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Results From Venezuela’s 2016 Report Card on Physical Activity for Children and Youth

Marianella Herrera-Cuenca, Betty Méndez-Perez, Vanessa Castro Morales, Joana Martín-Rojo, Bianca Tristan, Amilid Torín Bandy, Maritza Landaeta-Jiménez, Coromoto Macías-Tomei, and Mercedes López-Blanco

Background: The Venezuelan Report Card on Physical Activity for Children and Youth is the first assessment of information related to physical activity in Venezuela. It provides a compilation of existing information throughout the country and assesses how well it is doing at promoting opportunities for children and youth. The aim of this article is to summarize the information available. Methods: Thirteen physical activity indicators were graded by a committee of experts using letters A to F (A, the highest, to F, the lowest) based on national surveys, peer review studies, and policy documents. Results: Some indicators report incomplete information or a lack of data. Overweight and Obesity were classified as A; Body Composition and Nongovernmental Organization Policies as B; Municipal Level Policies as C; and Overall Physical Activity Levels and National Level Policies as D. Conclusions: 63% of children and youth have low physical activity levels. Venezuela needs to undergo a process of articula- tion between the several existing initiatives, and for said purposes, political will and a methodological effort is required. Invest- ments, infrastructure, and opportunities will be more equal for all children and youth if more cooperation between institutions is developed and communication strategies are applied. Keywords: obesity, epidemiology, sedentary behavior, fitness, policy

There is no doubt that noncommunicable diseases (NCD) are lished international recommendations of physical activity (PA).3 a global health concern and that obesity, type 2 diabetes, and car- The last Standard Life Conditions Survey for Venezuelans 2015, diovascular diseases have been on the rise during the last decades conducted by 3 major universities in the country, reported that 53% at an alarming rate. In Venezuela, the leading cause of death is of Venezuelan adults are not physically active, and the intensity of cardiovascular diseases, and the rates of type 2 diabetes and obesity PA increases as socioeconomic status improves.4 Similarly, child- have been increasing during the past decade.1 The cost of the high hood physical inactivity has reached levels that deserve media atten- prevalence of obesity and type 2 diabetes is not only economic, but tion and public awareness. In this regard, figures published by the also results in a deteriorated quality life for those who suffer from National Institute of Nutrition (INN) and reported from a national these diseases. It is a major topic of scientific, social, and policy sample, 98.16% of obese children and youth, aged 7 to 12 years old, making discussions, especially when there are concerns about do not perform enough PA to meet the international recommenda- productivity and wellbeing of societies. Thus, Venezuela is facing tions. Out of those, 47.14% of overweight adolescents between increases of these NCD while still dealing with undernutrition and 13- to 14-years-old were sedentary, and 47.71% performed light communicable diseases.2 This has been a complex scenario when intensity activities.5 On the other hand, inhabitants from low-income addressing the right interventions because at least ideally the aim neighborhoods have reduced access to a healthy environment that should be to provide care for those who are overweight and/or obese could promote participation in PA, like sports practice or outdoor and compensate those who are undernourished while attending to play. This is to say: poverty and socioeconomic status (SES) influ- the normal population. ences the level of PA in people living in disadvantaged conditions.6,7 Besides these challenges, the country is facing a relevant eco- Within this context, it is important to make a diagnosis of what nomic and social crisis in which the increase of poverty results in the situation is in terms of the PA status in children and youth in social disparities, constituting an obstacle for achieving the estab- Venezuela. Related information and figures are scarce and disorga- nized. International reports will mention the fact that governmental and nongovernmental actions for PA promotion are being taken but Herrera-Cuenca is with the Center for Development Studies (CENDES), lack detailed description.1 Identifying if children and adolescents Central University of Venezuela; Bengoa Foundation for Food and Nutri- are achieving the PA level recommended by national and/or inter- tion; and the Venezuelan Health Observatory. Méndez-Perez is with the national standard is relevant. In addition, identifying what areas do Bioanthropology, Physical Activity, and Health Unit, Central University not have an availability of data are an important task to improve of Venezuela, and the Bengoa Foundation for Food and Nutrition. Morales data compilation and information collection, so that the design of is with the Bioanthropology, Physical Activity and Health Unit, Central adequate public policies can be achieved. In consequence, interven- University of Venezuela. Martín-Rojo is with the Inmunology Institute, tions based on the results of this report card would help to increase Faculty of Medicine, Central University of Venezuela. Tristan is with the PA level of these population groups and would promote benefits Venezuelan Health Observatory. Bandy, Landaeta-Jiménez, Macías-Tomei, from PA, such as the prevention of chronic NCD at early ages. and López-Blanco are with the Bengoa Foundation for Food and Nutrition. To develop the Venezuelan Report Card according to the estab- Herrera-Cuenca ([email protected]) is corresponding author. lished rules of the steering committee and the Healthy Active Kids

