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Journal of Sport and Health Science 2 (2013) 47e57

www.jshs.org.cn

Review

Children and adolescents with Down syndrome, physical fitness

and physical activity
Ken Pitetti a,*, Tracy Baynard b, Stamatis Agiovlasitis c
a
Department of Physical Therapy, College of Health Professions, Wichita State University, Wichita, KS 67260-0043, USA
b
Department of Kinesiology & Nutrition, University of Illinois at Chicago, Chicago, IL 60612, USA
c
Department of Kinesiology, Mississippi State University, Mississippi State, MS 39762, USA
Received 8 July 2012; revised 7 September 2012; accepted 26 September 2012

Abstract

Children (5e12 years) and adolescents (13e19 years) with Down syndrome (DS) possess a set of health, anatomical, physiological,
cognitive, and psycho-social attributes predisposing them to limitations on their physical fitness and physical activity (PA) capacities. The
paucity of studies and their conflicting findings prevent a clear understanding and/or substantiation of these limitations. The purpose of this
article was to review the measurement, determinants and promotion of physical fitness and PA for youth (i.e., children and adolescents) with DS.
The existing body of research indicates that youth with DS: 1) have low cardiovascular and muscular fitness/exercise capacity; 2) demonstrate
a greater prevalence of overweight and obesity; 3) a large proportion do not meet the recommended amount of daily aerobic activity; and 4) their
PA likely declines through childhood and into adolescence. Future research should focus on: 1) strength testing and training protocols; 2)
methodologies to determine PA levels; and 3) practical interventions to increase PA.
Copyright Ó 2012, Shanghai University of Sport. Production and hosting by Elsevier B.V. Open access under CC BY-NC-ND license.

Keywords: Activity; Adolescents; Children; Down syndrome; Fitness

1. Introduction displayed facial features (e.g., epicanthal fold) that shared

1.1. Background and genetics
The condition of Down syndrome (DS) was first described in
a clinical lecture report delivered in 1866 by the British physi-
cian, John Langdon Down, entitled “Observation on the ethnic
classification of Mongoloid idiots”.1 Dr. Down used the
derogatory term “Mongoloid” because children with DS
* Corresponding author.
E-mail address: ken.pitetti@wichita.edu (K. Pitetti)
Peer review under responsibility of Shanghai University of Sport
Production and hosting by Elsevier
similarities with the prevailing erroneous ethnic theory estab-
lished by the German anatomist, Johann Friedrich Blu-
menbach.2 Catalyzed by editorials in The Lancet, together with
political pressure by advocacy groups and parental organiza-
tions in the 1960s, the term “mongolism” was dropped from
medical references by the World Health Organization and
replaced by “Down syndrome” during the 1970s.3 The cause of
DS remained unknown until the 1950s when it became possible
to identify chromosomal abnormalities with the discovery of
karyotype techniques. In 1959 the French geneticist, Dr. Jerome
Lejeune, reported that DS was caused by an extra 21st chro-
mosome, an aneuploidy condition known as trisomy 21.4 The
vast majority of cases of DS are due to full trisomy 21, with
every somatic cell in the body having an extra 21st chromosome
(Table 1). A smaller percentage of persons with DS are due to
mosaic trisomy (2%e4%) and Robertsonian translocation
(3%e4%).5 Reports have suggested that children with mosaic

2095-2546 Copyright Ó 2012, Shanghai University of Sport. Production and hosting by Elsevier B.V. Open access under CC BY-NC-ND license.
http://dx.doi.org/10.1016/j.jshs.2012.10.004
48 K. Pitetti et al.

DS have similar health and developmental difficulties as chil-
dren with full trisomy 21, but to a lesser degree6 and those with
DS caused by Robertsonian translocation have increased
frequency of psychiatric disorders.7
1.2. Demographics
In the United States the incidence of DS at birth from 1979
to 2003 increased from 9.0 to 11.8 per 10,000 births
(Table 1).8 It is suggested that the probable cause for the
increase in DS is related to the trend toward later child
bearing, with women over 35 being five times more likely than
younger women to have children with DS.5
1.3. The intellectual and health profiles of persons with
Down syndrome
Although about one-third of the causes of intellectual
disabilities (ID) remain unknown, the three major known
causes of ID are DS, Fetal Alcohol Spectrum Disorder, and
Fragile X syndrome.6 As is the case for all persons with ID,
the degree of ID in persons with DS is determined by limi-
tations in both cognitive function and in adaptive behavior
(e.g., conceptual, social, and practical adaptive skills).7-9 The
degree of cognitive impairment is variable, with the majority
classified as mild (IQ: 50e55e69) or moderate (30e35 to
50e55) while a smaller percentage (<10%) are severe
(IQ < 20e25 to 30e35).10,11 Adaptive behavior encompasses
conceptual skills (language, reading and writing, self direc-
tions), social skills (self esteem, gullibility, naiveté, avoids
victimization) and practical adaptive skills (dressing, toileting,
preparing meals, using transportation, occupational skills) that
allow individuals to be functional in their everyday life.10,11
Adaptive behavior may improve with early intervention but
the level of function varies according to innate capacities and
social support systems (Table 1).10,11
Table 1
Description, demographics, and health profiles of persons with Down
syndrome.
