Integrating the 2008 Physical Activity
Guidelines for Americans and the Guide
to Community Preventive Services into
Adventure Programs
Judy Kruger, PhD
U.S. Centers for Disease Control and Prevention
Division of Nutrition and Physical Activity
Physical Activity and Health Branch
5th Annual Research and Evaluation of
Adventure Programming (REAP)
March 20, 2009
Atlanta, GA
Objectives
• Why evidence-base?
• Discuss evidence from 2008 Guidelines
• Identify evidence from the Community
Guide
• Identify potential strategies to include
in adventure programs
Why evidence-base?
• Based on what we KNOW…rather
than what we THINK works
• Process of planning, implementing
and evaluating programs
• Individual & community
– gain skills/adopt behaviors
– improve physical environment
What is evidence = proof?
• Evidence of a
health effect
• Evidence of a
program effect
• Evidence of
program design
& context
SOME action needed
SPECIFIC program effect
SPECIFIC delivery effect
Perceptions
• Advantages
– Lead to efficient use of
resources
– Continuity & growth
of the program
– Common performance
measures
– Supports quality
improvement
– Helps establish
partnership
• Disadvantages
– Need to know where to
find evidence
– Added expense as tools
and process are
unfamiliar
– Program appears
standardized instead of
tailored
– May impact
community buy-in
Common components
•
•
•
•
Specific target population
Specific, measurable goals
Proven benefits
Defined program (structure, timeframe,
reasoning)
• Support (staffing skills, facility,
equipment)
Summary
• Evidence-based concepts includes:
planning, implementing and
evaluating
• Many advantages and disadvantages
• Multiple evidence-based components
to consider
Resources
• CDC, Framework for program evaluation in
public health. MMWR. 1999 48 (RR-11): 1-40.
• CDC, Youth Risk Behavior Surveillance
System. www.cdc.gov/HealthyYouth/yrbs
• CDC, Behavioral Risk Factor Surveillance
System. www.cdc.gov/brfss
• RWJF, Active Living by Design – Case studies.
www.activelivingbydesign.org
QUIZ
• Evidence-based research includes
the process of planning,
implementing and evaluating
programs adapted from testing
interventions in order to address
health issues at the individual and
community level?
A) True
B) False
QUIZ
• Which of the following are
perceived advantages of EB?
A) Makes it easier to justify funding
B) Facilitates spread of program
C) Supports continuous quality
improvement
D) Helps to establish partnership
E) All of the above
QUIZ
• Which of the following are common
components of EB?
A) Specific target population
B) Specific, measurable goals
C) Proven benefits
D) A and B
E) All of the above
Overview of the 2008
Physical Activity
Guidelines for Americans
Scientifically established benefits
of physical activity (PA)
•
•
•
•
•
•
•
•
•
•
↓ risk of dying prematurely
↓ risk of dying from heart disease
↓ risk of developing diabetes
↓ risk of developing high blood pressure
Helps ↓ blood pressure in people who already
have high blood pressure
↓ risk of developing colon cancer
↓ feelings of depression and anxiety
Helps control weight
Helps build and maintain healthy bones,
muscles, and joints
Promotes psychological well-being
2008 Physical Activity
Guidelines for Americans
• First major review of the science on
benefits of physical activity in over a
decade
• Complement previous
recommendations
• Information and guidance on the
types and amount of physical activity
that provide substantial health
benefits
2005 Dietary Guidelines
www.health.gov/DietaryGuidelines
2008 Physical Activity Guidelines
www.health.gov/paguidelines
3 Phases & Products
• Evidence review (managed by CDC)
– Database
• Advisory committee report (expert
panel)
– Federal Advisory Report
• Writing process (appointed panel)
– 2008 Physical Activity Guidelines
for Americans
2008 Guidelines strategy
Phase I
Phase II
Phase III
CDC triaged
14,472
abstracts
CDC reviewed
1,598
papers
FACA
developed
650 page
report
HHS writing
group created
65 page
document
Phase I
Evidence Review
• Literature review examined original
research published since January 1995
• Health outcome chapters:
– All-cause mortality, cardio-respiratory, musculoskeletal,
functional health, cancer, mental health, adverse events,
metabolic, & energy balance
• Stratified by age groups
– Children and youth (6-18 years)
– Adults (19-64 years)
– Older adults (65 + years)
Initial research questions
Is physical activity (PA) associated with
the health outcome of interest [x]?
