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Physical Activity Questionnaire for Children and

Adolescents: English norms and cut-points

Article in Pediatrics International · March 2013

Impact Factor: 0.73 · DOI: 10.1111/ped.12092 · Source: PubMed

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Pediatrics International (2013) ••, ••–•• doi: 10.1111/ped.12092

Original Article

Physical Activity Questionnaire for children and adolescents: English

norms and cut-off points

Christine Voss,1 Ayodele A Ogunleye2 and Gavin RH Sandercock2

1
Department of Orthopaedics, Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada and
2
Department of Biological Sciences, Centre for Sport and Exercise Science, University of Essex, Colchester, UK

Abstract Background: The Physical Activity Questionnaire for Children and Adolescents (PAQ-C/-A) provides general estimates
of physical activity levels. Following recent expert recommendations for using the PAQ for population surveillance, the
aim of this paper was twofold: first, to describe normative PAQ data for English youth; and second, to determine a
criterion-referenced PAQ-score cut-off point.
Methods: Participants (n = 7226, 53% boys, 10–15 years) completed an anglicized version of the PAQ. Peak oxygen
uptake (VO2peak) was predicted from PACER lap count according to latest FITNESSGRAM standards and categorized
into “at-risk” and “no-risk” for metabolic syndrome. ROC curves were drawn for each age–sex group to identify PAQ
scores, which categorized youth into “sufficiently active” versus “low-active” groups, using cardiorespiratory fitness as
the criterion-referenced standard.
Results: PAQ scores were higher in boys than in girls and declined with age. Mean PAQ score was a significant, albeit
relatively weak (area under the curve < 0.7) discriminator between “at-risk” and “no-risk.” PAQ scores of ⱖ2.9 for boys
and ⱖ2.7 for girls were identified as cut-off points, although it may be more appropriate to use lower, age-specific PAQ
scores for girls of 13, 14 and 15 years (2.6, 2.4, 2.3, respectively).
Conclusion: The normative and criterion-referenced PAQ values may be used to standardize and categorize PAQ scores
in future youth population studies.

Key words cardiorespiratory fitness, child, physical activity, questionnaires, receiver–operator curve.

Physical activity (PA) is a powerful predictor of cardiovascular,1
skeletal,2 and mental health3 in children and adolescents, yet
contemporary youth, and especially girls, are often insufficiently
active.4,5 Accurate measuring and monitoring of PA is a priority
for researchers and public health professionals alike. Accelerom-
etry is the tool of choice to objectively measure PA in youth,6 but
may not be feasible and affordable in all studies, especially field-
or school-based assessments of larger samples. Self-reported
PA offers a frequently used alternative despite the well-
acknowledged potential limitations of subjectivity and question-
able recall ability, particularly in younger people.6,7 Self-report
measures are further limited by their relative insensitivity as
estimates of the actual duration and intensity of PA;6 a well-
designed questionnaire may, however, be able to correctly rank
individuals within groups according to their PA levels.8 PA ques-
tionnaires, unlike accelerometry, can also provide valuable infor-
mation regarding the types, locations and circumstances of
activities that the individual engages in. Such qualitative infor-
mation may be important for population surveillance and the
exploration of many research questions.6
1 Correspondence: Christine Voss, PhD, Centre for Hip Health and
2 Mobility, 685E-2635 Laurel Street, Vancouver, BC, V5Z 1M9,
3 Canada. Email: christine.voss@hiphealth.ca
4 Received 10 September 2012; revised 24 February 2013; accepted
5 26 February 2013.
The Physical Activity Questionnaire for Older Children
(PAQ-C) and for Adolescents (PAQ-A) are self-administered,
7-day recall instruments, which were designed to provide a
general estimate of PA levels in 8–20-year-old youth during
the school year.9 Questionnaire items include weekly participa-
tion in different types of activities and sports (activity
checklist), effort during physical education (PE), and activity
during lunch, after school, evening and at the weekend. The
PAQ have acceptable reliability and convergent validity,10,11 as
well as construct validity as evidenced by their sensitivity to
identify known sex- and age-differences in PA.12–15 Thus, it is
important to have normative data in order to standardize
(or rank) individual PAQ scores relative to age and sex. In light
of the growing use of the PAQ in English studies,16,17 as well as
recent expert recommendations for using the PAQ for youth
population surveillance,18,19 the first aim of this paper was to
describe normative PAQ data for English youth; we also
aimed to describe an anglicized version of the activity
checklist.
The meaningful interpretation of PA measurements typically
requires dichotomization of PA into active and non-active,
whereby this classification is linked with clinically relevant
health outcomes. Accelerometry-derived measures of youth PA,
for example, are usually expressed as daily min of moderate-to-
vigorous physical activity to allow classification of PA according

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2 C Voss et al.