Characteristic Description
Description and demographics 1. Caused by trisomy 21
2. 11.8 per 10,000 births (USA)
3. Mild/moderate intellectual disability
4. Limited adaptive skills
5. Life span near 60 years
Health profiles
Childhood 1. Congenital heart disease (septal and
valvular defects)
2. Respiratory illnesses (pneumonia
and chronic bronchitis)
Adulthood 1. Deterioration of functional capacities
due to dementia of Alzheimer’s type
2. Recurrent pneumonia
3. Sensory impairments (hearing and
vision)
4. Musculoskeletal disorders (joint
instability and osteoporosis)
Although ID affects every day functioning, the health
profiles of children and adolescents with ID without DS are
unremarkable. In contrast, the effects of DS involve a range of
medical conditions in addition to ID that may be identified at
birth or develop during the life span (Table 1). These condi-
tions include increased risk of congenital heart disease (50%),
hearing loss (75%), eye disease (60%), obstructive sleep apnea
(75%), gastrointestinal conditions (10%), thyroid (hypothy-
roidism) disease (15%), and atlanto-axial/atlanto-occipital
instability (10%e30%).8,9 Excluding birth, nearly half of
children with DS are hospitalized before age 3, with the
principle causes for hospitalization being congenital heart
disease (e.g., septal and valvular anomalies) and respiratory
illnesses (pneumonia, acute, and chronic bronchitis).10
These medical conditions increase demands on the health
care system that can be as much as 13 times higher than for
children (0e4 years) without DS.11 Health care costs have
been reported to decline with age, and by adolescence the cost
of health care services have been reported to decrease to
1.1e1.7 times of those without disabilities.12,13 However,
diagnosis of congenital heart disease and level of indepen-
dence influence total health care cost, independent of age.12
These health care estimates do not address overall cost to
families affected by DS, such as special education, individual
transport needs, housing modifications, and related cost to
family members (e.g., employment opportunities).
Survival for persons with DS has improved over the past
few decades with life expectancy nearing 60 years paralleling
the improvement in social and medical support systems.14e16
However, mortality rates of persons with DS remain higher
overall than those of the general population with the leading
causes of death being congenital anomalies (e.g., heart
defects), Alzheimer’s disease, pneumonia, leukemia, and all
circulatory diseases (e.g., ischemic heart disease, cerebrovas-
cular disease).14,17,18 Death rates for persons with DS increase
significantly after age 40.19 The main cause for the upsurge in
mortality in middle-aged adults with DS is the deterioration in
functional abilities and rise in behavioral problems due to
Alzheimer’s disease.20e23 Because of early onset of meno-
pause, women with DS are four times more likely to develop
Alzheimer’s disease than their male counterparts.24 Other
disorders of aging in DS are pulmonary disorders (recurrent
pneumonia caused by recurrent aspiration), sensory impair-
ments (hearing and vision), and musculoskeletal disorders
(e.g., osteoporosis and orthopedic complications caused by
joint instability).23
2. Physical fitness: cardiovascular, muscle, and body
composition
2.1. Cardiovascular fitness
2.1.1. Cross-sectional studies
Uniformly, peak aerobic capacity (VO2peak) in both youth
and adults with DS is reduced in comparison to their peers
without disabilities (WOD) and with ID but without DS.25e27
This is accompanied by lower peak work rates as well as
Youth with DS: Fitness and activity
a faster time to exhaustion (Table 2).27 Such findings were first
reported by Eberhard et al.28 in 1989, whereby they demon-
strated a 15% lower VO2peak using bicycle ergometry compared
to age-matched children WOD. In 1990, Fernhall et al.,26 using
a validated treadmill protocol, reported lower VO2peak in
adolescents with DS when compared to adolescents WOD and
that lack of motivation or understanding protocol instructions in
participants with DS did not contribute to their findings.
Following these initial contributions, the literature has
consistently demonstrated lower VO2peak values when indi-
viduals with DS are compared to individuals WOD and with
ID but without DS. In the largest sample to date (total n ¼ 635;
n ¼ 133 with DS, n ¼ 180 with ID, n ¼ 322 WOD), Baynard
et al.25 reported that VO2peak (absolute and relative values) is
lower in children and adolescents with DS through young
adulthood and into middle age, regardless of the comparison
group. Furthermore, the authors also demonstrated VO2peak
does not significantly change after the age of w16 years.25
Interestingly, the average VO2peak at this age in individuals
with DS is similar to normative values found in middle-aged to
older persons WOD, yet individuals with DS do not appear to
experience the age-related decline in VO2peak as is expected in
those WOD (Table 2).25
Three physiologic factors that potentially contribute to low
VO2peak values in persons with DS are autonomic dysfunction,
reduced ventilatory capacity, and metabolic dysfunction.