What dose of PA is associated with [x]?
What level of PA intensity influences [x]?
Do different modes (types) influence [x]?
Physical Activity Abstraction Database
Evidence table
Direct link to pdf
Phase II
Advisory Committee Report
• Utilized literature database to
develop consensus on PA & health
literature
• Health outcome chapters:
– All-cause mortality, cardio-respiratory, musculoskeletal,
functional health, cancer, mental health, adverse events,
metabolic, & energy balance
• Additional chapters on understudied
populations
– Persons with disabilities
– Women during pregnancy and the postpartum period
– Adults with selected chronic conditions
Phase II
Advisory Committee
William L. Haskell, Stanford University - Chair
Miriam Nelson, Tufts University - Vice Chair
Rod K. Dishman, University of Georgia
Edward T. Howley, University of Tennessee
Wendy Kohrt, University of Colorado
William Kraus, Duke University
I-Min Lee, Harvard University
Anne McTiernan, Fred Hutchinson Cancer Center
Kenneth E. Powell, Atlanta Georgia
Russell R. Pate, University of South Carolina
Judy Regensteiner, University of Colorado
James Rimmer, University of Illinois, Chicago
Antronette Yancey, UCLA
Phase II
Advisory Committee
Reviewed existing scientific
literature to identify
sufficient evidence to
develop a comprehensive
set of specific physical
activity recommendations
Phase III
Writing Committee
Phase III
Writing Process
• Strong reliance upon
Advisory Committee
Report
• Final product - 8
chapters
• Fact sheet, toolkits,
PowerPoint
presentation
Children and Adolescents
(ages 6-17)
• 1 hour (60 minutes) or more of Aerobic
physical activity that is at least moderate:
– Most of the 1 or more hours a day should
be either moderate- or vigorous-intensity
PA
– Do vigorous-intensity PA at least 3 days a
week
• Encourage participation in PA that are:
 Age appropriate, enjoyable, offer variety
Examples of moderate-intensity
aerobic activities
• Children
– Brisk walk, hiking
– Active recreation (canoeing)
• Adolescents
– Brisk walk, hiking
– Active recreation (canoeing)
– Yard work such as raking leaves/ bagging
leaves
– Softball, baseball that require catching and
throwing
Examples of vigorous-intensity
aerobic activities
• Children
– Active games (tag - running and chasing)
– Martial arts (karate)
– Sports (soccer, hockey, basketball, tennis)
• Adolescents
– Active games (flag football - running and
chasing)
– Martial arts (karate)
– Sports (soccer, hockey, basketball, tennis)
– Vigorous dancing
Children and Adolescents
continued
• As part of 60 minutes of daily activity to
include:
Muscle-strengthening: Include musclestrengthening physical activity on at least 3
days of the week
Bone-strengthening: Include bonestrengthening physical activity on at least 3
days of the week
Examples of muscle
strengthening activities
• Children
– Games (tug-of-war) or climbing (ropes or playground)
– Resistance exercises (body weight or resistance
bands)
– Ropes, tree climb, swinging on bars/equipment
• Adolescents
– Climbing (pull-ups, push-ups)
– Resistance exercises using hand-held
weights or weight machines
– Swinging on bars/equipment, rope or tree
Examples of bone strengthening
activities
• Children
– Games (hopscotch)
– Jumping rope
– Gymnastics, basketball, volleyball
• Adolescents
–
–
–
–
Running
Hopping, skipping, jumping
Jumping rope
Gymnastics, basketball, volleyball
Youth aerobic physical activity
principle
Principle = F I T
2008 Guideline = minimum
• F – Frequency
• I – Intensity
• T – Time/Duration
• F – Daily
• I – Moderate or Vigorous
• T – 60 minutes
Muscle & bone strengthening
principles
As part of the daily 60 minutes to include:
• Muscle strengthening
– 3 days per week
• Bone strengthening
– 3 days per week
Key Guidelines – Adults
(ages 18–64)
• Minimum aerobic activity for health
– 2 hours and 30 minutes (150 minutes/week)
moderate-intensity aerobic activity; or
– 1 hour and 15 minutes (75 minutes/week)
