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Sports Participation and Health-Related Behaviors Among US Youth FREE

Russell R. Pate, PhD; Stewart G. Trost, PhD; Sarah Levin, PhD; Marsha Dowda, DrPH
[+] Author Affiliations

From Department of Exercise Science and Prevention Research Center (Drs Pate, Trost, and Dowda), and the Department of Epidemiology and Biostatistics (Dr Levin), University of South Carolina, School of Public Health, Columbia.


Arch Pediatr Adolesc Med. 2000;154(9):904-911. doi:10.1001/archpedi.154.9.904.
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Objective  To examine the relationship between sports participation and health-related behaviors among high school students.

Design  Cross-sectional design using data from the 1997 Centers for Disease Control and Prevention Youth Risk Behavior Survey.

Participants  A nationally representative sample of 14,221 US high school students.

Main Outcome Measures  Prevalence of sports participation among males and females from 3 ethnic groups and its associations with other health behaviors, including diet, tobacco use, alcohol and illegal drug use, sexual activity, violence, and weight loss practices.

Results  Approximately 70% of male students and 53% of female students reported participating on 1 or more sports teams in school and/or nonschool settings; rates varied substantially by age, sex, and ethnicity. Male sports participants were more likely than male nonparticipants to report fruit and vegetable consumption on the previous day and less likely to report cigarette smoking, cocaine and other illegal drug use, and trying to lose weight. Compared with female nonparticipants, female sports participants were more likely to report consumption of vegetables on the previous day and less likely to report having sexual intercourse in the past 3 months. Among white males and females, several other beneficial health behaviors were associated with sports participation. A few associations with negative health behaviors were observed in African American and Hispanic subgroups.

Conclusion  Sports participation is highly prevalent among US high school students, and is associated with numerous positive health behaviors and few negative health behaviors.

SPORTS PARTICIPATION has long been thought to provide youth with a prosocial environment that fosters basic values, such as fair play, competitiveness, and achievement.13 Sports may also help protect participants against negative influences that can lead to delinquency and drug abuse.46 Because sports participation typically involves substantial amounts of physical activity, the health benefits of regular exercise would be expected to accrue to young athletes. Also, because team rules and guidelines often promote health-enhancing behaviors, such as proper nutrition and avoidance of cigarette smoking, sports participation might promote healthy lifestyles via social environmental pathways. Indeed, there is some evidence that youthful sports participants manifest better health habits than nonparticipants.7 However, the health benefits of sports participation have been questioned recently,8 and some studies have found sports participation to be associated with certain risk-taking behaviors among elementary school,9 junior high school,10 high school,11 and college students.12,13

In the past decade it has been suggested that sports participation may have different meanings and consequences for different ethnic groups14,15 and that the benefits of sports participation may have been overestimated for minority youth.16 No previous study to date, however, has examined the impact of sports participation on other health behaviors in a nationally representative sample of minority youth. A further limitation of the existing literature is that few studies have examined the relationship between sports participation and health by observing multiple health behaviors, and no studies have examined the relationship between sports participation and a comprehensive set of health behaviors in a nationally representative sample of male and female adolescents.

The Youth Risk Behavior Survey (YRBS) conducted by the Centers for Disease Control and Prevention provides data on a nationally representative sample of US high school students and allows for investigation of the relationship between sports participation and various behaviors known to influence health.17 The purposes of this investigation were to describe the rates of sports participation among US high school students and to explore associations between sports participation and selected positive and negative health behaviors. These relationships were examined separately for males and females, and possible interactions with ethnicity were considered for both sexes.

SURVEY DESIGN

Data for this study were taken from the 1997 YRBS. The survey design is described in detail elsewhere.18 Briefly, a 3-stage cluster sampling procedure was used to produce a nationally representative sample of 9th through 12th-grade students in public and private schools in the 50 states and District of Columbia. The 3 stages consisted of (1) large counties or groups of smaller adjacent counties that made up the primary sampling units, (2) schools, and (3) classes. Schools with substantial numbers of African American and Hispanic students were sampled at a higher rate to ensure adequate numbers to reliably produce prevalence estimates for these ethnic groups. Response rates were 79.1% for schools and 87.2% for students.