1 to whether health-related PA guidelines are met.20 As the PAQ are shuttle-run test.32 This progressive running test requires partici- 56
2 not designed to provide measures of time or intensity, classifica- pants to run back and forth a 20-m distance (laps) at a given pace, 57
3 tion relative to PA guidelines is impossible. Instead, various arbi- which increases every min, until volitional exhaustion or when 58
4 trary PAQ-score cut-off points have been proposed to categorize the required pace can no longer be maintained. The test is com- 59
5 youth according to their self-reported PA. For example, we have monly administered during PE in England. Researchers provided 60
6 previously grouped youth as “active” or “low-active” based on an uniform instructions prior to the test, acted as spotters and 61
7 age–sex-specific median split of PAQ scores.17 The University of recorded final lap count; researchers also acted as pacers when 62
8 Saskatchewan’s Pediatric Bone Mineral Accrual Study grouped younger age groups were tested (ⱕ grade 7). Peak oxygen uptake 63
9 youth into “active,” “average” and “inactive” based on age–sex- (VO2peak; mL/kg/min) was predicted from final PACER lap count 64
10 specific PAQ-score quartiles (top, middle two, and bottom quar- as per the latest FITNESSGRAM standards33 and categorized 65
11 tiles, respectively).21,22 Chen et al.23 assigned PAQ scores ⱕ 2 as into “at-risk” (includes high-risk and some-risk) and “no-risk” 66
12 “low activity,” >2 and ⱕ3 as “moderate activity,” and >3 as “high (“healthy-fit”) for metabolic syndrome according to published 67
13 activity.” It is a shortcoming of the PAQ that there is currently no fitness cut-off points.28 Participants self-reported their ethnic 68
14 uniform and meaningful categorization of PAQ scores which background, and area level deprivation (Indices of Multiple 69
15 would differentiate youth at risk of ill-health from those with- Deprivation 2007 [IMD2007]) was determined based on home 70
16 out health risks. Cardiorespiratory fitness (CRF) is moderately postal codes.34 71
17 related to PA24 and is a powerful health marker in youth due to its 72
18 well-documented inverse association with metabolic health.25–27 PAQ 73

19 Thus, CRF lends itself as a potential screening tool in field-based The administration and scoring of the PAQ-C and PAQ-A are 74
20 research where a direct assessment of metabolic health (including described elsewhere.9 In brief, the self-administered, 7-day recall 75
21 blood profiling) may not be feasible. questionnaire comprises nine or eight items (PAQ-C includes an 76
22 The primary aim of this paper was to describe normative PAQ additional item on recess), respectively, and collects information 77
23 data for English youth; the second aim was to investigate if the on participation in different types of activities and sports (activity 78
24 PAQ has discriminative power to differentiate between “healthy- checklist), effort during PE, and activity during lunch, after 79
25 fit” youth and those whose low CRF puts them “at risk” of school, evening and at the weekend during the past 7 days. Each 80
26 developing metabolic syndrome according to published fitness item is scored between 1 (low PA) and 5 (very high PA) and the 81
27 cut-off points,28 and to derive criterion-referenced PAQ-score average score denotes the PAQ score. Most participants com- 82
28 cut-off points. pleted the PAQ-A (92%), as recess no longer forms part of a 83
29 typical school day at secondary school in the East of England 84
30 Methods (ⱖgrade 7 and approximately ⱖ11 years). The PAQ was 85
designed in Canada. Given cultural and climatic differences, 86
31 Sample
some activities (e.g. cross-country skiing) on the original activity 87
32 The sample was drawn from the East of England Healthy Hearts checklist are unsuitable for use in countries such as England. 88
33 Study, which is an ongoing, school-based health and fitness Thus, similarly to how the test originators adjusted the PAQ-C 89
34 survey and is an opportunity sample designed to be broadly activity checklist for the adolescent version,12 we adjusted the 90
35 representative of youth from the East of England. To date, over Canadian activity checklist to our own anglicized version (see 91
36 8800 schoolchildren from 26 public secondary and primary results). The choice of sports and activities was largely guided by 92
37 schools have participated in all or most aspects of the study, with national surveys on sports participation, such as “Taking Part: 93
38 a high overall response rate of 98%. The analytical sample for the The National Survey of Culture, Leisure and Sport”35 and the 94
39 present study was restricted to schoolchildren who had valid “Active People Survey,”36 as well as the researchers’ own expert 95
40 information on sex, age (10.0–15.9 years) and complete PAQ opinion. 96
41 data (n = 7226, 53% boys). The study was approved by the 97
42 institutional ethics committee and conforms to the Declaration of Statistical analyses 98
43 Helsinki. Parental consent and participant assent were obtained. Descriptive statistics (mean ⫾ SD, frequencies) were calculated 99
44 for relevant variables and where appropriate, stratified by sex and 100
45 Protocol age. Between-group differences were assessed via Pearson’s 101
46 Schoolchildren undertook a variety of health assessments during c2 analyses for categorical variables and anova for continuous 102
47 regularly scheduled physical education (PE) lessons, the full variables (post-hoc Bonferroni-adjusted pairwise comparisons). 103
48 details of which have been described elsewhere.17,29 In brief, all Associations between continuous variables were assessed via 104
49 measurements took place during the summer months (predomi- two-tailed Pearson’s correlation coefficients and age-dependent 105
50 nantly June and September) to account for potential seasonal declines in PAQ scores or individual PAQ items were calculated 106
51 variations in physical activity behaviours.30 Stature (cm) and via linear regression analyses. To determine criterion-referenced 107
52 body mass (kg) were measured, body mass index (BMI) (kg/m2) standards for PAQ-score cut-off points that discriminate between 108
53 calculated and classified according to International Obesity Task “healthy-fit” and “at risk” youth,28 receiver–operator curves 109
54 Force (IOTF) criteria.31 CRF was measured by the FITNESS- (ROC) were created for each sex–age group, whereby the best 110
55 GRAM PACER, which is a modified version of the original 20-m discriminating PAQ-score cut-off point equated to the coordinate 111

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Norms and cut-off points for PAQ-C/-A 3