vigorous-intensity aerobic activity; or
– Equal combination for 150 minutes/week
• Muscle-strengthening activities that involve
all major muscle groups should be performed
on 2 or more days of the week
Key Guidelines – Adults
continued
• For additional health benefits
– 5 hours (300 minutes) moderate-intensity
aerobic activity a week; or
– 2 hours and 30 minutes (150 minutes)
vigorous-intensity aerobic activity a week;
or
– An equivalent combination (150 minutes)
Key Guidelines – Older adults
(ages 64+)
• The key guidelines for adults apply
to older adults with additional
qualifying guidelines:
– Guideline for adults who cannot do
150 minutes/week
– Balance exercise
– Only use relative intensity to
determine the level of effort
Adult aerobic physical activity
principle
Principle = F I T
2008 Guideline = minimum
• F – Frequency
• I – Intensity
• T – Time/Duration
• F – Weekly
• I – Moderate or Vigorous
• T – 150 minutes/week
Flexibility in meeting minimal aerobic
2008 Guideline
Intensity
Moderate
or
Duration
Frequency
≥ 150 minutes
Week
Vigorous
or
≥ 75 minutes
Week
Equivalent
Combination
≥ 150 minutes
Week
Summary
• Most recent scientific review for
Americans in the past decade
• 2008 Guidelines specify a minimum of
aerobic PA based on total time per week
• For children and adolescents the 2008
Guidelines specify 3 days a week of bone
& muscle strengthening activity
• For adults the 2008 Guidelines specify 2
days a week of muscle-strengthening
activity
Summary
• Avoid inactivity
– Some activity is better than none
• Aerobic activity for children & adolescents
– ≥60 mins/day moderate intensity or
equivalent
• Aerobic activity for adults
– Substantial health benefits from medium
amounts
• ≥150 mins/week moderate intensity or
equivalent
– More health benefits from high amounts
• ≥ 300 mins/week moderate intensity or
equivalent
Resources
Office of the Surgeon General Healthy Youth for a Healthy Future, HHS
http://www.surgeongeneral.gov/obesityprevention/index.html
CDC Division of Adolescent and School Health (DASH), HHS
http://www.cdc.gov/HealthyYouth/about/index.htm
CDC DASH Plan to Address Physical Activity, HHS
http://www.cdc.gov/HealthyYouth/physicalactivity/pdf/Addressing_Phys_Activity.pdf
OWH Powerful Bones. Powerful Girls.™, HHS
http://www.girlshealth.gov/bones
SmallStep Kids, HHS
http://www.smallstep.gov/kids/flash/index.html
NIH Ways to Enhance Children's Activity and Nutrition (We Can!), HHS
http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan
Eat Smart. Play Hard.™, USDA
http://www.fns.usda.gov/eatsmartplayhard
QUIZ
• What is the minimal recommended
amount of aerobic physical activity
for children and adolescents?
A) 30 minutes every day
B) 60 minutes every day
C) 90 minutes every day
QUIZ
• What is the minimal recommended
amount of aerobic physical activity
for adults?
A) 90 minutes a week
B) 120 minutes a week
C) 150 minutes a week
QUIZ
• What is the minimal recommended
amount of aerobic physical activity
for older adults?
A) 90 minutes a week
B) 120 minutes a week
C) 150 minutes a week
Overview of the Task Force on
Community Preventive Services
(TFCP) Recommendations
AKA: Community Guide
The Community Guide:
A Tool for Evidence-Base
• Independent Task Force on
Community Preventive Services
• Population-based prevention
strategies
• Set of recommendations based
on systematic reviews of
literature
The Community Guide Uses
A Systematic Approach
• Form team
• Develop conceptual framework
• Define, group and select interventions to be
evaluated
• Search for and collect evidence of effectiveness
• Evaluate quality of studies
• Summarize evidence
• Consider economics, feasibility, and harms
• Translate evidence into recommendations
Physical Activity
Conceptual Framework
Interventions
Modifiable
Behavioral
Determinants
Outcomes
Intermediate
Physiological
Outcomes
Health
Outcomes
Search strategy
6,238 screened
849
retrieved
253
candidates
94 evaluated
What are some strengths of the
Community Guide?