When considering autonomic dysfunction, lower peak heart
rate (HR) responses have been consistently reported across all
age groups for persons with DS.25 The cause of lower peak HR
in persons with DS is still not completely understood at this
time, but Fernhall et al.29 demonstrated in a group of young
Table 2
Physical fitness in youth with Down syndrome (DS).
Characteristic Description
Cardiovascular fitness 1. Low peak aerobic capacity/time to exhaustion
2. Low peak heart rate
3. Peak aerobic capacity does not change
significantly with age after w16 years
4. Autonomic dysfunction a primary factor
related to low fitness
5. Field tests largely support laboratory findings
6. Responsive to aerobic endurance training,
particularly with improvements in work
capacity
Muscular strength 1. Lower strength compared to individuals
without disabilities
2. Resistance training appears safe and beneficial
for improving strength
3. Improved leg strength does not appear
improve aerobic capacity
Body composition 1. Youth with DS in North America and Europe
are more obese/overweight vs. counterparts
without disabilities
2. Cause of high rate of overweight/obesity is
multifactorial (physiological, societal,
environmental, psychological, etc.)
3. Studies show no improvement in body
composition from exercise training alone,
likely due to lack of dietary control
49
adults with DS (mean age 24 years) a blunted to non-existent
catecholamine response to peak exercise. This suggests that
some portion of the autonomic pathway is dysfunctional and
contributes to the lower HR response. Although diminished
sympathoexcitation in adults with DS has been reported,30,31
to date no studies have included youth with DS (Table 2).
Further, with higher obesity levels generally observed in
persons with DS, the interaction between autonomic control
and obesity may be an important avenue to investigate in this
population.
It was also postulated that due to the relatively large
tongues (macroglossia) compared to the bony confines of the
oral cavity in persons with DS, ventilation would be restricted
at high work levels and thus limit peak performance. Indeed,
adolescents and young adults with DS have been reported to
have low peak ventilation.26 However, Fernhall and Pitetti27
concluded that peak ventilatory parameters (e.g., ventilatory
equivalents, and peak minute ventialation) were appropriate
for a given VO2peak. In addition, imaging work has established
that children with DS do not have true macroglossia, although
they have relatively large tongues compared to their oral
cavity volume.32 Therefore, ventilation capacity does not
appear to restrict the peak performance of youth with DS.
However, gaps do exist in the literature with little to no data
available for additional ventilatory parameters, such as peak
minute ventilation/maximal ventilatory volume or peak tidal
volume/ventilatory capacity. This type of data would broaden
our understanding of potential limitations to exercise in
persons with DS.
Metabolic limitations have also been suggested to constrain
the physical capacity of youth and young adults with DS.
However, only two studies actually measured ventilatory
threshold in adolescents and young adults with DS.33,34
Collectively, these two studies reported that ventilatory
threshold was difficult to detect (e.g., V-slope method);
however, in those participants where it was detectable, normal
ventilatory thresholds were observed when expressed as
a percentage of VO2peak. Given that the respiratory exchange
ratio is related to substrate utilization and exercise intensity,
collection of blood lactate would assist in determining the role
that metabolic function may have in limiting exercise perfor-
mance in youth with DS. However, submaximal and maximal
exercise blood lactate levels have not been reported in the
literature for youth with DS. In line with this, supramaximal
testing (e.g., Wingate testing) is not reliable enough to date to
help complete a metabolic profile in youth with DS.35
It is important to note that several studies using field tests
also report lower predicted VO2peak and/or exercise perfor-
mance in youth and young adults with DS compared to peers
WOD (Table 2).36,37 The largest field study to date to measure
run performance (20-m shuttle run) had 119 youth (11e18
years) with DS, 394 youth with ID but without DS, and 80
youth WOD.38 Children and adolescents with ID but without
DS had better run performance than their peers with DS
independent of age, sex, and body mass index (BMI).38
Furthermore, those WOD had better run performance than
their peers with ID, again independent of age, sex, and BMI.38
50
Thus, poor running performance of children and adolescents
with ID, with and without DS, is not a consequence of age,
sex, or BMI.
Furthermore, Fernhall et al.39,40 produced a regression
equation from the results of the 20-m shuttle run to predict
VO2peak in children and adolescents with ID, with and without
DS. This equation was cross-validated in 2003 by Guerra
et al.,41 however, this study consisted of a greater percentage
of children and adolescents with DS and they were not able to
validate Fernhall’s39,40 original equation designed for persons
with ID to a sample with DS alone. The prediction of VO2peak,
from a 20-m shuttle run test, was further examined by
Agiovlasitis et al.,42 whereby they reported that while shuttle
performance was a predictor of VO2peak in youth with DS, the
equation had low predictability at the individual level.
