Physical Activity and Fitness
Contents
1.1 Coronary heart
disease
1.2 Overweight
1.3 Moderate physical activity
1.4 Vigorous physical activity
1.5 Sedentary lifestyle
1.6 Muscular strength, endurance, and flexibility
1.7 Weight loss practices
1.8 Daily school physical education
1.9 School physical education quality
1.10 Worksite fitness programs
1.11 Community fitness facilities
1.12 Clinician counseling about physical
activity
1. Physical Activity and Fitness
Introduction
Evidence of the multiple health benefits
of regular physical activity continues to mount. Regular
physical activity can help to prevent and manage coronary
heart disease, hypertension, noninsulin-dependent diabetes
mellitus, osteoporosis, obesity, and mental health problems
(e.g., depression, anxiety). 16 Regular physical activity
has also been associated with lower rates of colon cancer
31 and stroke 34 and may be linked to reduced back injury.
7 On average, physically active people outlive those
who are inactive. 27 Regular physical activity can also
help to maintain the functional independence of older
adults and enhance the quality of life for people of
all ages. 18
Because coronary heart disease is
the leading cause of death and disability in the United
States, the potential role of physical activity in preventing
coronary heart disease is of particular importance.
Physically inactive people are almost twice as likely
to develop coronary heart disease as people who engage
in regular physical activity. 32 This is only slightly
less than the relative risk for such well-known risk
factors as cigarette smoking, high blood pressure, and
high blood cholesterol. Furthermore, more people are
at risk for coronary heart disease due to physical inactivity
than for any other single risk factor, and those with
other risk factors for coronary heart disease, such
as obesity and hypertension, may particularly benefit
from physical activity.
Increasing evidence suggests that
light to moderate physical activity, below the level
recommended for cardiorespiratory fitness, can have
significant health benefits, including a decreased risk
of coronary heart disease. 21,33 For the inactive, even
relatively small increases in activity are associated
with measurable health benefits. In addition, light
to moderate physical activity is more readily adopted
and maintained than vigorous physical activity. Therefore,
compared to the 1990 objectives, the year 2000 objectives
place greater emphasis on reducing inactivity and increasing
light to moderate physical activity.
The relationships between physical
activity and health are numerous and complex. 8 Many
different physiologic and physical effects are associated
with the many different types of physical activities
that a person can choose to do. While it is unclear
what exact types and amounts of physical activity are
required for precise health benefits, several health-related
dimensions of physical activity are thought to be most
important in producing selected health effects. 8 The
year 2000 objectives are proposed to ensure that health-related
dimensions of physical activity that encompass key physiologic
and physical mechanisms become part of regular behavioral
patterns.
For example, Objective 1.3 addresses
the dimension of physical activity associated with energy
or caloric expenditure which results in energy utilization,
thereby enhancing weight loss or control. Pursuing activities
that result in energy expenditure may also produce physiologic
changes that favorably affect blood pressure, platelet
aggregation and fibrinolysis, and glucose tolerance,
thereby helping to prevent or manage coronary heart
disease and diabetes mellitus. 20 Objective 1.4 addresses
aerobic intensity which increases the ability of the
cardiorespiratory and other systems to do physical work,
but may also have an additional beneficial influence
on preventing cardiovascular disease. Objective 1.6
addresses muscular strength, muscular endurance, and
flexibility which are important because they may protect
against disability and, therefore, may serve to ensure
regular physical activity participation. As research
continues to elucidate the links between physical activity
and selected health outcomes, individuals will be able
to increasingly select physical activity patterns optimally
suited to individual health risks and physiologic benefits
as well as to individual preferences.
Unfortunately, few Americans engage
in regular physical activity despite the potential benefits.
Less than 10 percent of the U.S. adult population exercises
at the level recommended by the 1990 objectives: "exercise
which involves large muscle groups in dynamic movement
for periods of 20 minutes or longer, 3 or more days
per week, and which is performed at an intensity of
60 percent or greater of an individual's cardiorespiratory
capacity." 9 Less than half the adult population
exercises 3 or more days per week for 20 minutes or
longer regardless of intensity of dynamic movement of
large muscle groups. The prevalence of physical inactivity
increases with advancing age especially during adolescence
and early adulthood.
Note: Except as otherwise noted, all
rates in the following objectives are annual. Where
the baseline rate is age adjusted, it is age adjusted
to the 1940 U.S. population, and the target is age adjusted
also. If a rate is age adjusted, the crude baseline
rate may be found in Appendix D.