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International core group for the previous countries report cards, a for each indicator and to discuss behaviors, environments, practices cooperative research group from different institutions was developed and policies in terms of potential reach, adoption and impact. The with the help of Active Healthy Kids Colombia. RWG agreed that grading through letters from A to F would be used The aims of this article are 2-fold: first, to summarize the results since it was equivalent to the academic grading system used in most of the Venezuelan children and youth report card by a systematic Venezuelan elementary and middle schools. Grades were based on review of relevant information, and secondly, to identify the areas criteria set by the Scientific Advisory Panel of South African Report in which the information is scant, to influence decision making Cards for 2007 and 2010,8,9 and the benchmarks for the Venezuelan through evidence-based information. grading scale used models from Canada10,11 and Scotland,12 allow- ing comparisons against an ideal scenario while also identifying trends for moderate improvements in the future.13,14 As a result, Methods the Venezuelan Report Card grading scale was defined as follows: Researchers at the Central University of Venezuela developed a grade of A indicates success in reaching the best results for the and produced the 2016 Venezuelan Report Card by means of a indicator for the majority of children and youth (81% to 100%), B cooperative program between the Center for Development Studies indicates being successful with well over half of children and youth (CENDES), the Bioanthropology, Physical Activity and Health Unit (61% to 80%), C indicates success with about half of children and (Bio An Unit) and the Bengoa Foundation for food and nutrition. youth (41% to 60%), D indicates succeeding with less than half, but In addition, Sucre County’s department of health provided input some, children and youth (21% to 40%), and F indicates success through the director and epidemiology personnel. In addition, a with very few children and youth (0% to 20%). Major’s office representative was included. The third step included meetings of the RWG that considered Altogether the research working group (RWG) consisted of a different perspectives on how the country is doing in gathering data, total of 12 experts from the above mentioned institutions. CENDES the respective analysis and promotion of PA. The RWG then held 3 and Bio An Unit members had been mentored by leaders from the meetings. The first one of those meetings was for discussing, along Epiandes research group from Colombia, a team with experience with Sucre County’s personnel, the impact of health public policies in developing the Colombian report card in previous years. All the and communication campaign for promoting PA in the county’s experts met 7 times, although the team at the Bio An Unit (librarians children and youth. Then, 2 more meetings were held, during which and research assistants) reviewed the literature since the beginning the RWG assessed the available evidence for each indicator, con- of the project, independent of these meetings. sidering the quality of evidence, trends over time, disparities in PA The first step was a review of the available literature, to check and risk factors, and international comparisons, and proceeded to the existing published national data reports and peer-reviewed give the grades average according to the selected scale. journal papers. Parallel to this, an examination of the existing gray It is important to note that due to a lack of national data in some literature produced by major universities was performed with the indicators, and to cover some local disparities, the RWG decided to aim to check the information contained in theses and/or dissertations include local academic studies from different sources in this report at all graduate levels. National and local reports on physical activities card. National and local studies were individually scored and all and public policy actions for quality exercise programs and sports were included for obtaining final results. Finally, an average was were equally reviewed for the development of this Report Card. calculated as an overall grade for each indicator at the national level, This step included the development of the indicators; 2 meetings including local and academic studies, when available. Comments of the RWG were held for this purpose. Evidence was summarized and/or recommendations from the experts were also incorporated for the design of 13 indicators classified into 3 categories according with the indicators and in explanatory notes. to associations with overall levels of PA. The first category com- To illustrate the report card, a cover story was developed prised behaviors contributing to PA levels: 1) Overall PA Levels, according to the current situation in Venezuela. Baseball is a very 2) Active Transportation, and 3) Organized Sport Participation. important sport in Venezuela. Many of the Major League Baseball The category Active Play was not included since neither national players are Venezuelans, and kids usually engage in its practice at nor local information was available. The second category included an early age. But nowadays, several behaviors in the Venezuelan factors associated with elevated cardio metabolic risk: 1) Sedentary population have been changing, and due to the huge economic Behaviors (screen-time), 2) Overweight (BMI for age > 1SD and crisis in the country, there have been food shortages. Some of the ≤ 2SD), 3) Obesity (BMI for age > 2SD), 4) Below Health Fitness changes include endless lines for buying basic food products. Thus, Zone (low cardiorespiratory fitness), and 5) Body Composition parents must take their children along with them, sometimes not (body fat percentage above the 75th percentile reference by age even sending their kids to school for several days per week, and and sex according to the sum of skinfolds). The third category com- many times kids are not able to eat breakfast, depending on what is prised factors that influence PA: Policy. The indicators of School, available at home.4,15 These elements of Venezuelan daily life are Family, and Community and Built Environment were not assessed included in this cover story. due to lack of national and/or local data. The Policy indicator was subdivided into 3 categories of initiatives: National, Local (state Results and Discussion and municipal levels), and Nongovernmental Organization Activi- ties. Primary sources of national data were the National Institute The 2016 Venezuelan Report Card is the first assessment for com- of Statistics (INE) and the National Institute of Nutrition5 surveys piling the existing information of about PA levels and enabling and current policy governmental documents. Data from local state environments for children and youth in the country to the best of our and municipal governments’ policy documents were also included. knowledge. The cover of Venezuela’s Report Card may be observed In the second step, a review of the grading system and criteria in Figure 1. All indicators were evaluated based either on national used in report cards from other countries was performed to select or local/community evidence. Grading scores are summarized in the grading scale and benchmarks to be used by the Venezuelan Table 1. Appendix Table 1 summarizes the grades assigned by the Report Card. The RWG held 2 meetings to define the benchmarks RWG for each indicator and the sources of the data.

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Table 1 Grades According to Physical Activity Indicators in the 2016 Venezuelan Report Card on Physical Activity for Children and Youth Indicator Grades Overall Physical Activity Levels D Organized Sport Participation INC Active Play INC Active Transportation D/F Time Spent in Sedentary Behavior D/F Overweight A Obesity A Below health fitness zone INC Body Composition B Family INC School INC Community and the Built Environment INC National Policy D Municipal Policy C Nongovernment B Note. The grade for each indicator is based on the percentage of children and youth meeting a defined benchmark: A is 81% to 100%; B is 61% to 80%; C is 41% to 60%, D is 21% to 40%; F is 0% to 20%; INC is Incomplete data. The grades assigned in this table are based on national studies and local academic studies; however, local studies and their given grades can be observed in detail in Table 2.

Active Transportation: D / F A grade of D / F was assigned to the Active Transportation indicator based on the lack of national information and local data on the subject. Reports showed that no more than 21.4% of boys and 16.8% of girls either walk or bike to and from school for approximately 3 days during the week.17,25