Therefore, the use of the regression equation developed by
Fernhall et al.39,40 to predict VO2peak in persons with ID does
not appear to be specific for youth with DS.
2.1.2. Training studies
There are relatively very few longitudinal training studies
in persons with DS, particularly in youth. For this reason,
training studies in young adults with DS will be utilized here
with the understanding that it would be likely that youth with
DS would experience similar findings. A meta-analysis was
conducted by Dodd and Shields43 that included four papers,
which met their inclusion criteria.44e47 They reported that
aerobic training programs, which conformed to the American
College of Sports Medicine guidelines, were effective for
improving VO2peak, peak ventilation, time to exhaustion, and/
or maximum workrate.43
One of the first training studies in adolescents with DS was
conducted by Millar et al.,45 with 14 individuals participating
in a 10-week walking/jogging program, 3 days/week at 65%e
75% peak HR, which resulted in no change in VO2peak, but did
improve treadmill test time by 9%.45 Training studies that
have measured VO2peak since the report by Millar et al.45 have
supported those initial findings, in that improvements have
been seen in exercise/work capacity without significant
improvements in VO2peak with training interventions lasting
12e16 weeks (Table 2).9,48 Further evidence of positive
training effects stems from an often overlooked study,
whereby HR recovery following a 3-min step test and resting
HR were decreased in a group of 10 individuals with DS
(8e18 years) after a 13-week training program.49 Lastly, an
interesting case study reported that a young 10.5-year-old
female with DS following 6 weeks of training did not alter her
estimated VO2peak, but her submaximal HR was lower during
the treadmill test, as was her respiratory rate, indicating
improved work capacity and capacity for change.50
While aerobic training studies are limited in persons with
DS, let alone youth, previous work suggests exercise training
is beneficial in youth with DS even if VO2peak itself is not
necessarily an expected outcome. It is especially important to
consider training studies in youth with DS in that early
intervention to improve their work/exercise capacity could
impact the health anomalies specific to the condition of DS.
K. Pitetti et al.
2.2. Muscular strength
Few studies exist that have employed strength testing and/
or training in youth with DS. Strength decrements were first
characterized in youth with DS in 1994 by Cioni et al.,51 in
which children and adolescents with DS (n ¼ 25) exhibited
weak knee extensor strength compared to a WOD control
group. Furthermore, these authors concluded that adolescents
with DS generally do not show improvements in strength
beyond the age of 14 years.51 These findings can be extended
to the hip abductors as well.52 Interestingly, Pitetti and Fern-
hall53 explored the relationship between VO2peak and strength
in youths aged 10e17 years with ID (n ¼ 29), including eight
children with DS, and found a significant relationship between
knee flexion/extension strength and aerobic capacity
(r ¼ 0.56e0.62). Their data suggest that leg strength may be
a limiting factor in both work and aerobic capacity in persons
with DS, which is also supported by similar work in adults
(Table 2).54
There is a small body of literature in young adults with DS
(mean age w24e25 years) that further extends the limited
findings in youth. Several studies have demonstrated lower
muscle strength in young adults with DS for both knee, and/or
elbow extensors/flexors compared to participants WOD.55e58
In those studies that distinguished between individuals with
ID with or without DS, no general differences in strength were
observed between these two groups, whereas the control group
WOD was always stronger (65%e225% stronger). However, it
should be noted that while not different, Croce et al.57 have
reported lower hamstring to quadriceps ratios in adults with
DS (20%) vs. those WOD and 10% lower compared to adults
with ID without DS. This may suggest reduced muscular
performance and knee joint stability.
The number of strength training intervention studies that
included individuals with DS is even smaller, with two studies
known to have specifically trained youth with DS.59,60 Weber
and French59 found that resistance training improved overall
muscular strength in adolescents with DS (e.g., 10 muscular
tests performed), yet this study lacked a control group.
Recently, Shields and Taylor60 demonstrated that a 10-week
community-based progressive resistance training intervention
was successful in increasing lower limb strength (as well as
muscle endurance) in 23 adolescents with DS, with no changes
in upper limb strength. Unfortunately, no measure of work
and/or aerobic capacity was performed in these studies.59,60
Lastly, a case study demonstrated that a young girl with DS
improved general muscle strength (e.g., trunk, hip, knee, and
shoulder) following a 10-week combined aerobic and resis-
tance program.50 These data collectively suggest that strength
training in youth is beneficial. Little to no data exist on the
relationship between strength training and improving work
capacity in youth with DS (Table 2). A recent study by Cowley
et al.61 reported a small, but significant increase in relative
VO2peak following a 10-week strength training program in
young adults with DS, yet no difference in absolute VO2 was
observed, suggesting this improvement was mediated by
weight loss (w5 kg).