1 yielding the greatest sum of specificity and sensitivity.27 All Item 1: Activity checklist 57
2 analyses were carried out in pasw Statistics v. 18.0 (spss, Table 2 shows in detail our anglicized version of the activity 58
3 Chicago, IL, USA) and significance set at P < 0.05. checklist that comprises item 1 of the PAQ; it also reports mean 59
4
responses to each activity item and the proportion of youth who 60
5 Results
participated once or more than five times in each activity during 61
6 Sample the last 7 days. Where participation in a particular activity 62
7 The East of England Healthy Hearts Study sample benefited from declined linearly with age, linear regression analyses provided 63
8 a very high overall response rate of 98%, resulting from the regression coefficients indicating the mean (95%CI) reduction in 64
9 school-based recruitment and measurement and the option to the activity score per year older. Most activity responses signifi- 65
10 partake in only parts of the protocol. Missing PAQ scores were cantly declined with age in both boys and girls, but the magnitude 66
11 almost exclusively resulting from incomplete questionnaires, and of the decline was relatively small for most activities (<-0.10 67
12 less so due to withdrawal of parental consent for the PA assess- points per year older); this was observed either when participa- 68
13 ment (n = 4). Prevalence of ethnic groups (data available for 97% tion at any age was relatively low (i.e. rowing or sailing), or the 69
14 in this analytical sample) was broadly similar to Census 2001 activity was comparably stable across the age-course studied (i.e. 70
15 data for the East of England region; the sample was predomi- cycling in boys). Activities with the greatest age declines (>-0.20 71
16 nantly “white” (96%), but individuals of “mixed” backgrounds points per year older) were particularly evident for certain activi- 72
17 were the second most common group (2.7%); this may be indica- ties in girls (i.e. cycling and swimming), where weekly partici- 73
18 tive of a new generation of British-born children from inter- pation at younger ages was comparable to (or higher than) boys, 74
19 ethnicity relationships. According to area level deprivation (90% but drastically reduced over the age course studied (see also 75
20 with valid data), our sample was slightly more affluent than the Fig. 1). 76
21 regional average (mean ⫾ SD IMD2007 scores: 12.4 ⫾ 7.6 vs 77
22 14.9 ⫾ 6.0). BMI was available for 97% of participants in this Items 2–8: Physical activity at school, after school and 78
23 analytical sample, and prevalence of underweight (4.5%), normal at weekends 79
24 weight (67.4%), overweight (21.4%) and obesity (6.1%) accord- Table 3 summarizes the mean responses to each of the PAQ items 80
25 ing to IOTF criteria did not differ between sexes and was similar in our sample of 10–15-years-olds. Similarly to what has been 81
26 to what others have reported for contemporary British youth.37,38 previously reported,12 the mean score for the activity checklist 82
27 The sample’s age–sex distribution is reported in Table 1, and (item 1) was lowest, and the mean score for PE (item 2) the 83
28 prevalence of “healthy-fit” and “at risk” within these groups is highest, with boys scoring higher on all items than girls. Indi- 84
29 later reported as part of Table 3. vidual items’ mean scores differed significantly by age in girls, 85
30 and to a lesser extent in boys, and although a full description for 86
31 PAQ
each age–sex group was beyond the scope of this paper, we 87
32 Boys’ and girls’ mean (SD) PAQ scores are presented in Table 1. provide a brief description of age differences in Table 3. 88
33 There were significant main effects for sex (F = 258.4, P < 0.001) 89
34 and age (F = 42.6, P < 0.001), as well as age–sex interaction PAQ score and cardiorespiratory fitness 90
35 (F = 5.3, P < 0.001). Post-hoc comparisons Bonferroni-adjusted In boys at every age, PAQ scores were positively correlated with 91
36 independent t-tests (P < 0.0083) revealed significant sex- CRF test performance (shuttle lap count; r = 0.361–0.418, all P < 92
37 differences at each age, except for 10-year-olds (P = 0.028). The 0.001). The associations between PAQ scores and VO2peak pre- 93
38 observed sex-differences resulted in all further analyses to be dicted as per recent FITNESSGRAM standards33 were also sig- 94
39 stratified by sex. In boys, PAQ scores changed on average by nificant for all boys, but weaker (r = 0.273–0.309, all P < 0.001). 95
40 -0.06 (95%CI -0.07– -0.04) points per year older and by -0.11 In girls, associations between PAQ scores and CRF test perform- 96
41 (95%CI -0.13– -0.10) points in girls. ance (shuttle lap count) were significant at all ages (r = 0.222– 97
42 0.323, all P < 0.001), whereas PAQ scores and VO2peak predicted33 98

43 Table 1 Mean PAQ scores and SD for boys and girls aged 10.0–
were weakly associated only in girls aged 11–14 (r = 0.122– 99
44 15.9 years 0.156, P < 0.01). Furthermore, when predicted VO2peak was clas- 100
45 sified according to potential health risk,28 boys’ mean PAQ scores 101
46 Boys Girls were lower in those classified “at risk” compared with “healthy 102
47 n Mean (SD) n Mean (SD) fit” (all P ⱕ 0.001 except for 15-year olds: P = 0.063), and 103
48 10.0–10.9 years 163 3.206 (0.724) 143 3.044 (0.551) the same was true in girls (all P < 0.05 except for 10-year-olds: 104
49 11.0–11.9 years 693 3.066 (0.700) 657 2.819 (0.625) P = 0.514). 105
50 12.0–12.9 years 998 3.072 (0.700) 955 2.783 (0.596) 106
51 13.0–13.9 years 848 2.951 (0.723) 799 2.649 (0.626) ROC 107
52 14.0–14.9 years 701 2.977 (0.723) 607 2.515 (0.617)
53 15.0–15.9 years 390 2.830 (0.751) 272 2.435 (0.594) ROC were created for each age–sex group; details for areas under 108
54 All ages 3793 3.007 (0.720) 3433 2.695 (0.628) the ROC (AUC), as well as PAQ scores equivalent to the coor- 109
55 Significant sex-differences at each age, except for in 10-year-olds. dinates with the greatest sum of sensitivity and specificity are 110
56 PAQ, Physical Activity Questionnaire. illustrated in Table 4. For most age–sex groups, PAQ scores were 111