SAMPLE

Of 16,262 survey respondents, 14,221 were included in these analyses (87.4%). Approximately 39% were white, 31% African American, and 30% Hispanic. Excluded were students with missing information for any 1 of the following items: age (n = 18), sex (n = 9), ethnicity (n = 118), participation in school sports (n = 167), participation in sports teams run by organizations outside of school (n = 225), and participation in vigorous physical activities (n = 31). Also excluded, due to small numbers, were those who described themselves as Asian or Pacific Islander (n = 641), Native American or Alaskan Native (n = 139), or other (n = 693).

MEASURES

The 88-item YRBS self-report instrument was administered in school classrooms by trained administrators. Data for the present study were obtained from a subset of 27 items pertaining to participation on sports teams, vigorous physical activity, dietary habits, substance abuse, sexual activity, violence, and weight loss (Table 1). Sports participation was defined as playing on 1 or more sports teams, run by the school or by organizations outside of the school, during the past 12 months. Six survey items related to dietary habits were collapsed to create 3 measures of dietary behavior: fruit consumption, vegetable consumption, and fat intake on the previous day. Substance abuse variables included alcohol consumption, binge drinking, tobacco use, marijuana use, cocaine use, other illegal drug use, sniffing glue, and anabolic steroid use. Two survey items related to sexual activity were used to create 3 variables related to sexual behavior: having sexual intercourse during one's lifetime, having sexual intercourse in the past 3 months, and having sexual intercourse with more than 1 partner in the past 3 months. Weight loss practices were assessed with 3 items including (1) trying to lose weight, (2) vomiting or using laxatives to lose weight, and (3) using diet pills to lose weight. The latter 2 items were combined for the analyses. One survey item was used to measure frequency of participation in vigorous physical activity during the previous week. Responses to all items were dichotomized as "ever" vs "never" except for the vigorous physical activity item, which was dichotomized as fewer than 3 days or 3 to 7 days per week, and the multiple sexual partners item, which was dichotomized as 1 or fewer vs 2 or more partners in the past 3 months. The YRBS has been shown to have acceptable reliability in measuring health-related behaviors in adolescents.19

Table Graphic Jump LocationTable 1. Selected Items From the 1993 Youth Risk Behavior Survey
DATA ANALYSES

All analyses were performed using a SAS version of SUDAAN.20 Males and females were analyzed separately. Weighted percentages for sports participation (school, nonschool, and combination of school and nonschool sports) were calculated for the total sample and for population subgroups defined by sex, ethnicity, and age. Unadjusted odds ratios and 95% confidence intervals (CIs) were first calculated to examine the crude association between sports participation and each health behavior. Individual multiple logistic regression analyses were then used to examine the relationship of sports participation and each health behavior while controlling for age, race/ethnicity, and days of vigorous physical activity. Vigorous physical activity was included in each model because previous studies have shown participation in vigorous physical activity to be associated with some other health behaviors.21,22 With the exception of vigorous physical activity, each health behavior was coded as a negative health behavior (eg, not eating fruits or vegetables on the previous day). Thus, an odds ratio of less than 1 always indicated that sports participants were less likely than nonparticipants to engage in that behavior. To determine if the association between sports participation and other health behaviors varied by ethnicity or age group, interaction terms (eg, sports participation × ethnicity) were created and added to each logistic model. To minimize the possibility of type I errors, only interactions with associated probabilities of less than .01 were considered statistically significant. When an interaction term was statistically significant, separate logistic analyses were performed to estimate group-specific odds ratios and 95% CIs.

Prevalence estimates for participation in high school and/or nonschool sports are shown in Table 2. Nationwide, 62.4% of high school students reported participating on 1 or more school and/or nonschool sports teams in the previous year. Male students (69.9%) were more likely than female students (53.4%) to participate in sports and this pattern was consistent across all 3 ethnic groups. Younger students (65.6%) were more likely than older students (58.1%) to participate in sports, while white students (65.4%) were more likely than African American (55.2%) or Hispanic students (52.5%) to report sports participation. The majority of sports participants played on a school sports team (22.5% of total) or a combination of school and nonschool sports teams (29.0% of total). Only 11.0% of all students participated solely on a team run by an organization outside of school.