Organized Sports Participation: INC Figure 1 — Front cover of the 2016 Venezuelan Physical Activity Report Despite a lack of national information, which resulted in a indica- Card. tor grade of INC, of the 2 local studies one was graded A because 94.6% of the adolescents from public and private schools studied were engaged in vigorous PA in sports, such as swimming, vol- 20 Overall Physical Activity Levels: D leyball, and basketball. On the other hand, the second study was graded F; only 11% of the adolescents in the study sample spent The grade of D for Overall PA Levels in children and youth was their leisure time in sports activities.26 given based on 2 criteria: first, data from the National Institute of Statistics (INE)16 reports that based on the WHO guidelines, the Time Spent Maintaining Sedentary Behavior: low levels of PA for the age group of 3 to 18 years do not meet the D / F weekly time recommendations; and second, the data does not show detailed levels of intensity. Figures from the National Institute of The information from national and local samples comprises a broad Nutrition (INN) show that 9.8% of children between the ages of 7 range of percentages for this indicator. In addition, the condition of to 12 were obese, and of those, 98.16% were sedentary. The data sedentary behavior was pointed out in studies of overweight and does not show the PA levels of the normal population.5 However, obese children and adolescents. This is the case with a national study published academic research shows high variability when assessing that reported 98.16% of the obese kids sample were not engaged in different communities. Grades from F to A can be observed through physical activities.5 In the group of adolescents aged 13 to 14, the detailed assessment of PA levels and intensity in public and private frequency of a sedentary lifestyle was 47.14%. Local reports derived schools in several regions in the country.17–19 This shows that when from representative samples showed that about 40% of adolescents adequate actions exist, the outcomes are positive, resulting in an spent an average of 4 hours sitting in front of the TV, playing com- outstanding performance. puter and video games, talking to friends, or taking a nap; during

JPAH Vol. 13, Suppl. 2, 2016 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC 2016 Venezuelan Report Card S317 the weekend usage increased sometimes up to 77.5%.20,21,24,25,28 As highlight the fact that the existence of body fat distribution altera- it has been reported in several studies, physical inactivity was more tions, even in small percentages, cannot be considered as a success frequent in girls and generally in overweight and obese children at this time. Moreover, the awareness of the consequences of early and youth.17,27 These results should call the attention of private and impairments in nutritional status have been supported by research governmental agencies to assume a greater emphasis on prevention since the pioneering research by David Barker related to the early and highlighted the protective effect of PA. origins of adult disease.55,56 It is not a goal of this report card to engage in a detailed discussion about the early origin of diseases in Overweight: A Venezuela, but because of the relevance of identifying all stages of malnutrition, and the current situation of food shortage in Venezu- A grade of A was given to this indicator based on information ela, the detailed analysis of body composition should be a priority. provided by a national sample in which a prevalence of 17.57% of overweight in children and youth aged 7 to 12 years was found, a Below Health Fitness Zone: INC prevalence that moderately decreases from age 13 years.5 On the other hand, reports from different samples that cover the outskirts Though national data were lacking, scant information provided by of major cities revealed a prevalence of overweight children that local records showed overall that Venezuelan children and adoles- ranged mainly from 11.4% to 17%,20,21,31–34,36 although 2 studies cents performed at levels of physical fitness that can be classified found as much as 30% to 32.1% of overweight children measured from moderate to poor, based on the resulting profile of aerobic by BMI.29,35 There was not a clear pattern of sexual dimorphism that PA and the 1000 m race.39–41 One article reports that time spent assigned the condition to one sex or the other, although 2 papers on vigorous aerobic PA favors reaching a normal systolic blood reported an increased prevalence in girls and in those who attended pressure in 29% of adolescents aged 14 to 15.38 Local data grades private schools. ranged between C to F, showing the high variability in the outcomes according to different geographical situations and contexts. Obesity: A Policy: D / C / B The Obesity indicator received an overall grade was A. However, a note for clarification is needed: the classification for assessing The constitution of the Bolivarian Republic of Venezuela has a legal obesity in a national sample resulted in a grade of A based on the framework that states the right to perform PA through article 111; criteria; overall, the prevalence of obesity in boys was 10.62% it also says that the State shall guarantee resources for the promo- compared with 8.53% in girls.5 The other national (academic) study tion of sports and recreation to improve individual and collective was graded B because obesity in boys was 31.4% and 22.3% in lifestyles.42 The grade D was given to National Policy due to the girls.32 This can be explained due to the sample sizes, but also the lack of specific and articulated action that permeates to all societal composition of these samples, showing that inequities and environ- factors. Local government initiatives (Municipality Policy) also mental conditions that Venezuelan population has been exposed to exist, and a grade of C was given based on the number of programs in the recent years have an influence on the presence of obesity, thus implemented by municipalities around the country.46–52 Nongovern- presenting a trend of lowering while the social scale descends. In mental Organizations were given a B since they have a very detailed both studies it is evident that low-income groups have become more description of the promotion of activities; the number of actions food insecure and have difficulties accessing food, while affluent taken and coverage is larger than central and local governments in groups have access and may feed their families and children.5,32,57 this population group.53,54 It should be noted that these initiatives are not officially coordinated; thus, an encouragement to work in Body Composition: B alignment is important. This indicator was included based on its importance in assess- Strengths and Limitations ing the body composition and fat distribution as a risk factor for developing cardiometabolic diseases in the future. In developing This is the first time the Venezuelan Report Card has been developed. countries, where “the double burden of malnutrition” phenomena The usefulness of having a diagnosis of the availability of data will presents as the coexistence of obesity on one side of the popula- definitely constitute a major contribution toward better actions for tion, while still working to eradicate undernutrition on the other promoting PA at all levels in the near future. Having access to the side, anthropometric evaluation with parameters other than body representatives from the health and major’s offices was, is, and mass index (BMI) is key.2 It is important to create awareness of the will continue to be a strength for promotion of PA within the com- identification of those children with normal BMI yet high percent- munity. In addition, the initiative of an interinstitutional RWG is ages of fat or high central adiposity are present. Although there is an important step toward integrated work that will promote PA in a lack of national governmental data related to body composition, the most accurate and evidence-based way. several local and academic national studies exist. In these existing On the other hand, we had some limitations. The first one was studies, 12.7% to 36.6% of adolescents are reported to have high that although grades were based on the best available data, there fat according to the results obtained by the sum of skin folds and were significant research gaps, particularly in national documents. high waist circumference values in children who do not perform This should be addressed in the future to provide a more compre- enough vigorous physical activities; these values are less than 40% hensive and complete overview of the PA profile of Venezuelan of the children in those studies20,26. Another study found a central children and youth. The need for more national input on environ- adiposity distribution that reached 42% for boys and 44% for girls, mental conditions and family, school, and community influence is being less than half of the children studied.21 According to these relevant, as well as a continuous monitoring and evaluation of the results a grade of A / C was assigned to the above mentioned studies, established programs. These actions would improve availability which averaged to a grade of B for this indicator. It is important to of the necessary data for undertaking a multilevel approach that