© 2013 The Authors

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Table 2 Boys’ and girls’ mean responses to the anglicized activity checklist (Q1), weekly participation in activities and corresponding age-dependent declines

2 Boys (n = 3533)† Girls (n = 3188)†

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3 Mean (SD)‡ ⱖ Once/week§ ⱖ5¥/week Age decline Mean (SD)‡ ⱖ Once/week§ ⱖ5¥/week Age decline
4 % (n) % (n) (points/year)¶ % (n) % (n) (points/year)¶
5 Games/skipping 3.00 (1.32) 84.5 (2986) 34.8 (1229) -0.14 (-0.17– -0.11) 2.74 (1.16) 86.9 (2770) 23.2 (741) -0.21 (-0.24– -0.18)
6 Walking for exercise 2.85 (1.47) 76.0 (2685) 35.0 (1236) -0.08 (-0.11– -0.04) 3.37 (1.40) 87.9 (2803) 50.4 (1608) -0.05 (-0.08– -0.01)
7 Cycling 2.78 (1.47) 73.9 (2614) 33.9 (1196) -0.03 (-0.07– -0.00)NS 1.92 (1.14) 52.2 (1665) 11.1 (354) -0.21 (-0.24– -0.18)
8 Jogging and/or running 2.74 (1.31) 79.9 (2823) 27.9 (984) -0.11 (-0.14– -0.08) 2.39 (1.14) 76.3 (2433) 16.7 (532) -0.17 (-0.20– -0.14)

Pediatrics International © 2013 Japan Pediatric Society

9 Aerobics 1.22 (0.64) 14.2 (502) 2.0 (72) -0.02 (-0.04– -0.01) 1.34 (0.76) 22.1 (705) 3.1 (100) -0.08 (-0.10– -0.06)
10 Soccer 2.78 (1.48) 73.4 (2592) 33.1 (1169) -0.07 (-0.11– -0.04) 1.49 (0.87) 31.8 (1013) 4.4 (139) -0.09 (-0.11– -0.06)
11 Rugby/touch/7s†† 1.52 (0.95) 30.7 (1083) 5.5 (196) -0.04 (-0.07– -0.02) 1.11 (0.44) 7.3 (233) 0.9 (28) -0.02 (-0.03– -0.01)
12 Netball or basketball†† 1.58 (0.96) 36.1 (1276) 6.1 (216) -0.09 (-0.11– -0.07) 1.58 (0.88) 39.5 (1258) 4.4 (139) -0.14 (-0.17– -0.12)
13 Hockey 1.17 (0.59) 10.6 (376) 1.8 (62) -0.02 (-0.04– -0.01) 1.14 (0.47) 10.0 (320) 0.8 (25) -0.05 (-0.06– -0.04)
14 Cricket†† 1.64 (1.00) 38.5 (1360) 6.7 (237) -0.08 (-0.09– -0.05) 1.23 (0.62) 16.4 (523) 1.6 (52) -0.09 (-0.10– -0.07)
15 Rounders/Base-/softball 1.55 (0.89) 36.3 (1283) 4.6 (161) -0.09 (-0.11– -0.06) 1.62 (0.87) 43.2 (1377) 4.2 (135) -0.05 (-0.08– -0.03)
16 Badminton/tennis/squash 1.70 (1.03) 42.3 (1493) 7.4 (263) -0.03 (-0.06– -0.01) 1.43 (0.76) 30.3 (966) 2.7 (85) -0.10 (-0.12– -0.08)
17 Rowing/canoeing 1.15 (0.51) 10.0 (355) 1.2 (41) -0.01 (-0.02– -0.00)NS 1.07 (0.33) 5.7 (181) 0.3 (10) -0.02 (-0.02– -0.01)
18 Martial arts†† 1.27 (0.73) 15.9 (563) 2.9 (103) -0.03 (-0.05– -0.01) 1.19 (0.62) 11.8 (377) 2.0 (65) -0.04 (-0.05– -0.02)
19 Swimming 1.74 (0.99) 47.8 (1688) 7.0 (247) -0.13 (-0.15– -0.11) 1.83 (1.03) 52.9 (1686) 7.5 (239) -0.20 (-0.22– -0.17)
20 Gymnastics†† 1.17 (0.58) 10.2 (362) 1.6 (58) -0.04 (-0.05– -0.02) 1.40 (0.83) 25.9 (825) 3.7 (118) -0.12 (-0.14– -0.10)
21 Dance/cheerleading 1.14 (0.54) 9.1 (320) 1.7 (60) -0.02 (-0.03– -0.01) 2.01 (1.22) 54.1 (1726) 13.7 (438) -0.10 (-0.13– -0.07)
22 Roller or inline skating 1.25 (0.69) 15.1 (535) 2.5 (90) -0.04 (-0.06– -0.02) 1.32 (0.76) 20.4 (650) 3.3 (105) -0.07 (-0.09– -0.05)
23 Skateboarding 1.36 (0.88) 19.3 (683) 4.8 (170) -0.06 (-0.08– -0.04) 1.12 (0.50) 8.2 (260) 1.2 (39) -0.03 (-0.05– -0.02)
24 Horse riding†† 1.07 (0.42) 3.9 (139) 1.1 (39) -0.01 (-0.02– -0.01) 1.41 (1.01) 18.9 (602) 6.9 (221) -0.05 (-0.08– -0.02)
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25 Sailing/windsurfing†† 1.11 (0.49) 6.4 (225) 1.3 (46) -0.01 (-0.02– -0.00)NS 1.07 (0.37) 4.0 (129) 0.7 (22) -0.01 (-0.01– -0.00)NS
26 Ice-skating 1.15 (0.54) 9.7 (342) 1.4 (48) -0.02 (-0.03– -0.1) 1.21 (0.61) 14.4 (460) 1.7 (53) -0.04 (-0.05– -0.02)
†
27 Sample to whom anglicized Q1 version was administered (93%); ‡PAQ Q1 scoring: 1 = none, 2 = 1–2¥/week, 3 = 3–4¥/week, 4 = 5–6¥/week, 5 = ⱖ7¥/week; §ⱖ Once/week includes
28 ⱖ5¥/week. ¶Regression coefficients (95%CI) all significant (P < 0.05) unless indicated (NS). ††Items different to Canadian list of activities.9 NS, not significant.
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Norms and cut-off points for PAQ-C/-A 5