Table Graphic Jump LocationTable 2. Weighted Percentages of Participation in High School Sports and Nonschool Sports: 1997 Youth Risk Behavior Survey

Crude odds ratios and 95% CIs for the associations between sports participation and selected health behaviors are shown in Table 3. Female sports participants were significantly less likely than female nonparticipants to report not eating fruits and vegetables on the previous day and were more likely to report 3 or more 20-minute sessions of vigorous physical activity during the previous week. In addition, female sports participants were less likely than female nonparticipants to report cigarette smoking, using marijuana or cocaine, having sexual intercourse during their lifetime, having sexual intercourse during the past 3 months, and contemplating or attempting suicide. The only negative behavior associated with sports participation in females was reported use of chewing tobacco or snuff; however, only 1.5% of all females reported this behavior.

Table Graphic Jump LocationTable 3. Weighted Percentages and Crude Odds Ratios (ORs) for Selected Health-Related Behaviors Among High School Students by Participation in School and Nonschool Team Sports: 1997 Youth Risk Behavior Survey

Male sports participants were less likely than male nonparticipants to not report eating fruits and vegetables on the previous day and were more likely to report 3 or more 20-minute sessions of vigorous physical activity during the previous week. In addition, male sports participants were significantly less likely than male nonparticipants to report cigarette smoking; using marijuana, cocaine, or other illegal drugs; sniffing glue; contemplating suicide; carrying a weapon; and trying to lose weight.

The results of the multiple logistic regression analyses are shown in Table 4. Compared with female nonparticipants, female sports participants from all ethnic groups were less likely to report not eating vegetables on the previous day and were less likely to report having sexual intercourse in the past 3 months. Most other significant associations were specific to white females, among whom there were 11 protective associations. There were, however, several negative health behaviors associated with sports participation. African American female sports participants were more likely than nonparticipants to report "other illegal drug" use, while Hispanic female sports participants were more likely than nonparticipants to report carrying a weapon and using steroids.

Table Graphic Jump LocationTable 4. Adjusted* Odds Ratios (ORs) and 95% Confidence Intervals (CIs) for Selected Health-Related Behaviors Among High School Students by Participation in School and Nonschool Team Sports

Among males, sports participants across all 3 ethnic groups were less likely than nonparticipants to report cigarette smoking, cocaine and other illegal drug use, steroid use, and trying to lose weight. They were also less likely to report not eating fruits and vegetables on the previous day. Among white males there were 5 additional protective associations. White male participants were less likely than male nonparticipants to report smoking marijuana, sniffing glue, having sexual intercourse with multiple partners, carrying a weapon, and contemplating suicide. In contrast, in African American males, sports participants were more likely than nonparticipants to report having sexual intercourse during their lifetime, having sexual intercourse with multiple partners, and contemplating suicide. No significant race-specific associations were observed among Hispanic males.

While many significant associations between sports participation and health behavior were observed, it is important to note that several health behaviors were not associated with sports participation in any population group. For example, sports participants were equally as likely as nonparticipants to report eating foods high in fat, engaging in 1 or more episodes of binge drinking in the previous month, being involved in a physical fight, and vomiting or using laxatives to lose or control weight.

The results of this study demonstrate that American high school students are exposed to an enormous amount of organized sports programming. The YRBS indicates that, in 1997, approximately 62% of US high school students participated on at least 1 sports team in school and/or nonschool settings. This proportion corresponds to more than 10 million youth. This exposure, while observed to be large in all demographic subgroups, was unevenly distributed across age, sex, and ethnic groups. White students were more likely to report sports participation than African American and Hispanic students, and, despite the tremendous increase in sports programming for girls since the passage of Title IX legislation in 1972,23 a substantially greater percentage of males than females reported sports team participation. The sex differences were particularly dramatic in African American and Hispanic youth, among whom only 40% of girls participated on a sports team. Nonetheless, despite these inequities, organized sports programs clearly represent a large and influential component of American youth culture. Hence, the potential for these programs to affect health behavior in the nation's population of high school–aged students appears to be great.

The major conclusion drawn from the analyses performed in this study is that, in the most populous demographic subgroups of US high school students, sports participation is associated with multiple positive health behaviors. This trend was most striking for white females and white males, among whom sports participation was significantly associated with numerous positive health behaviors and almost no negative health behaviors. Among African American and Hispanic students, fewer associations with positive health behaviors and some associations with negative behaviors were observed. Our finding of a generally favorable relationship between sports participation and health behaviors may be attributable, in part, to the organizational structures and cultural norms that characterize school and community-based sports programs. For example, sports programs may promote positive health behaviors and deter negative health behaviors by placing a premium on personal health and fitness as prerequisites to optimal sports performance. Also, it is possible that participation in organized sports promotes health by placing youth in prosocial environments during time periods that are otherwise available for participating in problem behaviors.