JPAH Vol. 13, Suppl. 2, 2016 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC S318 Herrera-Cuenca et al allows better understanding on the PA levels of Venezuelan chil- 6. Florindo AA, Curi Hallal P, De Moura EC, Carvalho Malta D. Práctica dren and youth. de atividades físicas e factores asociados em adultos, Brasil, 2006. The local studies show the high variability of the achievement Rev Saude Publica. 2009;43(Supl 2):65–73. PubMed doi:10.1590/ of adequate PA levels in children and youth, particularly within the S0034-89102009000900009 school environment. This fact highlights the need for a methodologi- 7. Roberts K, Cavill N, Hancock C, Rutter H. Social and economic cal effort in structuring and designing studies that will measure PA inequalities in diet and physical activity. Public Health England. levels with comparable methods across the country, identifying 2013:14–22. the influence of the many factors that interact with and ultimately 8. Sport Science Institute of South Africa. Healthy Active Kids South constitute the PA profile of children and youth. It was difficult to Africa: Report card on the physical activity, nutrition and tobacco assess the existing national and local policies due to the lack of use for South African children and youth 2007. 2007. http://dvqdas- structured design of the models of public policies, and difficulties 9jty7g6.cloudfront.net/resources/southafricarc.pdf. Accessed March in evaluating their interventions and programs. 16, 2016. 9. Sport Science Institute of South Africa. Healthy Active Kids South Africa Report Card 2010. Sandton; 2010. https://www. discovery. Conclusion co.za/discovery_coza/web/linked_content/pdfs/vitality/parenting/ healthy_active_kids_report_card.pdf. Accessed March 16, 2016. The majority of children and youth in Venezuela are sedentary or 10. Colley RC, Brownrigg M, Tremblay MS. A model of knowledge perform low levels of PA. 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Child’s Play 2013? Active Healthy Kids the population should be included in the formulation of a structured Scotland Report Card. Glasgow, Scotland; 2013. http://www.active- model of public policy so PA levels can be improved for the major- healthykidsscotland.co.uk/. Accessed March 16, 2016. ity of the population. The next challenge is to translate evidence 13. Weissman NW, Allison JJ, Kiefe CI, et al. Achievable benchmarks of into practice to introduce changes that will improve health in these care: the ABCs of benchmarking. J Eval Clin Pract. 1999;5(3):269– population groups. 281. PubMed 14. Ellis J. All inclusive benchmarking. J Nurs Manag. 2006;14(5):377– Acknowledgments 383. The authors thank the following members of the Research Working Group 15. Pardo D. ¿Cuánta Hambre hay realmente en la Venezuela de la emer- for their contributions to the 2016 Report Card: Rodmar Rodríguez, Rania gencia alimentaria? BBC Mundo. 2016. http://www.bbc.com/mundo/ Khawam, Karina Mangia, Norelys Lucena, Lourdes García, Ana Patrón, noticias/2016/04/160412_venezuela_hambre_escasez_dp. Accessed and Carolina Machado from the Departments of Health and Nutrition at March 16, 2016. Sucre Municipality; and José Luis López, officer from the Mayoralty’s 16. Instituto Nacional de Estadística INE. Encuesta Nacional de Consumo office of Sucre Municipality. This work was supported by the cooperation de Alimentos. 2013. http://www.ine.gov.ve/. of the Venezuelan Health Observatory, which has the mission of compiling 17. Granero RM, Poni E, Sánchez Z. Patrones de actividad física durante accurate health data in Venezuela, and the team received a grant (# PSU- tiempo de ocio entre estudiantes del séptimo al noveno grado en el 05-8844-2016/1) at the Scientific and Humanities Council from the Central Estado Lara, Venezuela. Adv Cardiol. 2007;27(4):160–167. 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Alcaldía de Baruta. Programas. http://www.alcaldiadebaruta.gob.ve/ Caracas). Trabajo especial de grado para optar por el título de v2/programas/. Accessed March 16, 2016. Antropólogo. Caracas: Universidad Central de Venezuela; 2011. 47. Alcaldía del Municipio Sucre. Instituto Autónomo de Deporte y 29. Agobian G, Agobian S, Soto E. Malnutrición por exceso en escolares Recreación (I.A.M.D.E.R.) https://alcaldiamunicipiosucre.gob.ve/ de una institución pública y privada. Barquisimeto Estado Lara. Rev gobierno-municipal/institutos/instituto-autonomo-de-deporte-y- Venez Salud Publ. 2013;1(2):7–13. recreacion-i-a-m-d-e-r/. Accessed March 16, 2016. 30. Rincón Y, Paoli M, Zerpa Y, et al. Sobrepeso-obesidad y factores 48. Alcaldía de Chacao. Deporte Chacao. http://chacao.gob.ve/?vivo=994- de riesgo cardiometabólico en niños y adolescentes de la ciudad de deporte. Accessed March 16, 2016. Mérida, Venezuela. Invest Clin. 2015;56(4):389–405. 49. Alcaldía El Hatillo. Deporte. http://alcaldiaelhatillo.gob.ve/viveelha- 31. Pérez BM, Ramírez G, Landaeta-Jiménez M, Vásquez M. Iconografía tillo/deporte/. Accessed March 16, 2016. del dimorfismo sexual en dimensiones corporales y proporcionalidad, 50. Alcaldía de Caracas. Instituto Municipal de Deporte y Recreación según estado nutricional en niños. El Hatillo, Caracas. An Venez Nutr. (IMDERE). http://www.caracas.gob.ve/alcaldiaDeCCS/instituto- 2010;23(1):10–17. municipal-de-deporte-y-recreacion/entes/instituto-municipal-de- 32. Herrera Cuenca M, Velásquez J, Rodríguez G, et al. Obesidad en esco- deporte-y-recreacion/imdere. Accessed March 16, 2016. lares venezolanos y factores de riesgo para el desarrollo de diabetes 51. Alcaldía de Valencia. Deporte. http://www.alcaldiadevalencia.gob. tipo 2. An Venez Nutr. 2013;26(2):95–105. ve/deporte.php#sthash.g70KtNOH.dpuf. 33. Camacho-Camargo N, Alvarado J, Paoli M, et al. Relación entre el 52. Alcaldía de Iribarren. Instituto Municipal de Deporte y Recreación índice de masa corporal y las cifras de tensión arterial en adolescentes. de Iribarren. http://www.alcaldiadeiribarren.com.ve/estructura/entes- Rev Venez Endocrinol Metabol. 2009;7(2):17–24. municipales/imderi.html. Accessed March 16, 2016. 34. Di Gianfilippo M, Calvo MJ, Chávez M, et al. Prevalencia de sobrepeso 53. Criollitos de Venezuela. Historia. http://loscriollitos.com.ve/historia. y obesidad en escolares de la parroquia Coquivacoa del municipio php. Accessed March 16, 2016. Maracaibo-Venezuela. Rev Latin Hipert. 2013;8(3):68–76. 54. Polar F. Recreación y Buen Uso del Tiempo Libre. http://fundacionem- 35. Zambrano R, Colina J, Valero Y, Herrera H, Valero J. Evaluación de presaspolar.org/home/desarrollo-comunitario–3/recreaci%C3%B3n- hábitos alimentarios y estado nutricional en adolescentes de Caracas, y-buen-uso-del-tiempo-libre–2. Accessed March 16, 2016. Venezuela. An Venez Nutr. 2013;26(2):86–94. 55. Barker DJP. Mothers, Babies and Disease in Later Life. 2nd ed. New 36. Paoli M, Uzcátegui L, Zerpa Y, et al. Obesidad en escolares de Mérida, York: Churchill Livingstone; 1998. Venezuela: asociación con factores de riesgo cardiovascular. Rev Venez 56. Uauy R, Garmendia ML, Corvalan C. Addresing the Double Burden Endocrinol Metabol. 2009;56(5):218–226. of Malnutrition with a Common Agenda. Black RE, Singhal A, Uauy 37. Hernández Hernández RA, Herrera Mogollón HA, Pérez Guillen R (eds): International Nutrition: Achieving Millenium Goals and A, Bernal J. Estado nutricional y seguridad alimentaria del hogar Beyond. Nestlé Nutr Inst Workshop Ser, vol 78, pp 39-52. 2014. en niños y jóvenes de zonas suburbanas de Caracas. An Venez Nutr. 57. Herrera-Cuenca M, Castro J, Mangia K, Correa MA. Are social 2011;24(1):21–26. inequities the reason for the increase in chronic non communicable 38. Madariaga W, Donís JH. Efecto de la dosis de actividad física sobre la diseases? A systematic review. JDiabetes Metab Disord Control. presión arterial, índice de masa corporal y circunferencia abdominal 2014;1(3):00017. en adolescentes. Rev Venez Endocr Metab. 2014;12(2):102–111. 39. Alexander P, Pérez BM. Perfil de actitud física en población escolar de Biruaca, San Fernando de Apure, Venezuela. Arch Venez Pueric Pediatr. 2014;77(3):116–127.