1 Fig. 1 Age-dependent decline in boys and girls reporting participation in select activities ⱖ once/week. , Bike; , Swimming;
2 , Soccer.

4 Table 3 Mean and SD for all individual PAQ items and brief descriptions of their respective age differences in boys and girls aged 10.0-15.9 years
5
6 Boys (n = 3793)† Girls (n = 3433)†
7 Mean (SD) Description of age Mean (SD) Description of age
8 differences differences
9 1. Activity 1.69 (0.43)* Relatively stable between ages 10 and 12, 1.60 (0.39)* Continuous decline with age
10 Checklist followed by relatively sharp drop
11 between ages 12 and 13; further drop at
12 age 15
13 2. Physical 4.01 (0.91)* Increased between ages 10 and 12, 3.90 (0.88)* Mean score increased between ages 10
14 Education remained relatively stable thereafter and 12, decreased again thereafter
15 (slight drop at age 15) (age 15 equaled score are age 10)
16 [Recess; PAQ-C 4.02 (1.03) n = 302, 10-11 years olds only; 3.45 (1.17)* n = 279, 10-11 years olds only;
17 only] non-significant decline between ages 10 significant decline between ages
18 and 11 10 and 11
19 3. Lunch 3.23 (1.25)* Relatively sharp drop between ages 10 and 2.41 (0.99)* Relatively sharp drop between ages 10
20 11, more moderate, continuous decline and 11, more moderate, continuous
21 thereafter decline thereafter
22 4. After School 3.01 (1.32)** Fluctuated during the age-course studied 2.71 (1.24)* Steep continuous decline between the
23 (highest at 12 and 14 years) ages of 11 and 15
24 5. Evenings 2.85 (1.21)* No age differences during the age-course 2.63 (1.12)* Peaked at ages 11 and 12, declined
25 studied thereafter.
26 6. Weekend 3.02 (1.13)* Relatively stable between ages 10 and 12, 2.74 (1.04)* Relatively stable between ages 10 and
27 sharp drop between ages 12 and 13, 12, continuous decline after age
28 further decline thereafter 12 years
29 7. Describes 3.08 (1.26)** Mild decline with age, sharper drop 2.75 (1.13)* Continuous decline with age
30 Best between ages 14 and 15
31 8. Week 3.11 (0.98)*** Fluctuated during the age-course studied 2.78 (0.90)* Sharp drop between ages 12 and 14,
32 summary (highest at 12 and lowest at 15) relatively stable before and thereafter
33 PAQ-C or -A 3.01 (0.72)* Decline with age, but relatively stable 2.69 (0.63)* Continuous decline with age
34 score between ages 11 and 12, and between
35 ages 13 and 14
36 †
All items significantly different between sexes (P < 0.001) therefore further analyses stratified by sex; significant main effect for age: *P < 0.05;
37 1
bs_bs_query
**P < 0.01; ***P < 0.001. Item 1 is the average score from the activity checklist, each item is scored between 1 (never) and 5 (7+ times); items
38 2–7 are individual questions, each of which is scored on a scale from 1 (low or no physical activity [PA]) to 5 (high PA); item 8 is the average score
39 derived from responses for each day during the last 7 days, ranging from 1 (no PA) to 5 (very high PA); PAQ-C or PAQ-A is the average score of
40 items 1 to 8 (PAQ-C includes additional item on recess). PAQ, Physical Activity Questionnaire; PAQ-A, PAQ for Adolescents; PAQ-C, PAQ for
41 Children.

