overcome an acquired strength deficit.
Absent the necessary intervention, they may never catch up to
their more active peers who possess average or better levels of
muscular fitness.

532 Volume 19  Number 12  December 2020 Muscular Fitness in Youth

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Figure 1: The multifactorial development of youth physical inactivity.
Rethinking the Pediatric Physical Activity Pyramid
The current global focus on accumulating at least 60 min of
MVPA daily has shifted the focus away from specific critical
components of health- and skill-related physical fitness that drive
ongoing participation in MVPA in youth. Health-related compo-
nents of physical fitness include cardiorespiratory endurance, mus-
cular strength, muscular endurance, and flexibility; skill-related
components of physical fitness include agility, balance, coor-
dination, speed, power, and reaction time (67). Persistent
levels of insufficient physical activity in youth over many years
call for intervention strategies that move past the question of
“how much MVPA?” to “what type of MVPA?” to better un-
derstand and develop interventions that produce desired out-
comes (68). Because of the timing of brain development and
associated neuroplasticity for learning new skills, childhood
and adolescence provide a unique opportunity to enhance
both health- and skill-related components of physical fitness
in supportive settings (68). Pediatric researchers and clinicians
are beginning to consider both the quantity and the quality of
the MVPA experience to reinforce desired movement patterns
which underlie sustainable participation in a range of physical
activities (68,69).
The pediatric activity pyramid (PAP) illustrates the integra-
tive relationship among three interrelated activity components
and the foundational importance of strength activities (designed
to enhance muscular fitness) and skill activities (designed to
enhance fundamental movement skills) in the promotion of
physical activity for all youth (Fig. 2). Unlike the hierarchical de-
sign of traditional youth physical activity pyramids with moder-
ate intensity aerobic physical activities at the base (presumed to
be more important) and muscular fitness activities toward the
top (presumed to be less important), PAP recognizes the shared,
coequal importance of strength, skill, and aerobic activities for
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the successful implementation of sustainable youth physical
activity interventions.
The concept of integrating both health- and skill-related fit-
ness components into youth programs is not new. Throughout
the early 20th century, physical education classes incorporated
strength-building calisthenics into the physical conditioning les-
son plan and circuit training developed in the 1950s included
different stations of aerobic and strength activities arranged con-
secutively. More recently, training that includes strength- and
skill-building activities has been found to improve health, en-
hance performance, and reduce the risk of youth sports-related
injuries (61,70). Although there is not one optimal combination
of exercises, sets, and repetitions that will promote favorable ad-
aptations in all children and adolescents, technique-driven pro-
gression and performance of more complex movement skills
over time will keep the training stimulus effective and enjoyable
(70). Integrative training does not involve expensive exercise
equipment or heavy external loads. A circuit of exercises with
elastic bands, fitness ropes, medicine balls, and one's own body
weight may be used to enhance the ability to express muscular
force safely within a spectrum of movement competencies
(71,72). Notably, integrative training has been found to pose a
moderate to vigorous cardiometabolic stimulus in children (73).
Although there is no minimum starting age, in general most
6- and 7-year olds are ready from some type of integrative train-
ing that includes variety, progression, and game-like activities.
For example, animal-like movements, such as “bunny jumps”
and “frog squats,” can capture the imagination of younger
children. Youth with training experience could advance to
more complex exercises that target key movement patterns
that involve pulling, pushing, bracing, accelerating, and decel-
erating (70,74). As such, training experience is an impor-
tant consideration since it impacts the ability of youth to
Current Sports Medicine Reports 533
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Figure 2: The PAP consists of three interrelated components that influence participation in MVPA in youth.
perform simple and complex movements with competence
and confidence.
Interindividual differences in physical development and
fitness abilities between youth of the same age are important
considerations when designing exercise programs for children
and adolescents.
At a time when physical education is considered expendable
in some communities and too many aspiring young athletes
appear ill-prepared for the physical demands of sports practice
and competition, efforts are needed to inform relevant stake-
holders that, rather than having an isolated focus on aerobic
activities, youth physical activity interventions should con-
sider an integrative approach that includes strength- and
skill-building activities (13,61,68). Integrative exercise interven-
tions that enhance both health- and skill-related components of
physical fitness are needed to prevent the accumulation of risk
factors, functional limitations, and interrelated processes that
drive physical inactivity throughout childhood and adolescence
(61,70). Although most youth will develop a minimal level of
physical fitness with free play, the acquisition of necessary
strength is not automatic: structured movement experiences
with qualified instruction are needed to optimize gains in both
health- and skill-related components of physical fitness (75).
Notably, quality based physical education programs have been
found to improve physical fitness outcomes and fundamental
movement skills in children and adolescents (76,77).
Conclusions
An increasing number of children and adolescents world-
wide are not accumulating the recommended amount of MVPA.
There is a dire need to update policies and actions at all levels
in order to shift the paradigm in support of successful daily
physical activity in modern-day youth. The mounting evidence
534 Volume 19  Number 12  December 2020
Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
of the detrimental effects of physical inactivity on youth warrant
a review of existing national physical activity recommendations.
Generic recommendations to simply move more are not enough
to activate this generation of girls and boys who are weaker and
slower than previous generations. An understanding of the mul-
tidimensional development of youth physical inactivity and the
importance of muscular fitness is needed to have the most signif-
icant impact on youth physical activity at the population level.
The activity-promoting and health-enhancing benefits of mus-
cular fitness warrant a stronger emphasis on this issue and a
new conceptual PAP model for promoting MVPA in all youth.
In view of troubling trends in measures of muscular fitness
in modern-day youth over the past few decades, specific rec-
ommendations to address neuromuscular deficiencies early
in life are an important first step to support ongoing participa-
tion in MVPA. About 60 years ago Hans Krauss and Wilhelm
Raab coauthored a seminal text entitled Hypokinetic Disease
in which they stated it was incongruous for underexercised
youth to spend countless hours performing therapeutic exer-
cise to restore the loss of muscular fitness that never should
have been lost in the first place (78). These words are still rel-
evant today. It is, at last, time for a change.
The authors declare no conflict of interest and do not have
any financial disclosures.
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