JPAH Vol. 13, Suppl. 2, 2016 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC 17 20 24 18 19 21 22 23 (continued) Granero et al, 2007 Granero, 2003 et al, Nava 2011 Suárez Belandria et al, 2014 López and Martínez, 2012 Díaz et al, 2012 Rodríguez, 2015 Sal - Aliaga cedo and Landaeta Jiménez, In Press Source 12–16 yrs. 13–15 yrs. 4–6,9 yrs. 14–19 yrs. 14–17 yrs. 14–17 yrs. 2–5 yrs. 9–15 yrs. Age group Age Sample 2070 2249 173 863 210 150 151 791 -

Complimentary data from local studies from In Lara 17.3% of the boys and In Lara 17.3% of the boys in physical 7.5% of girls engaged at least 60 min for 5 days activity or more. and In Barinas 11.8% of boys in daily 4.8% of girls engaged for at least 60 activity, physical minutes. 55.9% of preschool children a zone of Caracas presented a level activity, of vigorous physical especially in girls. Mérida In the Libertador county, 91.5% adolescents from public institutions reported and private activity. moderate physical 86% of adolescents from La Rinconada-Caracas, performed The activity. vigorous physical 2.17 days spent on average boys a week with duration of 1 hr and 35 min each; girls 1.60 days during 1hr 52 min. reported that Valencia A study in than girls, were more active boys of moderate physical with a level activity. 65.6% of children in Caracas, spent 3 days or more a week per - activ forming moderate physical ity; while 34.4% spent less than 2 days a week for the same activity. 54% of the preadolescents and adolescents practice less and than 30 min per day of PA, is higher in women this behavior (63%) than men (45%). Grade F F C A A INC B C 16 INE, 2013 Source Age group Age 3–17 yrs. Appendix Sample 8,175,434 Data for the grading Data for In a national subsample, the levels of In a national subsample, the levels for the age group (PA) activity physical 63% of between 3–17 years showed PA; 30.8% suf - insufficient activity• very PA •• and 6.5% ficient activity active•••. Grade D Grades According to Physical Activity Indicators in the 2016 Venezuela Report Card on Physical Activity for Children and Youth and Children for Activity on Physical Card Report Venezuela in the 2016 Indicators Activity Physical to According Grades Indicator Overall Physical Physical Overall Levels Activity Category that Behaviors to contribute - activ physical ity levels Appendix Table 1 Table Appendix

S320 JPAH Vol. 13, Suppl. 2, 2016 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC 17 20 17 25 26 18 27 (continued) Aguilar et al, 2010 Suárez Belandria et al, 2014 Granero et al, 2007 Angulo et al, 2014 Granero, 2003 Granero et al, 2007 Pérez et al, 2012 Source 13–19 yrs. 14–19 yrs. 12–16 yrs. 7–11 yrs. Age group Age 13–15 yrs. 12–16 yrs. 9–13 yrs. Sample 232 863 2070 160 2249 2070 300