Youth with DS: Fitness and activity
A group of progressive resistance exercise training studies
clearly demonstrate that strength training is a safe and
important component of exercise prescription in young adults
with DS (24e29 years).61e64 These studies lasted 10e12
weeks and all employed a 2e3 days/week training of large
muscle groups, with improvements found in both upper- and/
or lower-body strength. Interestingly, Cowley et al.61
concomitantly measured aerobic capacity and reported no
change in absolute VO2peak and a small but significant
decrease in relative VO2peak (Table 2).
2.3. Body composition
Equivocal evidence exists regarding body composition in
persons with DS. The lack of consistency may involve meth-
odological issues for measuring body composition (e.g.,
skinfolds vs. dual energy X-ray absorptiometry) or perhaps
comparing weight status using different vehicles, such as
a laboratory measures versus BMI. Another possible contrib-
utor may be ethnic and/or environmental issues as well.
Caution is urged when interpreting global statements on body
composition in DS for these reasons.
Numerous investigations have reported that the prevalence
of overweight and obesity are substantially higher in individ-
uals with DS compared to their age-matched peers WOD and
with ID but without DS.65,66 Prasher67 reported that w48% of
adults with DS were obese, with w27% being overweight
(both sexes averaged) and that being overweight and/or obese
was associated with living at home compared to group-home
situations. This is consistent with Rubin et al’s65 report of
w48% for men and w56% of women being overweight/
obese. Interestingly, BMI was found to decrease throughout
the lifespan in males and females with DS, whereas BMI
increases through the lifespan in the general population.67 This
is in contrast to Baynard et al.,25 whereby they reported BMI
increases not only in the control group, but also in groups of
ID, with and without DS, up through middle-age. Prasher67
was unable to adequately explain why BMI would decrease
from young adulthood (16e19 years) through the 20 s into the
60 s. Perhaps the Alzheimer’s issues that individuals with DS
often experience could provide a possible explanation.
Early work by Sharav and Bowman68 demonstrated that
young children with DS (w4e5 years) were not different from
their siblings WOD in BMI. Additionally, Luke et al.69 reported
non-significant but higher BMI and lower fat-free mass in
children with DS (9 years old) versus a control group WOD,
whereas other investigators have observed higher BMIs and/or
percentage of body fat in youth with DS compared to peers
WOD.52,70 However, these studies also included adults in their
samples.52,70
In contrast to Luke et al.,69 others have observed lower total
muscle mass in persons with DS versus individuals WOD.70
This has been further substantiated recently in Spanish youth
with DS that did exhibit higher body fat content and lower lean
mass than peers WOD.71 In Greece, researchers observed that
22% of adolescents in their sample were obese and that percent
body fat, BMI, fat mass and fat-free mass were also greater in
51
adolescents with DS (10e18 years) than in children with DS
(2e9 years).72 It is important to note that several studies do
suggest that children and adults with developmental disabilities
in the United States and Australia have greater prevalence rates
of overweight and obesity compared to non-disabled age-
matched controls. Yet these studies only have a small portion of
individuals with DS included.65,66 However, the prevalence of
overweight/obesity has recently been questioned and it may not
be as high as previously thought.73 It is also possible interna-
tional differences exist that need further examination. More
work will need to be conducted not only at the physiological
level, but work at the environmental, community, societal and
psychological levels to fully delineate the numerous factors
involved in obesity (Table 2).
3. Physical activity (PA) in youth with DS
Apart from physical fitness, PA has the potential to improve
health in youth with DS. Although the relationship of PA and
health outcomes has not been directly examined in youth with
DS, it is reasonable to assume that the findings in the general
population of youth also apply to those with DS. PA may
improve the cardiovascular, metabolic, musculo-skeletal, and
psychosocial health profiles of all youth.74e76
For this reason, the 2008 Physical Activity Guidelines for
Americans devoted a section to children and adolescents.76
Specifically, it is recommended that youth older than 6 years
perform 60 min of PA daily. Most of aerobic activity should be
of either moderate or vigorous intensity, defined as 3.0e5.9
and >5.9 metabolic equivalent units (METs), respectively;
however, vigorous-intensity activity should be performed at
least 3 days/week. Muscle- and bone-strengthening activities
are important components of the recommended 60 min of
daily activity and each should be performed at least 3 days/
week. Importantly, the Guidelines call for the promotion of
physical activities that are age-appropriate, enjoyable, and
offer variety. Recent evidence, however, suggests that most
American youthdespecially adolescentsddo not meet the
required amount of daily PA and that their activity levels
decline as they grow.77 The issues of interest therefore are: (a)
whether the PA levels of youth with DS differ from those of
youth WOD, and (b) whether youth with DS meet the current
recommendations for PA.