School and community sports programs have the potential to help youth establish lifelong, healthy, physical activity patterns.2427 National organizations and physical activity experts recommend regular vigorous physical activity for youth,2830 yet many youth do not engage in the quality and quantity of physical activity recommended.24,31 In this study, sports participants were much more likely to report participation in regular vigorous activity (at least 3 times per week, for 20 minutes or more per session) than nonparticipants. These findings suggest that sports participation, through its independent association with other selected health behaviors and its association with increased participation in regular vigorous physical activity, may have important public health consequences for youth.

For white students, sports participation was consistently associated with positive health behaviors. However, among African Americans and Hispanics, the relationship between sports participation and other health behaviors was less consistent. Relative to whites, fewer significant associations with positive behaviors were observed among African American and Hispanic students, and all but one of the significant associations with negative health behaviors were observed in minority students. Similar observations have been reported in previous surveys conducted with state- and school-level samples of youth.7,22 The less positive findings observed among African American and Hispanic students may be explained by cultural and/or socioeconomic factors. Exposure to less favorable social and environmental influences may offset the protective effects of sports participation. In support of this hypothesis, Jessor et al32 found adolescents' involvement in problem behaviors to be a function of the balance between exposure to risk factors and protective factors. Future studies in this area should consider the potentially important role of socioeconomic and cultural factors in mediating the relationship between sports participation and health behaviors.

The results of this study have important implications for physicians and other health professionals who provide health care services to young athletes. The generally positive relationships between sports participation and health behaviors suggest that physicians should actively encourage young people to take advantage of the opportunity to join sports teams. Indeed, the American Medical Association has published guidelines that recommend that physicians and other health professionals encourage youth to engage in physical activities such as organized sports.33 Nevertheless, health care providers should be aware that some negative health behaviors are more common among athletes than nonathletes, particularly in certain ethnic groups. Consequently, primary care physicians, with the assistance of parents, coaches, and athletic trainers, should routinely screen young athletes for health-risk behaviors and provide appropriate health information and counseling. Preparticipation physical examinations, which are typically mandatory for high school athletes, provide a unique opportunity to perform such a service. Traditionally these examinations have focused on identification of medical exclusions to sports participation.34 Our findings support the view that the preparticipation physical examination be broadened to include screening for health behaviors.35 A recently completed trial with high school football players provides evidence that education programs designed to deter health risk behaviors in high school athletes are feasible and effective in reducing problem behaviors such as anabolic steroid use, alcohol consumption, and illegal drug use.36

The results of this study should be interpreted with consideration of certain methodological limitations. First, the cross-sectional study design precludes establishing a causal relationship between sports participation and health behaviors. Second, because YRBS does not provide information on participation in specific sports (eg, basketball, swimming), we were unable to assess the possibility that the relationship between sports participation and health behaviors varies across sports. This is likely since certain negative behaviors are known to be particularly prevalent in specific sports (eg, smokeless tobacco use in baseball players).37 Furthermore, although the YRBS protocol ensures subject confidentiality, we cannot exclude the possibility that some respondents may have underreported participation in socially undesirable health behaviors. Also, because we were interested in examining the relationship between sports participation and several health behaviors, multiple statistical comparisons were performed. Hence, a small percentage of the observed significant associations may have been due to chance. Nonetheless, we conclude that analyses of this nationally representative sample of US high school students suggest that participation in organized sports is associated with an array of health benefits for most students, but also with some negative health behaviors in certain subgroups. These findings suggest that prospective, longitudinal and/or experimental studies of the relationship between sports participation and health behaviors are needed to fully delineate the public health impact of youth sports participation.

Accepted for publication March 10, 2000.

This study was supported by grant U48/CCU409664 from the Centers for Disease Control and Prevention, Atlanta, Ga.

Reprints: Russell R. Pate, PhD, Department of Exercise Science, University of South Carolina, Columbia, SC 29208 (e-mail: rpate@sph.sc.edu).