Complimentary data from local studies from A study in adolescents from the found that it was city of Maracay, daily to get only 17.24% walks to school. Mérida In the Libertador county, 94.6% of adolescents from public institutions reported and private in activity vigorous physical - volley sports such as basketball, ball and swimming. and 29.6% In Lara 26.2% of boys of girls spent 3 h or more their leisure time sitting in front of TV or computer in a normal the school day. 87.5% and 79.2% Valencia In children of obese and healthy computer TV, watch respectively, for 4 h or more. or video games Results from obese and healthy depicted Valencia, children from 96,6% and 81,9% respectively performing not enough physical activity. In Barinas 22.8% of boys and In Barinas 22.8% of boys 3 hours or 18.5% of girls engaged like more in sedentary activities, computer television, watching or sitting with friends. games In Lara 21.4% of boys and 16.8% In Lara 21.4% of boys to and from or bike of girls walk school for 3 or more days weekly. In Caracas and Mérida 11% of adolescents spent their leisure sports time in extracurricular activities. Grade F A B F/D F B/A D/F F 5 Source INN, 2013. Age group Age 7–14 yrs. Sample 1545 Data for the grading Data for The obese group between 13-14 years old reported 48.15% of sedentary life - style. Lack of national data Lack of national data Lack of national and local data In a national sample of overweight children and adolescents 7–12 years of found that 98.16% were not age, it was The age activity. in physical engaged group between 13 to 14 years with the 47.14% of sed - same condition showed entary lifestyle Grade INC D/F INC INC - (continued) Indicator Active Transpor Active tation Time spent Time in sedentary behaviors Organized Sport Organized Participation Play Active - Category that Behaviors to contribute - activ physical ity levels diometabolic risk Factors asso - Factors ciated with car elevated Appendix Table Appendix Table

JPAH Vol. 13, Suppl. 2, 2016 S321 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC 20 29 21 28 30 23 25 (continued) López and Martínez, 2012 Herrera, 2011 Agobian et al, 2013 Rincón et al, 2015 Rodríguez, 2015 Aguilar et al, 2010 Suárez Belandria et al, 2014 Source 14–17 yrs. 11–13 yrs. 9–11 yrs. 9–18 yrs. 2–5 yrs. 13–19 yrs. Age group Age 14–19 yrs. Sample 210 85 180 922 151 232 863

Complimentary data from local studies from The adolescents from La Rinco - that the nada-Caracas revealed time spent in sedentary behaviors sitting at the com - TV, (watching daily on puter or in class) was and 4 5 h 9 min for boys average h 56 min for girls. In a group of adolescents from found that 40% Caracas, it was were sedentary and 14.1% spent TV more than 5 hours per day on activities. and video games In a sample of school children in the city of Barquisimeto, it was found that 56.3% of children with engaged malnutrition by excess 1 hr a day at least to physical activity. Merida, In the Libertador county, the adolescents reported 49.3% of sedentary lifestyle 69.5% of children reported using on a 5 typical day digital media computer and video TV, such as this during the weekend games; usage increased to 77.5%. A study in adolescents from that 62.07% showed Maracay, of the sample spends 2–6 h/day 81.47% play less TV; watching 49.57% use than 2 h/day games; the internet 2–6 h/day. In the Libertador county, Mérida In the Libertador county, adolescents reported taking a nap (31.2%) and use the computer (35.1%) for at least 2 hours a day. Grade INC B C C D D B Source Age group Age Sample Data for the grading Data for Grade (continued) Indicator Time spent Time in sedentary behaviors - diometabolic risk Category asso - Factors ciated with car elevated Appendix Table Appendix Table

S322 JPAH Vol. 13, Suppl. 2, 2016 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC 34 24 20 33 37 35 31 21 36 (continued) Pérez et al, 2010 Suárez Belandria et al, 2014 López and Martínez, 2012 Camacho- et Camargo al, 2009 Di Gianfilippo et al, 2013 Zambrano et al 2013 et al, Paoli 2009 Hernández et al, 2011 Aliaga Sal - Aliaga cedo and Landaeta- Jiménez Source 6–12 yrs. 14–19 yrs. 14–17 yrs. 11–19 yrs. 6–12 yrs. 13–18 yrs. 7 yrs. 3–16 yrs. Age group Age 9–15 yrs, Sample 191 863 210 385 210 80 370 112 791 -

Complimentary data from local studies from weight, more marked in females weight, more marked schools. from private In the peri-urban area of El Caracas, 17.1% Hatillo county, of children and adolescents were overweight. Merida, In the Libertador county, 12.8% of adolescents were over A study in adolescents from La Rinconada-Caracas, showed versus overweight, 13.3% of boys 15.9% in girls. In a study in Merida depicted and obesity 13.6% of overweight with a high association between - this condition and prehyperten sion and hypertension. In a community of Maracaibo schools from public and private found 9.4% of girls and it was with overweight 9.6% of boys condition. The adolescents from the Baruta Miranda, presented high county, of weight and height values measured by 30% of overweight BMI. In a study in Merida State, chil - dren of second grade elemen - tary school reported 13.8% overweight. com - In a sample from suburban munities of Baruta and El Hatillo found Caracas, it was county, and 11.5% (girls) 16.7% (boys) with nutritional excess. 47% of sample use 2–3 hours and 33% daily on screen activities more than 4 hours per day. Grade A A A A A B/A A A C 5 32 Herrera Cuenca et al, 2013. Source INN, 2013. Age group Age 7–12 yrs. 7–17 yrs. Sample 1052 12,945 Data for the grading Data for In 8 cities of Venezuela overweight overweight Venezuela In 8 cities of ranged from 11.4% to 18.2% of boys and girls respectively. In a national sample, children and 17.57% adolescents 7–12 yrs showed Among 13 to 17 yrs the overweight. stood at 12.03%. Difference overweight and reported 15.35% (boys) by sexes, 13.73% (girls) overweight. Grade A (continued) Indicator Time spent Time in sedentary behaviors Overweight - diometabolic risk Category asso - Factors ciated with car elevated Appendix Table Appendix Table