Answering these questions is difficult because research on
PA in youth with DS is limited. In a review of research pub-
lished prior to 2008,78 the authors could not conclude whether
the PA levels of youth with ID, including those of youth with
DS, are different from those of children WOD. As the authors
explained, this was due to methodological problems of
previous research such as insufficient description of samples
and questionable applicability of objective or subjective
measurements of PA to youth with ID.
3.1. Measurement of PA in youth with DS
Subjective PA assessments using questionnaires are not as
accurate as objective ones.77 This difficulty is magnified in
52
youth with DS by the need to use parental or caregiver/teacher
proxy reports.78 One study demonstrated questionable accu-
racy of PA measurement by proxy reports for adults with ID.79
It is possible that subjective assessment of PA in youth with
DS may benefit if questionnaires are obtained from both
parents and teachers or caregivers; such practice may offer
a more accurate representation of the activities youths with DS
engage in throughout the day. Nevertheless, to our knowledge,
the psychometric properties of subjective measures have not
been examined in youth with DS. Finally, in-depth inter-
viewsdtypically with parentsddo not allow for a quantifica-
tion of the amount of PA performed by youth with DS.
Objective PA measurements with accelerometers or
pedometers are preferable, but they should be used carefully in
youth with DS. Pedometers appear valid and reliable during
locomotion in youth with intellectual or developmental
disabilities,80,81 but their accuracy may be compromised
during games and sport activities conducted in physical
education.82 Additionally, spring-levered pedometers are less
accurate than piezoelectric in people with DS.83 Furthermore,
using step-rate cut-points to estimate moderate- and vigorous-
intensity activity in youth with DS may be problematic. Adults
with DS have lower step-rate cut-points for activity intensity
even when accounting for their shorter height compared to
adults without DS84dthis may potentially apply to youth with
DS. Similarly, accelerometry-determined cut-points for
moderate- and vigorous-intensity activity developed for youth
WOD may not be applicable to youth with DS. This has been
demonstrated for adults with DS85 and it has been suggested to
be partially due to an altered gait pattern that increases the
energy expenditure.86 It is possible that this also applies to
youth with DS who also exhibit altered gait patterns,87,88
potentially duedat least in partdto deficits of the cere-
bellum.89 Additionally, cut-offs developed in youth WOD may
be inappropriate for those with DS because the latter have very
low cardiovascular fitness. Finally, there have been some
reports of compliance issues with accelerometers secured at
the hip in youth with DS.90,91 Although these difficulties are
not extensive, they highlight the need for adequate familiar-
ization and parental supervision. Alternately, researchers could
consider other placement sites, such as the wrist, where the
accelerometer could be secured with an irremovable strap.
These measurement issues should be collectively considered
when evaluating previous reports of PA in youth with DS.
3.2. What are the PA levels of youth with DS?
In infants with DS, movementdespecially of the
legsdmay be important for motor development. Children with
DS appear to reach stages in motor development with some
delay.92 A notable example is the onset of independent
walking which occurs about a year later (wage 2) in children
with DS than children with typical development.93,94 It is
possible that low levels of motor activity during early infancy
may contribute to this phenomenon. One study found that,
during the first 6 months of life, infants with DS show lower
levels of general movements as measured by observation than
K. Pitetti et al.
infants with typical development.95 In contrast, analyzing
video recordings, others reported no differences between
infants with and without DS in the total amount of leg
movements93 which are presumably more relevant for the
development of walking. Subsequently, infants with DS were
found to show more low-intensity and less high-intensity leg
motor activity than infants with typical development.96,97
Furthermore, greater amount of high-intensity activity at
about 1 year of age was associated with earlier walking onset
in infants with DS.96,97 Finally, a randomized controlled study
showed that infants with DS, who underwent home-based
stepping training while supported over customized treadmills,
achieved independent walking by an average of 101 days
earlier than infants with DS not undertaking this intervention;
the intervention was initiated once infants with DS could sit
independently and it was conducted 5 days/week, 8 min/day,
until the onset of independent walking.94 Taken together, these
data suggest that alterations in PA patterns in infants with DS
are associated with their motor development, thus supporting
the need for early interventions.96
The objective data on PA levels of children and adolescents
with DS are limited and provide somewhat conflicting results.
