Judy Kruger, PhD U.S. Centers for Disease Control and Prevention

1. 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

2. Objectives • Why evidence-base? • Discuss evidence from 2008 Guidelines • Identify evidence from the Community Guide • Identify potential strategies to include in adventure programs

3. 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

4. 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

5. 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 Perceptions

6. Common components • Specific target population • Specific, measurable goals • Proven benefits • Defined program (structure, timeframe, reasoning) • Support (staffing skills, facility, equipment)

7. Summary • Evidence-based concepts includes: planning, implementing and evaluating • Many advantages and disadvantages • Multiple evidence-based components to consider

8. 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 RiskFactor Surveillance System. www.cdc.gov/brfss • RWJF, Active Living by Design – Case studies. www.activelivingbydesign.org

9. 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

10. 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

11. 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

12. Overview of the 2008 Physical Activity Guidelines for Americans

13. 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

14. 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

15. 2005 Dietary Guidelines 2008 Physical Activity Guidelines www.health.gov/DietaryGuidelines www.health.gov/paguidelines

16. 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

17. CDC triaged 14,472 abstracts CDC reviewed 1,598 papers FACA developed 650 page report HHS writing group created 65 page document 2008 Guidelines strategy Phase I Phase II Phase III

18. 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)

19. 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]?

22. Physical Activity Abstraction Database

23. Evidence table

24. Direct link to pdf

25. 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

26. 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

27. Phase II Advisory Committee Reviewed existing scientific literature to identify sufficient evidence to develop a comprehensive set of specific physical activity recommendations

28. Phase III Writing Committee

29. Phase III Writing Process • Strong reliance upon Advisory Committee Report • Final product - 8 chapters • Fact sheet, toolkits, PowerPoint presentation

30. 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

31. 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

32. 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

33. 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

34. 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

35. Examples of bone strengthening activities • Children • Games (hopscotch) • Jumping rope • Gymnastics, basketball, volleyball • Adolescents • Running • Hopping, skipping, jumping • Jumping rope • Gymnastics, basketball, volleyball

36. Principle = F I T F – Frequency I – Intensity T – Time/Duration 2008 Guideline = minimum F – Daily I – Moderate or Vigorous T – 60 minutes Youth aerobic physical activity principle

37. Muscle strengthening 3 days per week Bone strengthening 3 days per week Muscle & bone strengthening principles As part of the daily 60 minutes to include:

38. 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

39. 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)

40. 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

41. Principle = F I T F – Frequency I – Intensity T – Time/Duration 2008 Guideline = minimum F – Weekly I – Moderate or Vigorous T – 150 minutes/week Adult aerobic physical activity principle

42. Flexibility in meeting minimal aerobic 2008 Guideline Intensity Duration Frequency Moderate or ≥ 150 minutes Week Vigorous or ≥ 75 minutes Week Equivalent Combination ≥ 150 minutes Week

43. 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

44. 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

45. Resources Office of the Surgeon General Healthy Youth for a Healthy Future, HHShttp://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

46. 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

47. 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

48. 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

49. Overview of the Task Force on Community Preventive Services (TFCP) Recommendations AKA: Community Guide

50. 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