Waller  W The Sociology of Teaching.  New York, NY Russell & Russell1961;
Evans  JDavies  B Sociology of schooling and physical education. Evans  Jed.Physical Education, Sport and Schooling: Studies in Sociology of Physical Education London, England Falmer Press1986;11- 37
Fejgin  N Participation in high school competitive sports: a subversion of school mission or contribution to school goals? Soc Sport J. 1994;11211- 230
Kandel  D Final Report: Family Processes in Adolescent Drug Use.  Rockville, Md National Institute on Drug Abuse1978;
Jessor  RChase  JADonavan  JE Psychological correlates of marijuana use and problem drinking in a national sample of adolescents. Am J Public Health. 1980;70604- 613
Hastad  DNSegrave  JOPangrazi  RPeterson  G Youth sport participation and deviant behavior. Soc Sport J. 1984;1366- 373
Winnail  SDValois  RFDowda  MMcKeown  RESaunders  RPPate  RR Athletics and substance abuse among public high school students in a southern state. Am J Health Stud. 1997;13187- 194
Skolnick  AA Studies raise doubts about benefit of athletics in reducing unhealthy behavior among adolescents. JAMA. 1993;270798- 799
D'Elio  MAMundt  DJBush  PJIannotti  RJ Healthful behaviors: do they protect African-American, urban preadolescents from abusable substance use? Am J Health Promot. 1993;7354- 363
Aaron  DJDearwater  SRAnderson  ROlsen  TKriska  AMLaPorte  RE Physical activity and the initiation of high-risk health behaviors in adolescents. Med Sci Sports Exerc. 1995;271639- 1645
Smith  EACaldwell  LL Participation in high school sports and adolescent sexual activity. Pediatr Exerc Sci. 1994;669- 74
Kokotailo  PKHenry  BCKoscik  REFleming  MFLandry  GL Substance use and other health risk behaviors in collegiate athletes. Clin J Sport Med. 1996;6183- 189
Nattiv  APuffer  JCGreen  GA Lifestyles and health risks of collegiate athletes: a multi-center study. Clin J Sport Med. 1997;7262- 272
Snyder  EESpreitzer  E High school athletic participation as related to college attendance among black, Hispanic, and white males. Youth Society. 1990;21390- 398
Sabo  DFMelnick  MJVanfossen  BE High school athletic participation and postsecondary educational and occupational mobility: a focus on race and gender. Soc Sport J. 1993;1044- 56
Melnick  MJSabo  DFVanfossen  B Educational effects of interscholastic athletic participation on African-American and Hispanic youth. Adolescence. 1992;27295- 308
Kolbe  LJ An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Educ. 1990;2144- 48
Not Available, 1997 National School-Based Youth Risk Behavior Survey: Data Documentation Manual.  Atlanta, Ga Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion1997;
Brener  NDCollins  JLKenn  LWarren  CWWilliams  BL Reliability of the Youth Risk Behavior Survey Questionnaire. Am J Epidemiol. 1995;141575- 580
Shah  BVBarnwell  BGBrieler  GS SUDAAN User's Manual, Release 7.5.  Research Triangle Park, NC Research Triangle Institute1997;
Pate  RRHeath  GWDowda  MTrost  SG Associations between physical activity and other health behaviors in a representative sample of US adolescents. Am J Public Health. 1996;861577- 1581
Winnail  SDValois  RFMcKeown  RESaunders  RPPate  RR Relationship between physical activity level and cigarette, smokeless tobacco use, and marijuana use among public high school adolescents. J Sch Health. 1995;65438- 442
Thein  LAThein  JM The female athlete. J Orthop Sports Phys Ther. 1996;23134- 148
Centers for Disease Control and Prevention, Guidelines for school and community programs to promote lifelong physical activity among young people. MMWR Morb Mortal Wkly Rep. 1997;46 ((No. RR-6)) 1- 36
Luepker  RVPerry  CLMcKinlay  SM  et al.  Outcomes of a field trial to improve children's dietary patterns and physical activity: The Child and Adolescent Trial for Cardiovascular Health (CATCH). JAMA. 1996;275768- 776
Sallis  JFMcKenzie  TLAlcaraz  JEKolody  BFaucette  NHovell  MF The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Am J Public Health. 1997;871323- 1334
Simons-Morton  BGParcel  GSBaranowski  TForthofer  RO'Hara  NM Promoting physical activity and a healthful diet among children: results of a school-based intervention study. Am J Public Health. 1991;81986- 991
US Department of Health and Human Services, Healthy People 2000: National Health Promotion and Disease Prevention Objectives.  Washington, DC Dept of Health and Human Services, Public Health Service, US Government Printing Office1991;
US Department of Health and Human Services, Physical Activity and Health: A Report of the Surgeon General.  Atlanta, Ga US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion1996;
Sallis  JFPatrick  K Physical activity guidelines for adolescents: consensus statement. Pediatr Exerc Sci. 1994;6302- 314
Pate  RRLong  BJHeath  GW Descriptive epidemiology of physical activity in adolescents. Pediatr Exerc Sci. 1994;6302- 314
Jessor  RVan Den Bos  JVanderryn  JCosta  FMTurbin  MS Protective factors in adolescent problem behavior: moderator effects and developmental change. Dev Psychol. 1995;31923- 933
Elster  ABedKuznets  NJed AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale.  Baltimore, Md Williams & Wilkins1994;
Bratton  RL Participation screening of children for sports: current recommendations. Sports Med. 1997;24300- 307
American Medical Association, Council on Scientific Affairs, Ensuring the health of the adolescent athlete. Arch Fam Med. 1993;2446- 448
Goldberg  LElliot  DClarke  GN  et al.  Effect of a multidimensional anabolic steroid prevention intervention: The Adolescent Training and Learning to Avoid Steroids (ATLAS) program. JAMA. 1996;2761555- 1562
Davis  TCArnold  CNandy  I  et al.  Tobacco use among male high school athletes. J Adolesc Health. 1997;2197- 101