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•
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Systematic review
Credible
Evidence of effectiveness
Sometimes cost effectiveness
A good starting point….
What are some limitations of the
Community Guide
• Intervention headings arbitrary
• Limited to available evidence at
the time
• Not the only consideration; not
the only evidence
• Doesn’t account for different
contexts, e.g., history, culture
5 Recommended strategies
Recommended, strong evidence:
1. Community wide campaigns
2. Individually-adapted health behavior change
programs
3. School-based physical education
4. Social support interventions in community contexts
5. Creation of/enhanced access to places for PA
combined with informational outreach
What is the Guide to
Community Preventive Services
(Community Guide)?
• Effective population-level strategies to
promote physical activity (PA)
• 3 Intervention categories:
– Environmental & policy approaches
• Creation of/enhanced access to places
for PA combined with informational
outreach
Promoting PA: Environmental
and Policy Approaches
The Task Force Strongly Recommended
Creation of or enhanced access to places for PA combined with
informational outreach
• Multi-component
• Built environment – access to
trails/facilities, creating walking trails,
building exercise facilities nearby
• Reducing barriers (safety, affordability)
• Training & incentives (site-specific
programs, workshops, seminars)
Creation of/enhanced access to
places for PA combined with
informational outreach
• Community Guide use “places” instead of
“facilities” to avoid the implication that physical
activity needs a special type of structure.
• Interventions were not simply about building
trails or facilities; many of them also included
training, incentives education, risk factor
screening or programming to entice and support
use of these places for physical activity
Results from the Systematic Reviews
• In all 10 studies reviewed, creating or enhancing
access to places for physical activity was effective
in getting people to exercise more
– Aerobic capacity: median increase of 5.1%
(interquartile interval: 2.8% to 9.6%; 8 study arms)
– Energy expenditure: median increase of 8.2%
(interquartile interval: -2.0% to 24.6%; 3 study arms)
– Percentage of participants reporting some leisure-time
physical activity: median increase of 2.9% (interquartile
interval: -6.0% to 8.5%; 4 study arms)
– Exercise score: median increase of 13.7% (interquartile
interval: -1.8% to 69.6%; 6 study arms)
Results continued
• Most of the studies also reported weight losses or
decreases in body fat among program participants
• Many of these programs train participants to use
exercise equipment, health/fitness programs, and
support or buddy systems
• These interventions were effective among both
men and women and in various settings, including
industrial plants, universities, federal agencies,
and low-income communities
• If appropriately adapted to the target populations,
these interventions should be applicable to diverse
settings and groups
Resources
• The Guide to Community Preventive
Services: What works to promote
health? New York, NY: Oxford Press;
2005: 80-113.
• Kahn EB et al., Am J Prev Med. 2002;
22 (4 Suppl): 73-107.
• CDC, MMWR, 2001; 50 (RR18) 1-16.
QUIZ
• Which of the following Community
Guide recommendations are applicable
to adventure programs?
A) Creating places to places to be active
B) Enhancing access to places to be active
C) Informational outreach
D) A and B
E) All of the above
QUIZ
• The Community Guide recommendation
category for the creation or enhanced access
to places for physical activity combined with
informational outreach activities is?
A) Recommended, strong evidence
B) Recommended, sufficient evidence
C) Insufficient evidence
D) Recommended against due to lack of effect, cost,
harms
E) All of the above
Implications
• Awareness of scientific evidence
• Individuals need a flexible and
adaptable exercise prescription
• Translation of efforts are needed to
encourage inactive to consider
becoming active
• Need to continue monitoring levels of
activity in community
Wrap up
• What are some potential strategies to
include in adventure programming?
• What outcomes have you collected that
have demonstrated program
effectiveness?
• How have you used these outcomes to
leverage funding?
For more information
Websites:
www.thecommunityguide.org
http://www.health.gov/paguidelines/
www.cdc.gov/nccdphp/dnpa/physical
For more information
• Websites
www.thecommunityguide.org
http://www.health.gov/paguidelines/
www.cdc.gov/nccdphp/dnpa/physical