Non-resting total energy expenditure measured with doubly-
labeled water did not differ between 5- and 11-year-old chil-
dren with DS from the U.S. and peers WOD of similar age and
BMI.98 In another U.S. study, the amounts of total, low-
intensity, and moderateeintensity activity, as well as time
spent sedentary measured with hip-accelerometry over 7 days
did not differ between children with DS aged 3e10 years and
similarly-aged siblings WOD;90 however, the children with DS
participated in less and shorter bouts of vigorous-intensity
activity than their siblings. Notably, children both with and
without DS in that study exceeded the recommendations for
total and vigorous-intensity aerobic activity. Similarly,
Australian children and adolescents with DS met on average
the recommended amounts of moderate- and vigorous-inten-
sity activity as measured by hip-accelerometry91 and also
appeared more active than U.S. youth.77 But there was large
between-person variability in activity levels and 58% of the
children with DS did not meet the recommended amount. In
the same study, youths with DS aged 13e17 years showed
lower total, moderate-, and vigorous-intensity activity than
those aged 7e12 years, indicating a possible age-associated
decline in PA. Recent acceleromety-derived data from the U.S.
demonstrated that, on average, children and adolescents with
DS did not engage in moderate-to-vigorous PA for 60 min/
day.99 Furthermore, PA was lower and sedentary behavior was
higher in older youths with DS compared to younger ones.
Another U.S. study using accelerometry100 showed that, prior
to an intervention, youth with DS aged 8e15 years were active
at moderate-to-vigorous levels for an average of about 43 min,
although there was significant between-people variation in this
value. Finally, cross-sectional accelerometry-determined data
from England demonstrated lower amount and faster age-
associated decline of moderate-to-vigorous activity in people
with DS than people with ID but without DS across the life-
span (Table 3).101
Youth with DS: Fitness and activity
Table 3
Physical activity in youth with Down syndrome (DS).
Characteristic Description
Physical activity 1. Likely declines during the growing years
2. A large proportion of youth with DS does
not meet the recommendation for daily
aerobic activity
3. Youth with DS participate in a wide variety
of culturally-relevant leisure activities
Barriers to physical activity
Within the person 1. Health problems
2. Low fitness levels
3. Low motor skills
Environmental 1. Lack of accessible, inclusive, and properly
designed programs
2. Transportation difficulties
3. Negative attitudes towards people with
disabilities
4. Competing family responsibilities
5. Parental education and income
6. Lack of friends
Facilitators of physical activity
Within the person 1. Knowledge on physical activity and health
2. Positive attitude towards exercise
3. Determination to succeed
Environmental 1. Positive social and familial attitudes
2. Knowledgeable professionals
3. Structured programs that .
1) Are adapted to the needs of youth with DS
2) Provide knowledge on physical activity
and health
3) Are inclusive
4) Promote social interaction and enjoyment
Some subjective datadobtained with parental reports or in-
depth interviewsdsupplement the literature on PA of youth
with DS. Canadian children with DS aged 2e14 years were
rated by their parents as less active and as spending more time
indoors compared to siblings without DS,68 although all youth
in this study with DS participated in organized sports at least
once per week.69 Among 38 Australian youth with DS aged
11e18 years, only two engaged in PA more than 3 days/
weekda finding suggestive of low PA levels.102 In a second
Australian study, less than one third of 208 youth with DS
aged 5e18 years were found to be active at moderate-to-
vigorous intensity for 60 min/day, although most participated
in sports.103 Finally, during in-depth interviews, parents of
U.S. preschoolers with DS perceived their children as natu-
rally active. In contrast, parents of elementary-school students
perceived a gradual decrease in their children’s interest for PA,
supporting the possibility for an age-associated decline among
youth with DS.104
The existing objective and subjective data do not allow us
to conclude with confidence whether youth with DS have
lower PA levels than youth WOD, but this appears likely.
Additionally, it is not known if youth with DS meet the
required amounts of muscle- and bone-strengthening activi-
ties. Although there are no longitudinal data on the develop-
mental course of PA in youth with DS, it is likely that PA
declines with age in this population. Furthermore, a large
53
proportion of children and adolescents with DS may not meet
the recommended amount of daily aerobic activity.
3.3. Determinants of PA
The study of the determinants of PA in youth with DS is
still in its infancy. Following the approach of the International
Classification of Functioning, Disability and Health,105 PA
may be influenced by a child’s health status, functional profile,
participation in life activities, and contextual factorsdeither
within the person or in the environment. DS is associated with
many health conditions, but there is great variability in the
number and extent of conditions that youth with DS exhibit. In
one study, medical issues were not associated with function
among youth with DS.106 It is reasonable, however, to assume
that acute health problems might present barriers to PA for
youth with DS and that, when medical issues are efficiently
overcome, PA may be facilitated.
The functional profiles of youth with DS may also be
related to their PA levels. Quantitative and qualitative data
suggest that lower cognitive, behavioral, and motor skills may
present barriers to PA of youth with DS.103,104,107,108 Some
theorists also argue that people with DS may have a tendency
for slower, safer, and more accurate movement patterns due to
interactions between neurological, environmental, and task-
associated constraints.109 Additionally, the very low aerobic
and muscular fitness of youth with DS may potentially affect
their involvement in physical activities, especially of higher
intensities, but this has not been directly examined (Table 3).
