Integrating the 2008 Physical Activity Guidelines for Americans and the Guide to Community Preventive Services into

Adventure Programs

Judy Kruger, PhDU.S. Centers for Disease Control and Prevention

Division of Nutrition and Physical ActivityPhysical 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

www.health.gov/paguidelines

2008 Physical Activity Guidelines2005 Dietary Guidelines

www.health.gov/DietaryGuidelines

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

CDC triaged 14,472 abstracts

CDC reviewed 1,598 papers

FACA developed 650 page

reportHHS writing group created 65 page document

Phase I Phase II Phase III

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 - ChairMiriam Nelson, Tufts University - Vice ChairRod K. Dishman, University of GeorgiaEdward T. Howley, University of TennesseeWendy Kohrt, University of ColoradoWilliam Kraus, Duke UniversityI-Min Lee, Harvard University Anne McTiernan, Fred Hutchinson Cancer CenterKenneth E. Powell, Atlanta GeorgiaRussell R. Pate, University of South CarolinaJudy Regensteiner, University of ColoradoJames Rimmer, University of Illinois, ChicagoAntronette 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-intensityaerobic 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 muscle-

strengthening physical activity on at least 3 days of the week

Bone-strengthening: Include bone-strengthening physical activity on at least 3 days of the week

Examples of muscle strengthening activities

• Children– Games (tug-of-war) or climbing (ropes or play-

ground)– 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

• F – Frequency• I – Intensity• T – Time/Duration

2008 Guideline = minimum

• F – Daily• I – Moderate or Vigorous • T – 60 minutes

Muscle & bone strengthening principles

• Muscle strengthening– 3 days per week

• Bone strengthening– 3 days per week

As part of the daily 60 minutes to include:

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

• F – Frequency• I – Intensity• T – Time/Duration

2008 Guideline = minimum

• F – Weekly• I – Moderate or Vigorous • T – 150 minutes/week

Flexibility in meeting minimal aerobic 2008 Guideline

Intensity Duration Frequency

Moderateor ≥ 150 minutes Week

Vigorousor ≥ 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

ResourcesOffice 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), HHShttp://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.™, HHShttp://www.girlshealth.gov/bones

SmallStep Kids, HHShttp://www.smallstep.gov/kids/flash/index.html

NIH Ways to Enhance Children's Activity and Nutrition (We Can!), HHShttp://www.nhlbi.nih.gov/health/public/heart/obesity/wecan

Eat Smart. Play Hard.™, USDAhttp://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

Determinants

Behavioral

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?

• 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 campaigns2. Individually-adapted health behavior change

programs3. School-based physical education4. Social support interventions in community contexts5. 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

• 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)

The Task Force Strongly Recommended Creation of or enhanced access to places for PA combined

with informational outreach

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.orghttp://www.health.gov/paguidelines/

www.cdc.gov/nccdphp/dnpa/physical