Health Status Objectives
1.1 *Reduce coronary
heart disease deaths to no more than 100 per 100,000
people. (Age adjusted baseline: 135 per 100,000 in 1987)
Special
Population Target |
Coronary Deaths
(per 100,000) |
1987 Baseline |
2000 Target %
Decrease |
1.1a Blacks |
163 |
115 |
Baseline data source: National
Vital Statistics System (special analysis), CDC. 35,36
*For commentary, see Objective 15.1
in Heart Disease and Stroke. This objective also appears
as Objective 2.1 in Nutrition and as Objective 3.1 in
Tobacco .
1.2* Reduce overweight
to a prevalence of no more than 20 percent among people
aged 20 and older and no more than 15 percent among
adolescents aged 12 through 19.
(Baseline: 26 percent for
people aged 20 through 74 in 1976-80, 24 percent for
men and 27 percent for women; 15 percent for adolescents
aged 12 through 19 in 1976-80)
Overweight
Prevalence |
1976-80 Baseline |
2000 Target %
Decrease |
1.2a |
Low income women
aged
20 and older |
37% |
25% |
1.2b |
Black women aged
20
and older |
44% |
30% |
1.2c |
Hispanic women aged
20 and older |
|
|
|
Mexican-American
Cuban Women
Puerto Rican women |
39%
34%
37% |
|
1.2d |
American Indians
Alaska Natives |
29-75%
|
30%
|
1.2e |
People with disabilities |
36% |
25% |
1.2f |
Women with high blood
Pressure |
50%
|
41%
|
1.2g |
Men with high blood
Pressure |
39% |
35% |
Note: For people aged 20 and
older, overweight is defined as body mass index (BMI)
equal to or greater than 27.8 for men and 27.3 for women.
For adolescents, overweight is defined as BMI equal
to or greater than 23.0 for males aged 12 through 14,
24.3 for males aged 15 through 17, 25.8 for males aged
18 through 19, 23.4 for females aged 12 through 14,
24.8 for females aged 15 through 17, and 25.7 for females
aged 18 through 19. The values for adolescents are the
age and gender-specific 85th percentile values of the
1976-80 National Health and Nutrition Examination Survey
(NHANES II), corrected for sample variation. 39 BMI
is calculated by dividing weight in kilograms by the
square of height in meters. The cut points used to define
overweight approximate the 120 percent of desirable
body weight definition used in the 1990 objectives.
Baseline data sources: National
Health and Nutrition Examination Survey (NHANES), CDC;
Hispanic Health and Nutrition Examination Survey, CDC;
Indian Health Service; for people with disabilities,
National Health Interview Survey, CDC.
*For commentary, see Objective 2.3
in Nutrition . This objective also appears as Objective
15.10 in Heart Disease and Stroke and as Objective 17.12
in Diabetes and Chronic Disabling Conditions.
Risk Reduction
Objectives
1.3* Increase to at least 30 percent
the proportion of people aged 6 and older who engage
regularly, preferably daily, in light to moderate physical
activity for at least 30 minutes per day. (Baseline:
22 percent of people aged 18 and older were active for
at least 30 minutes 5 or more times per week and 12
percent were active 7 or more times per week in 1985)
Note: Light to moderate physical activity
requires sustained, muscular movements, is at least
equivalent to sustained walking, and is performed at
less than 60 percent of maximum heart rate for age.
Maximum heart rate equals roughly 220 beats per minute
minus age. Examples may include walking, swimming, cycling,
dancing, gardening and yard work, various domestic and
occupational activities, and games and other childhood
pursuits.
Baseline data source: Behavioral Risk
Factor Surveillance System, CDC.
Physical activity is defined as any
bodily movement produced by skeletal muscles that results
in caloric expenditure. 11 Caloric expenditure utilizes
energy. Energy utilization enhances weight loss or control
and is important in preventing and managing obesity,
coronary heart disease, and diabetes mellitus. Engaging
regularly in light to moderate physical activity for
at least 30 minutes per day will help to ensure that
calories are expended and confer health benefits. 21,33
For example, daily physical activity equivalent to a
sustained walk for 30 minutes per day would result in
an energy expenditure of about 1050 calories per week
(1.5 miles X 100 kcal per mile x 7 days per week = 1050
kcal per week). If caloric intake remains constant,
this would translate into a weight loss of roughly one-third
pound per week. Furthermore, epidemiologic studies suggest
that a weekly expenditure of 1000 calories could have
significant individual and public health benefit for
coronary heart disease prevention, especially for those
who are originally sedentary. 20
A minimum level of intensity for light
to moderate physical activity is set by the example
of a sustained walk. This level of activity is feasible
for most people. Those willing and able can perform
even more vigorous types of physical activity for the
purpose of improving and/or maintaining cardiorespiratory
fitness (see Objective 1.4). However, light to moderate
activities confer considerable health benefit, are more
likely to be adopted and maintained than intense activities,
and are less likely to result in injury. 30
Although light to moderate physical
activity for a sustained period of at least 30 minutes
is preferable, intermittent physical activity also increases
caloric expenditure and may be important for those who
cannot fit 30 minutes of sustained activity into their
schedules. The point is to encourage physical activity
as part of a daily routine. People engaging in light
to moderate physical activity less often than daily
also receive health benefits, but if the frequency falls
below three days per week, they may be less likely to
maintain a regular pattern of activity over time. 3
Most Americans engage in less physical
activity than is proposed by this objective. Currently
only 22 percent of people aged 18 and older engage in
at least 30 minutes of activity 5 or more times per
week and only 12 percent report that they are this active
7 or more times per week. Similar rates prevail for
older adults and low-income individuals.