Contextual factors within the person may also be at play. In
support of this argument, the aforementioned lower partici-
pation in vigorous-intensity activities of children with DS
compared to their siblings90 was collectively explained by age,
sex, race, ethnicity, income, maternal education, and BMI. It is
difficult, however, to determine the individual contributions of
these factors to PA of the children in that study. As previously
discussed, PA in youth with DS may decline with age,91,101,104
although one study did not find differences in sport partici-
pation between children and adolescents with DS.103
Furthermore, whether PA differs between sexes in youth
with DS, as in youth WOD,74,77 is not known. Data from
Taiwan, China showed no difference in recreational and sport
participation between boys and girls with DS.108 In contrast,
another study conducted in Taiwan, China demonstrated that,
among youth with ID including DS, boys and those who had
positive attitudes towards exercise were more likely to be
regularly active after school.110
It is also very likely that the social and physical environ-
ment contributes to the PA levels of children and adolescents
with DS (Table 3). This is supported by a wide variation in
types of leisure participation among youth with DS around the
world.68,102,103,108,110,111 Furthermore, it has been argued that
inactivity among youth with DS may be a learned behavior
partially resulting from exclusionary practices.112 Importantly,
lack of accessible, inclusive, and appropriately-designed
programs, as well as negative attitudes, transportation prob-
lems, competing family responsibilities, parental education
54
and income, and lack of friends, all reportedly present barriers
to PA for youth with DS.90,104,107
3.4. PA promotion
Youth with DS reportedly participate in a wide range of
recreational activities. Examples include walking, swimming,
bowling, dancing, and team sports.68,102,103,108,110,111 The
types of leisure participation among youth with DS likely vary
around the world; for example, swimming appears common in
Australia,102,103 ice-skating in Canada,68 and bicycling in
Taiwan, China.108 Notably, walking is one of the most
commonly performed activities among youth with
DS,108,110,111 suggesting that their altered gait pattern87,88 may
not present a barrier to PA. Supporting this proposition, chil-
dren and adolescents with DS exhibit functional independence
in locomotion tasks.106 Therefore, youth with DS have the
potential to participate in all types of culturally-relevant
physical activities.
Unfortunately, very little data exist on interventions to
promote PA in youth with DS. A randomized-controlled study
found that youth with DS who learned to ride a bicycle
increased their PA levels about 1 year after the intervention,100
suggesting that motor skill development may improve long-
term PA. Furthermore, well-designed school programs allow
students with ID including those with DS to meet the PA
recommendations.113 It should also be considered that 12
weeks of exercise training, combined with health education,
improves the attitudes towards exercise and psycho-social well
being of adults with DS,114 but, to our knowledge, similar
studies in youth with DS have not been conducted (Table 3).
It has been recommended that PA promotion in all youth
aimed at ameliorating the age-associated decline in PA, sup-
pressing the development of pathological processes, and
creating life-long PA habits.74 To achieve these goals in youth
with DS, PA promotion should be multi-factorial. Well-
designed programs should take into account the physical,
cognitive, and psycho-social health profiles of children with
DS as well as their need for enjoyment and participation. But
at the same time, the environmental contexts in which PA,
exercise, and recreation occur must be appropriately designed.
Parents tell us that the PA of their children with DS may be
facilitated by positive familial and social attitudes, and struc-
tured programsdones that are adapted to the abilities of their
children, offer youth with DS knowledge on PA and health,
utilize their determination to succeed, and promote social
interactions and enjoyment.104,107,111
4. Summary and future directions
4.1. Physical fitness
Youth with DS have low peak aerobic capacity coupled
with low peak HR, suggesting autonomic dysfunction may be
a primary reason explaining low work performance in this
population. Furthermore, persons with DS also have low
muscular strength compared to individuals WOD. Exercise
K. Pitetti et al.
training utilizing endurance and/or resistance exercise appears
beneficial for youth with DS. The role of overweight/obesity
in youth with DS does not currently explain lower aerobic
capacities in persons with DS, yet more work needs to be
conducted to completely understand its role with regards to
aerobic capacity and PA in this population. Studies involving
multi-factorial issues (e.g., physiological, environmental, etc.)
common to youth with DS are necessary to understand how to
optimize quality of life in this population.
4.2. PA
Cross-sectional data suggest that PA likely declines with
growth in youth with DS and that a large proportion of these
youths do not meet the recommended amount of daily aerobic
activity. Effective PA promotion should be multi-factorialdit
should be adapted to the physiological, cognitive, and psycho-
social profiles of youth with DS, but should also consider
environmental modifications. There is a need to improve the
assessment of PA with objective and subjective approaches.
Furthermore, longitudinal research is needed to examine how
PA levels change and what factors contribute to them during
growth in youth with DS. Finally, it is also important to
examine the effectiveness of specific interventions aimed at
increasing PA.
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