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1 Table 4 ROC analyses of PAQ scores against cardiorespiratory fitness

2
3 n† % fit‡ AUC (95%CI)§ ROC-derived PAQ cut-off point
4 (specificity, sensitivity)¶
5 Boys
6 10.0-10.9 years 150 89% 0.750 (0.643–0.857) 2.901 (0.765, 0.669)
7 11.0-11.9 years 653 91% 0.651 (0.585–0.716) 3.033 (0.694, 0.550)
8 12.0-12.9 years 928 89% 0.614 (0.556–0.671) 2.905 (0.582, 0.629)
9 13.0-13.9 years 798 87% 0.607 (0.552–0.662) 2.973 (0.664, 0.522)
10 14.0-14.9 years 656 88% 0.647 (0.583–0.710) 2.940 (0.718, 0.557)
11 15.0-15.9 years 352 87% 0.593 (0.508–0.678) 2.921 (0.660, 0.518)
12 All 3537 88% 0.630 (0.602–0.657) 2.905 (0.621, 0.591)
13 Girls
14 10.0-10.9 years 138 78% 0.537 (0.421–0.653)NS 3.178 (0.700, 0.435)NS,††
15 11.0-11.9 years 626 74% 0.566 (0.515–0.617) 2.697 (0.549, 0.606)
16 12.0-12.9 years 896 72% 0.555 (0.514–0.596) 2.777 (0.501, 0.587)‡‡,††
17 13.0-13.9 years 711 76% 0.568 (0.518–0.617) 2.611 (0.601, 0.562)
18 14.0-14.9 years 533 75% 0.600 (0.544–0.656) 2.427 (0.588, 0.595)
19 15.0-15.9 years 247 78% 0.606 (0.518–0.693) 2.339 (0.647, 0.608)
20 All 3131 75% 0.565 (0.542–0.588) 2.694 (0.592, 0.516)
21 All significant (P < 0.05) unless indicated (NS). †ROC analyses were restricted to students with a valid PAQ and cardiorespiratory fitness test
22 score (ª93% of Table 1). ‡Healthy-fit as per FITNESSGRAM standards.28,33 §1.0 = perfect test, 0.5 = non-discriminating test. ¶PAQ score at
23 coordinate with greatest sum of specificity (sp) and sensitivity (se). ††Use with caution. ‡‡Coordinate with greatest sum of sp and se was
24 disproportionate (0.858, 0.247); instead, the coordinate with the next greatest sum of sp and se, where sp and se contributed equally to the sum, was
25 used. AUC, area under the curve; NS, not significant; PAQ, Physical Activity Questionnaire; ROC, receiver–operator curve.
26

27 significant (P < 0.05), albeit it only weak (AUC <0.7) discrimi- aged 11 and above, and decreased significantly with age in both 39
28 nators between “healthy-fit” and “at risk” individuals. A sample sexes, and at a greater rate in girls than in boys. These patterns are 40
29 ROC is illustrated in Figure 2. well aligned with those reported in North American youth.12–15 41
30 More importantly, they agree with the sex–age differences 42
31 Discussion reported for objectively measured PA.39,40 Thus, we are confident 43
32 In line with our first aim, we described normative PAQ data for a in the construct validity of the PAQ for English youth and rec- 44
33 large sample of English boys and girls aged 10.0–15.9 years. ommend these normative data to be used to standardize PAQ 45
34 Mean PAQ scores were significantly higher in boys than in girls scores according to sex and age in future research. 46

Activity checklist 47
We also aimed to describe in detail the individual responses to 48
PAQ items. In particular, the activity checklist provides rare 49
qualitative insight into boys’ and girls’ self-reported PA partici- 50
pation and the age-related declines thereof. A discussion of each 51
activity is beyond the scope of this paper, but we highlight the 52
three most common activities reported by English children, ado- 53
lescents and adults:36,41 swimming, soccer and cycling. In line 54
with other national surveys on sports participation,36,41 weekly 55
swimming was among the most common activities in our 56
35 regional sample of 10–15-year-olds (approximately 50%). Nev- 57
ertheless, it is of note that we observed a dramatic age-dependent 58
decline in weekly swimming participation in both boys and girls 59
(Table 2 and Fig. 1), and at a much greater rate than for most 60
other activities. We are unable to offer a definite explanation for 61
this decline, especially as students from each age group were 62
assessed in each of the measurement years (2006–2009) and 63
there were, to the best of our knowledge, no changes in local 64
access to swimming pools during the time course studied. The 65
decline may, however, be linked to access to structured swim- 66
ming lessons up to the age of 10 or 11, after which point most 67
36 Fig. 2 Example receiver–operator curve for the Physical Activity children and youth are likely to opt for sporadic and unstructured 68
37 Questionnaire (PAQ)’s ability to identify “at risk” 14-year-old boys participation in swimming, and far fewer for regular participation 69
38 (n = 656). AUC, area under the curve. as part of competitive swimming clubs. 70

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Norms and cut-off points for PAQ-C/-A 7