JPAH Vol. 13, Suppl. 2, 2016 S323 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC 34 29 30 21 36 30 25 38 39 40 (continued) Padilla and Padilla Lozada, 2012 Rincón et al, 2015 López and Martínez, 2012 Di Gianfilippo et al, 2013 et al, Paoli 2009 Rincón et al, 2015 Aguilar et al, 2010 Alexander and Méndez- Pérez, 2014 Agobian et al 2013 Madariaga Madariaga and Donís, 2014 Source 11–16 yrs. 9–18 yrs. 14–17 yrs. 6–12 yrs. 7 yrs. 9–18 yrs. 13–19 yrs. 6–14 yrs. Age group Age 9–11 yrs. 14–15 yrs. 250 Sample 922 210 210 370 922 232 113 180 101 - -

was evaluated to assess aero - evaluated was 2 Complimentary data from local studies from bic fitness, a future cardiovascular bic fitness, a future cardiovascular and 53.1% in risk of 46% in boys recorded. girls was Adolescents from Libertador Merida, founded 9.5% of county, overweight. Adolescents from La Rinconada and 4.7% (boys) Caracas, showed 2.44% (girls) of obesity. A study in Maracaibo, found a of obesity 2.8% prevalence (girls) and 5.8% (boys). In a study in Merida State, children of second grade elementary school elicited 9.7% of obesity. The adolescents from Libertador Merida, reported 7.9% of county, obesity. A study in adolescents from presented 14.65% of Maracay, in which 4.3% were mor obesity, bidly obese. was fitness profile The physical in a group of adolescent evaluated Apure State, through the from proved 1,000 meters race; boys greater aerobic capacity to have than girls. The maximum consumption of V0 In a sample of school children from Barquisimeto, 32.1% (girls) classified with and 28.1% (boys) nutritional excess. In Merida 29% of adolescents who performed 105 min of vigor once activity ous aerobic physical a week, had high systolic blood pressure, compared with 10% who performed 120 minutes per 5 times a week of the same day, type of activity. Grade A A A A A A INC C D F 5 32 Source INN, 2013. Herrera Cuenca et al, 2013. Age group Age 7–17 yrs. 7–12 yrs. Sample 12,945 1052 Data for the grading Data for Children and adolescents 7–12 yrs presented the reported 9.87% of obesity, condition in a 9.33%, among 13-17 yrs. and girls reported obesity boys Overall, 10.62% vs 8.53% accordingly Lack of national data In 8 cities of Venezuela it was found it was Venezuela In 8 cities of of obesity as 31.4% for boys prevalence and 22.3% for girls. Grade A INC B (continued) Indicator Overweight Obesity health Below fitness zone - diometabolic risk Category asso - Factors ciated with car elevated Appendix Table Appendix Table

S324 JPAH Vol. 13, Suppl. 2, 2016 Unauthenticated | Downloaded 09/27/21 06:41 AM UTC 20 41 26 38 21 41 (continued) Padilla. Padilla. 2014 Suárez Belandria et al, 2014 Pérez et al, 2012 Madariaga and Donís, 2014 López and Martínez, 2012 Padilla, 2014 Source 12–18 yrs. 14–19 yrs. 9–13 yrs. 14–17 yrs. 14–17 yrs. 12–18 yrs. Age group Age 481 Sample 863 300 101 210 481 -

Complimentary data In a study in young athletes of the Talents Education Unit of Sports of Barinas State, the male athletes a maximum reported on average consumption of oxygen greater than their female counterparts in (54.41 and 44.37 respectively); presenting consequence, the boys a better aerobic performance. from local studies from ence was significantly higher in ence was adolescents who performed 105 min of vigorous aerobic physical once a week, compared activity 120 min with those who engaged 5 times a week of the same daily, type of activity. In the Libertador county, Merida, In the Libertador county, 36.6% of adolescents presented a high percentage of body fat. In Caracas and Merida 12.7% high fat of adolescents have in the especially boys reserves, area of Caracas. circumfer In Merida, the waist A group of adolescents from La Rinconada-Caracas, reported data of central adiposity as much and 44% for girls 42% for boys that increase Fact respectively. early risks for cardiovascular diseases. A study performed in young ath - letes from the Education of Sports Unit of Barinas state, Talents superi - in girls a marked showed ority of the sum skinfolds com - with an average pared with boys of 73.26 cm and 113.72 for male and female respectively. Grade C B A INC C INC 31 Source Herrera Cuenca et al, 2013. Age group Age 7–12 yrs. Sample 1052 Data for the grading Data for - Ven A study conducted in 8 cities of found that 26.5% of the ezuela, it was percent - a fat subjects have evaluated the 75th percentile reference age above according to age and sex. value Grade B (continued) Indicator Below health Below fitness zone Body composition - diometabolic risk Category asso - Factors ciated with car elevated Appendix Table Appendix Table

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Complimentary data from local studies from Grade 42 43 Ley Ley Orgánica de Deporte, Actividad Física y Educación Física, 2011. Consti - tución de la República Bolivariana - de Venezu ela, 1999. Source Age group Age N/A N/A Sample N/A N/A Data for the grading Data for The Organic Law of Sports, Physical Activity and Activity of Sports, Physical Law The Organic Education includes the entire population Physical of gender or age, and whose articles regardless indicate the main functions of state and - activ institutions, to strengthen physical private the infrastructure in country, providing ity, for of space and appropriate facilities availability enforcement in the basic practice and regulatory education subsystem. of Sport, National Fund for the Development (FON - and Education Physics Activity Physical Article of ADED): according to the provisions of sport, the fund is created with 68 of the law of 1% the income public the contribution created enterprises or other organisms and private in the country for to perform economic activity profit and whose net income or annual accounting exceeds 20,000 tax units. profit Lack of national and local data Lack of national and local data Lack of national and local data Republic of The Constitution of the Bolivarian that guaran - framework has a legal Venezuela Article 111: activity tees the right to physical has the right for sport and recreation “Everyone that benefit the quality of individual as activities The State assumes responsibil - life. and collective ity for sports and recreation as education policy and public health ensures the resources for promotion (...) “ Grade INC INC INC D (continued) Indicator Family School Com - munity and built - environ ment National Policy Category of Levels influence Appendix Table Appendix Table