Figures

Tables

Table Graphic Jump LocationTable 1. Selected Items From the 1993 Youth Risk Behavior Survey
Table Graphic Jump LocationTable 2. Weighted Percentages of Participation in High School Sports and Nonschool Sports: 1997 Youth Risk Behavior Survey
Table Graphic Jump LocationTable 3. Weighted Percentages and Crude Odds Ratios (ORs) for Selected Health-Related Behaviors Among High School Students by Participation in School and Nonschool Team Sports: 1997 Youth Risk Behavior Survey
Table Graphic Jump LocationTable 4. Adjusted* Odds Ratios (ORs) and 95% Confidence Intervals (CIs) for Selected Health-Related Behaviors Among High School Students by Participation in School and Nonschool Team Sports

References

Waller  W The Sociology of Teaching.  New York, NY Russell & Russell1961;
Evans  JDavies  B Sociology of schooling and physical education. Evans  Jed.Physical Education, Sport and Schooling: Studies in Sociology of Physical Education London, England Falmer Press1986;11- 37
Fejgin  N Participation in high school competitive sports: a subversion of school mission or contribution to school goals? Soc Sport J. 1994;11211- 230
Kandel  D Final Report: Family Processes in Adolescent Drug Use.  Rockville, Md National Institute on Drug Abuse1978;
Jessor  RChase  JADonavan  JE Psychological correlates of marijuana use and problem drinking in a national sample of adolescents. Am J Public Health. 1980;70604- 613
Hastad  DNSegrave  JOPangrazi  RPeterson  G Youth sport participation and deviant behavior. Soc Sport J. 1984;1366- 373
Winnail  SDValois  RFDowda  MMcKeown  RESaunders  RPPate  RR Athletics and substance abuse among public high school students in a southern state. Am J Health Stud. 1997;13187- 194
Skolnick  AA Studies raise doubts about benefit of athletics in reducing unhealthy behavior among adolescents. JAMA. 1993;270798- 799
D'Elio  MAMundt  DJBush  PJIannotti  RJ Healthful behaviors: do they protect African-American, urban preadolescents from abusable substance use? Am J Health Promot. 1993;7354- 363
Aaron  DJDearwater  SRAnderson  ROlsen  TKriska  AMLaPorte  RE Physical activity and the initiation of high-risk health behaviors in adolescents. Med Sci Sports Exerc. 1995;271639- 1645
Smith  EACaldwell  LL Participation in high school sports and adolescent sexual activity. Pediatr Exerc Sci. 1994;669- 74
Kokotailo  PKHenry  BCKoscik  REFleming  MFLandry  GL Substance use and other health risk behaviors in collegiate athletes. Clin J Sport Med. 1996;6183- 189
Nattiv  APuffer  JCGreen  GA Lifestyles and health risks of collegiate athletes: a multi-center study. Clin J Sport Med. 1997;7262- 272
Snyder  EESpreitzer  E High school athletic participation as related to college attendance among black, Hispanic, and white males. Youth Society. 1990;21390- 398
Sabo  DFMelnick  MJVanfossen  BE High school athletic participation and postsecondary educational and occupational mobility: a focus on race and gender. Soc Sport J. 1993;1044- 56
Melnick  MJSabo  DFVanfossen  B Educational effects of interscholastic athletic participation on African-American and Hispanic youth. Adolescence. 1992;27295- 308
Kolbe  LJ An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Educ. 1990;2144- 48
Not Available, 1997 National School-Based Youth Risk Behavior Survey: Data Documentation Manual.  Atlanta, Ga Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion1997;