1 Another sporting activity of great interest in the English likely to contribute very differently to achieving PA guidelines of 57
2 context is soccer, the nation’s most popular team sport.36,41 In our 60 min or more of daily moderate-to-vigorous PA.20 58
3 sample, nearly three-quarters of boys reported playing soccer at 59
4 least once in the last 7 days; this was the same at all ages (Table 2 Physical education 60
5 and Fig. 1). Less than a third of 10–15-year-old girls reported Boys’ and girls’ highest mean score on any individual PAQ item 61
6 playing soccer in the previous 7 days, and participation in soccer was the question relating to effort during PE (item 2). In both 62
7 halved over the age-range studied (Table 2 and Fig. 1). Neverthe- groups, the mean response broadly suggests participants were 63
8 less, given that gender ideology is thought to remain a barrier to active “quite often” during PE. This apparent commitment to PE 64
9 English girls’ participation in soccer,42 the fact that a quarter of participation is important and adds further strength to the notion 65
10 15-year-old girls reported to have played soccer at least once that well-designed PE offers an opportunity to help youth achieve 66
11 during the past 7 days is encouraging. health-related PA guidelines.48 However, Janz et al.49 reported 67
12 Lastly, cycling is not only one of the most commonly reported that the PAQ item relating to PE was one of the few items that 68
13 activities by English adults, children and adolescents,36,41 it is also were not significantly correlated with objectively measured PA. 69
14 a desirable, health-promoting commuting mode;43 the association The PE question is likely as susceptible to recall error as any 70
15 between cycling to school and CRF in children and youth is well other item in this population,6,7 but it is also important to bear in 71
16 established,29,44 and more recently, we have reported the same for mind that the PAQ questionnaires were completed during PE 72
17 recreational cycling.45 It is encouraging, therefore, that three- classes. Whilst researchers made every effort to assure partici- 73
18 quarters of 10–15 years old boys reported cycling at least once a pants of the anonymity of their questionnaire responses, it is 74
19 week (Table 2), and that this self-reported level of participation nonetheless possible that not all participants responded truthfully 75
20 changed little across the age-range studied (Table 2 and Fig. 1). over fears of their teacher’s finding out their true attitudes 76
21 Cycling was much less common in girls, with only half reporting towards PE. 77
22 this activity. More troubling, however, is the steep decline in 78
23 girls’ weekly cycling with age (Table 2 and Fig. 1). Whereas Association between PAQ scores and 79

24 cycling participation was similar in 10-year-old girls and boys cardiorespiratory fitness 80
25 (>70%), fewer than 30% of 15-year-old girls reported cycling Total PAQ scores and CRF test performance (laps completed 81
26 in the past 7 days. Given the stability of cycling in boys, it is in the shuttle run test) correlated weakly-to-moderately in the 82
27 unlikely that environmental provision for cycling, such as cycling present sample. Such typical weak-to-moderate associations 83
28 paths, plays a meaningful role. We do know, however, that bike between CRF and PA24 may in part be explained by genetics, 84
29 ownership in the present sample was lower in older girls; that which accounts for up to 30% of the variance in CRF and respon- 85
30 92% of 10-year-old girls owned a bike compared with 80% of siveness to training.50 The association between body fat and CRF 86
31 15-year-olds may partially explain the reduced cycling frequency test performance is well established.51 This may also explain why 87
32 in older girls. Such cross-sectional data cannot, however, be used we observed weaker associations between PAQ scores and pre- 88
33 to infer causality and it may also be that older girls (or their dicted VO2peak, as the prediction equation by Boiarskaia takes 89
34 families) do not invest in new bikes as they perceive girls would BMI into consideration.33 We have already alluded to the PAQ’s 90
35 not make use of them. inability to capture duration and intensity of PA, both of which 91
36 Physical activity patterns track from childhood into adoles- are related to CRF in a dose–response manner.52,53 Nonetheless, 92
37 cence and from adolescence into young adulthood.46,47 It is thus the fact that we observed significant associations of expected 93
38 concerning that English girls’ participation in the nation’s most strengths and direction, despite these limitations, speaks further 94
39 common activities, namely swimming, soccer, and cycling, to the validity of the PAQ as a tool to estimate general levels 95
40 appears to decline so dramatically during the teenage years; the of PA. 96
41 fact that the same is not observed in boys would suggest that 97
42 cultural factors rather than environmental factors, such as access ROC-derived criterion-referenced standards 98

43 to facilities, may be to blame. Future research and intervention We are the first to report that the PAQ score has discriminative 99
44 initiatives should investigate and address the underlying causes. power to distinguish between “healthy-fit” and “at risk” youth, 100
45 In any case, these data illustrate how the PAQ offers opportunity whereby “at risk” describes youth with CRF low enough to 101
46 to record and monitor frequency of participation in multiple increase the risk for developing metabolic syndrome.28 According 102
47 sports and activities, which the more “sophisticated” measures of to our findings, boys aged 10–15 years need to achieve a PAQ 103
48 PA, such as accelerometry, cannot do. It needs to be borne in score of 2.9 or higher to maintain a level of CRF associated with 104
49 mind, however, that the scoring of the PAQ does not weight a reduced risk of potential adverse metabolic health. This is 105
50 individual sports and activities relative to exercise intensity or interesting as boys’ PA levels, including PAQ scores, decline with 106
51 duration. For example, a student that reports no activities other age, whereas capacity for better CRF test performance increases 107
52 than walking four times a week receives the same overall activity as they progress through puberty. Tables 2 and 3 show age- 108
53 checklist score as another student who reports playing soccer related changes in boys’ individual PAQ items; it may thus be 109
54 four times a week. There may be further differences between important to give consideration to specific, more stable PAQ 110
55 structured participation in soccer (coaching) and free play. The items, such as cycling and certain types of organized sport, as 111
56 PAQ is unable to measure these important differences, which are well as PE, to ensure that boys can continue to achieve adequate 112

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8 C Voss et al.