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Complimentary data from local studies from Grade . 44 46 47 48 45 Ministerio del Poder Popular para el Eco - socialismo y Aguas (official web site) Alcaldía de Sucre (official web site). Alcaldía de Chacao (official web site). Source García- Avendaño and Rodrí - guez. 2015. Alcaldía de Baruta (official web site). Age group Age N/A N/A N/A N/A N/A Sample N/A N/A N/A N/A N/A Data for the grading Data for INPARQUES: The National Parks Institute is The National Parks INPARQUES: responsible for 43 national parks, 36 natural mon - uments and 65 recreational parks, which occupy Recreation about 16% of the national territory. courts for sports and leisure activities; parks have spaces for sports, national parks have likewise hiking, camping and other sporting activities. Autonomous Institute Sucre municipality has the of Sport and Recreation (I.A.M.D.E.R.) whose for recre - aim is to promote sport as an strategy ation and health of the inhabitants munici - gym where In addition, It has a vertical pality. teach sports such as athletics, weights, futsal, judo, karate, taekwondo, basketball, volleyball, TRX and dance classes, jui jitsu, kung fu, yoga, boot camp, boxing, chess, artistic gymnastics and sports for people with disabilities. gym that Chacao municipality has a vertical for and sports activities physical various offers residents. It also has sports recreation and training on the the street; yoga such as moving initiatives of colors. Sports schools: Tournament street and fitness and sports methodology; school leadership and sports training. Biohealthy parks have been a proposal adopted parks have Biohealthy and Youth for by the Ministry of Popular Power Sports and implemented through the National for At the national level Sports Institute (IND). the first year of installation (2012-2013) there states: were 44 parks located in the following (13), Distrito Capital (11), Miranda (6), Vargas (2), Guárico Trujillo Aragua (2), Zulia (2), (1), Carabobo Táchira (1), (1), Falcón Anzoátegui (1), Lara Cojedes (1). neighborhood Baruta municipality organizes sports: volleyball, in the following sports games kickball, baseball, basketball, beach volleyball, athletics, duathlon, aero - softball, futsal, soccer, bithón, swimming, tennis field, domino, table (road). In addition it has 12 tennis and cycling sports centers with a total of 11 multiple fields. On the other hand, Sports Schools teach bas - futsal, kickball, swim - baseball, soccer, ketball, and wushu for do, volleyball ming, tae kwon children between 4 and 14 years old. Grade (continued) Indicator National Policy Municipal C Category of Levels influence Appendix Table Appendix Table

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Complimentary data from local studies from Grade 49 50 51 52 Source Alcaldía de Iribarren (official web site). Alcaldía de Caracas (official web site). Alcaldía de Valencia (official web site). Alcaldía El Hatillo (official web site). Age group Age N/A N/A N/A N/A Sample N/A N/A N/A N/A - Data for the grading Data for rying out programs like: sports with you, play - rying out programs like: with people, activate making of future, cycling your field, checkmate, open active sports without barriers and Barquisi - Sunday, meto in motion. Libertador municipality has the Municipal Institute of Sport and Recreation (IMDERE) responsible for implementing plans and sports Among the initia - and recreational activities. system that drives there is the public bike tives, its use as a means of transportation and recre - ation. It has 5 stations for a total distance of 6 from Monday to Saturday 8 km; serves am to 5 pm. In addition, is “Caracas Freewheel Plan” program launched in 2012, which pro - It con - activity; motes recreation and physical a total of 12 km sists of 4 stations covering on Sundays from 7 am to 3 pm. Serves travel. has an Institute of Sport municipality, Valencia of the rehabilitation spaces sports, in charge such donation of sports equipment; initiatives Win Valencia and as JUDEMCA sports games Neighborhood Barquisimeto has the Municipal Institute of Sport and Recreation Iribarren (IMDERI) car El Hatillo municipality, has a sports center El Hatillo municipality, - vol where practiced football, basketball, Also has 2 and dance classes. yoga leyball, “Sports Routes” 1) La Lagunita (circuits for - trotting 6K, 8K and 12K, in addition to activi zumba, tai chi ties that complement as yoga, Volcán and functional training) 2) El and mountain (Circuit mountain to downhill Ulti - wish to climb and walk). climbers they it has the Municipal League of soccer, mately, which included schools in El Hatillo and other municipalities of Caracas. Grade (continued) Indicator Munici - pal Category of Levels influence Appendix Table Appendix Table

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Complimentary data from local studies from Grade 53 54 Source Fundación Polar (offi - cial web site) Criollitos - de Venezu ela (official web site). Age group Age N/A N/A Sample N/A N/A - and the National Institute of Statistics (INE) the categorization of PA levels is as follows: levels of PA and the National Institute of Statistics (INE) categorization 5 Data for the grading Data for - allocates invest Empresas Polar Foundation sports schools throughout the ments in various mainly promoting football, baseball country, - It also has community devel and basketball. opment programs for Recreation and proper the use of leisure time which aims to develop and com - families capacities of individuals, good cultivate that allow munity organizations and spiritual health as well social physical life. and family ent categories at national level. ent categories Criollitos de Venezuela: It is a training institu - Venezuela: Criollitos de tion of baseball for children, present in most Since 2005 the territory. Venezuela part of institution brought together more than 100,000 athletes between 5 and 19 years; for 2006, a census of 135 assigned leagues in 24 states and more than 5,220 teams participating in differ Grade B (continued) Indicator - Nongov ernment Category of Levels influence Appendix Table Appendix Table According to the National Institute of Nutrition (INN) Note. • Insufficiently active (low):: The population reports an amount of physical activity below the requirements for the other categories, or no physical activity; or no physical the requirements for other categories, below activity The population reports an amount of physical (low):: • Insufficiently active for 20 minutes or more; at least 3 days of vigorous activity have They (moderate): •• Sufficiently active for more than 30 minutes a day are performed 3 or days per week). moderate to intense walking for 30 minutes or more (eg, activity there are 3 days or more of vigorous physical active: Very •••

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