Brener  NDCollins  JLKenn  LWarren  CWWilliams  BL Reliability of the Youth Risk Behavior Survey Questionnaire. Am J Epidemiol. 1995;141575- 580
Shah  BVBarnwell  BGBrieler  GS SUDAAN User's Manual, Release 7.5.  Research Triangle Park, NC Research Triangle Institute1997;
Pate  RRHeath  GWDowda  MTrost  SG Associations between physical activity and other health behaviors in a representative sample of US adolescents. Am J Public Health. 1996;861577- 1581
Winnail  SDValois  RFMcKeown  RESaunders  RPPate  RR Relationship between physical activity level and cigarette, smokeless tobacco use, and marijuana use among public high school adolescents. J Sch Health. 1995;65438- 442
Thein  LAThein  JM The female athlete. J Orthop Sports Phys Ther. 1996;23134- 148
Centers for Disease Control and Prevention, Guidelines for school and community programs to promote lifelong physical activity among young people. MMWR Morb Mortal Wkly Rep. 1997;46 ((No. RR-6)) 1- 36
Luepker  RVPerry  CLMcKinlay  SM  et al.  Outcomes of a field trial to improve children's dietary patterns and physical activity: The Child and Adolescent Trial for Cardiovascular Health (CATCH). JAMA. 1996;275768- 776
Sallis  JFMcKenzie  TLAlcaraz  JEKolody  BFaucette  NHovell  MF The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Am J Public Health. 1997;871323- 1334
Simons-Morton  BGParcel  GSBaranowski  TForthofer  RO'Hara  NM Promoting physical activity and a healthful diet among children: results of a school-based intervention study. Am J Public Health. 1991;81986- 991
US Department of Health and Human Services, Healthy People 2000: National Health Promotion and Disease Prevention Objectives.  Washington, DC Dept of Health and Human Services, Public Health Service, US Government Printing Office1991;
US Department of Health and Human Services, Physical Activity and Health: A Report of the Surgeon General.  Atlanta, Ga US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion1996;
Sallis  JFPatrick  K Physical activity guidelines for adolescents: consensus statement. Pediatr Exerc Sci. 1994;6302- 314
Pate  RRLong  BJHeath  GW Descriptive epidemiology of physical activity in adolescents. Pediatr Exerc Sci. 1994;6302- 314
Jessor  RVan Den Bos  JVanderryn  JCosta  FMTurbin  MS Protective factors in adolescent problem behavior: moderator effects and developmental change. Dev Psychol. 1995;31923- 933
Elster  ABedKuznets  NJed AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale.  Baltimore, Md Williams & Wilkins1994;
Bratton  RL Participation screening of children for sports: current recommendations. Sports Med. 1997;24300- 307
American Medical Association, Council on Scientific Affairs, Ensuring the health of the adolescent athlete. Arch Fam Med. 1993;2446- 448
Goldberg  LElliot  DClarke  GN  et al.  Effect of a multidimensional anabolic steroid prevention intervention: The Adolescent Training and Learning to Avoid Steroids (ATLAS) program. JAMA. 1996;2761555- 1562
Davis  TCArnold  CNandy  I  et al.  Tobacco use among male high school athletes. J Adolesc Health. 1997;2197- 101

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Indicate what change(s) you will implement in your practice, if any, based on this CME course.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
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