1 PA levels to maintain health-related CRF. For girls, our findings moderate associations between the PAQ score and measures of 57
2 suggest that PAQ scores of 2.7 likely indicate adequate CRF CRF are very much in agreement with those reporting the asso- 58
3 levels, but we observed definite age differences in girls. As girls ciation between objectively measured PA and CRF (r = 0.21 to 59
4 progress through their teenage years, lower PAQ scores appear 0.45).55,56 On this basis, we are confident in the construct validity 60
5 necessary to maintain health-related CRF levels. Such a correla- of the PAQ for English youth. 61
6 tion mirrors the association between CRF and metabolic health, All measurements, including the administration of the PAQ, 62
7 whereby lower levels of CRF are required with age to protect took place during the summer months of a typical school year 63
8 against the metabolic syndrome.28 Thus, it may be more appro- (predominantly June and September). Longer days and milder 64
9 priate to use age-specific PAQ cut-off points for girls aged 13–15 temperatures in the East of England region may have resulted in 65
10 years (2.6, 2.4, 2.3, respectively). greater levels of PA when compared to the winter months.30 In 66
11 The discriminative power of the PAQ was, however, relatively addition, physical activity levels may also differ between summer 67
12 weak, as evidenced by the fairly small AUC (<0.7). The AUC months during the school year and during the summer break. This 68
13 provides an estimate of the “goodness” of a diagnostic test, potential effect of seasonality (and weather) on PAQ scores needs 69
14 whereby a theoretical perfect test with 100% specificity and to be borne in mind when using these proposed normative data 70
15 100% sensitivity yields an AUC of 1, and a non-discriminating and PAQ cut-off points. 71
16 test an AUC of 0.5.54 A diagnostic test that yields an AUC of <0.7, Lastly, it is a limitation that we had no direct measure of either 72
17 as observed here, may be deemed unacceptable for clinical use, CRF (indirect calorimetry) or metabolic health (blood profiling). 73
18 given the potentially severe repercussions of misclassifying pres- We predicted and classified VO2peak according to recent FIT- 74
19 ence or absence of disease. The PAQ is not, however, a clinical NESSGRAM standards;28,33 however, low accuracy of predicting 75
20 diagnostic test and comparatively low AUC are often published VO2peak in girls is a recognized phenomenon.33 This may also have 76
21 in a public health context; for example, for the association been the case in the present study, where girls’ PAQ scores were 77
22 between CRF and metabolic health in youth.27,28 There are two more strongly correlated with CRF performance test score (laps; 78
23 reasons for this: first, associations between variables of interest r = 0.222–0.323, all P < 0.001), than with predicted VO2peak (r = 79
24 are generally weaker (i.e. CRF levels are not the sole determinant 0.122–0.156, P < 0.01). Whilst part of that may be explained by 80
25 of metabolic health), and second, the benefit of having a diag- the fact that the VO2peak prediction equation adjusts for BMI,33 81
26 nostic test that identifies “at-risk” children and youth in need of low prediction accuracy may nonetheless have potential implica- 82
27 intervention as a preventive measure outweighs the disadvantage tions for using predicted VO2peak for girls’ risk classification28 as 83
28 of misclassification. The same applies in the present context. done in the present study. Future research is needed to confirm 84
29 Consider a false negative in our study: if a child is deemed “low the presently observed correlations between the PAQ and meta- 85
30 active” according to our proposed PAQ cut-off points, even bolic health. This may be achieved by either using a direct 86
31 though they may have adequate CRF levels and health status, measure of VO2peak (rather than predicted VO2peak) for the classi- 87
32 encouraging even greater participation in PA may potentially fication into “at-risk” and “no-risk” for metabolic syndrome,28 or 88
33 promote even better CRF, given the apparent dose–response cor- better still, by obtaining a direct measure of metabolic health 89
34 relation between CRF and amount/intensity of PA.52,53 (blood profiling). 90
35 In summary, the present limitations underline that our pro- 91
36 Limitations posed PAQ cut-off points should not be considered as a definitive 92
37 Subjectivity and limited recall ability are known limitations of diagnostic tool, but rather as an instrument to help identify chil- 93
38 self-reported PA, particularly in young people.6,7 However, early dren and youth who may be at risk of future health complications. 94
39 validation studies of both PAQ yielded acceptable 1-week test– 95
Conclusion 96
40 retest reliability (r = 0.75 to 0.82)12 and acceptable internal con-
41 sistency and validity when compared with: teacher evaluation of This paper provides normative PAQ scores for English boys and 97
42 activity (r = 0.45),10 various recall scales (r = 0.41 to 0.73),10,11 girls aged 10.0–15.9 years, which may be used in future studies 98
43 CRF measured using a step test (r = 0.28),10 Caltrac accelerom- to standardize English children’s and adolescents’ PAQ scores 99
44 eters (r = 0.33 to 0.39),10,11 and more recently, Actigraph accel- relative to their age and sex. We also provide the first evidence- 100
45 erometers (rho = 0.56).49 Nonetheless, it is a limitation that we based, meaningful categorization of PAQ scores into “sufficiently 101
46 had no objective measure of PA in the present study and were active” versus “low-active” groups using cardiorespiratory fitness 102
47 thus unable to directly assess the validity of the PAQ in our as the criterion-referenced standard. Boys need to achieve a PAQ 103
48 sample. The observed PAQ scores and sex–age differences are, score of 2.9 or greater; for girls, a highly conservative estimate 104
49 however, very similar to those previously reported in North suggests that PAQ scores should be 2.7 or greater, although it 105
50 American youth, including the samples in which the question- may be more appropriate to use lower, age-specific PAQ scores 106
51 naires were originally validated.12–15 Furthermore, the presently for girls of 13, 14 and 15 years (2.6, 2.4, 2.3, respectively). 107
52 observed correlation coefficients for the association between 108
53 PAQ scores and CRF test performance (laps completed in the Acknowledgments 109

54 20-m shuttle run test; r = 0.222 to 0.418) were similar to or We thank the principals, teachers, parents and schoolchildren for 110
55 greater than those Kowalski et al. reported in their validation their support and participation in the East of England Healthy 111
56 study for PAQ scores against a step test (r = 0.28).10 Indeed, these Hearts Study. We also thank our research staff and university 112

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