Increasing public awareness about
the many benefits of light to moderate physical activity
could help to attain this objective. For example, Americans
need to recognize the importance of daily physical activity
to weight management, to know that walking is a form
of exercise most people can do, and to understand that
one needs to remain active throughout life. It is also
important for people to realize that starting out slowly,
and gradually increasing the frequency and duration
of their physical activity over time is the key to successful
behavior change. 2 In the case of walking, the message
becomes "if you are not used to daily walking,
then walk slowly and take short, frequent walks, gradually
increasing distance and speed." Educational messages
should be appropriately tailored to reach older adults,
people with disabilities, and racial and ethnic minorities.
For young children, attaining this
objective will require public awareness messages targeted
to parents. Parents should be encouraged to exercise
with their children (e.g., daily family walks), to advocate
for daily school physical education (see Objective 1.8),
and to involve their children in the physical activity
programs of community organizations.
*This objective also appears as Objective
15.11 in Heart Disease and Stroke and as Objective 17.13
in Diabetes and Chronic Disabling Conditions.
1.4c Increase to
at least 20 percent the proportion of people aged 18
and older and to at least 75 percent the proportion
of children and adolescents aged 6 through 17 who engage
in vigorous physical activity that promotes the development
and maintenance of cardiorespiratory fitness 3 or more
days per week for 20 or more minutes per occasion. (Baseline:
12 percent for people aged 18 and older in 1985; 66
percent for youth aged 10 through 17 in 1984)
Special
Population Target |
Vigorous Physical
Activity |
1985 Baseline |
2000 Target
Percent Increase |
1.4a Lower income
people aged
18 and older (annual
family income $20,000 |
7% |
12% |
Note: Vigorous physical activities
are rhythmic, repetitive physical activities that use
large muscle groups at 60 percent or more of maximum
heart rate for age. An exercise heart rate of 60 percent
of maximum heart rate for age is about 50 percent of
maximal cardiorespiratory capacity and is sufficient
for cardiorespiratory conditioning. Maximum heart rate
equals roughly 220 beats per minute minus age.
Baseline data source: For people
aged 18 and older, the National Health Interview Survey,
CDC; for youth aged 10 through 17, the National Children
and Youth Fitness Study I, ODPHP.
Regular vigorous physical activity
helps achieve and maintain higher levels of cardiorespiratory
fitness than light to moderate physical activity. Cardiorespiratory
fitness or aerobic capacity describes the body's ability
to perform high intensity activity for a prolonged period
of time without undue stress or fatigue. Having higher
levels of cardiorespiratory fitness helps enable people
to carry out their daily occupational tasks and leisure
pursuits more easily.
The vigorous physical activities that
help to achieve and maintain cardiorespiratory fitness
can also contribute substantially to caloric expenditure,
and probably provide additional protection against coronary
heart disease over less vigorous forms of regular physical
activity. 5,28 Vigorous physical activities include
brisk walking, jogging/running, lap swimming, cycling,
dancing, skating, rowing, jumping rope, cross-country
skiing, hiking/backpacking, racquet sports, and competitive
group sports (soccer, basketball, volleyball). Activities
such as stair climbing; strenuous housework, yard work,
and occupational tasks; and children's games (tag, kickball)
and other childhood pursuits may also qualify as vigorous
activities if they are sustained and elevate the heart
rate to at least 60 percent of the maximum heart rate
for age.
Higher levels of cardiorespiratory
fitness can be achieved by increasing the frequency,
duration, or intensity of activity over that suggested
in this objective (i.e., more than three times per week
or more than 20 minutes per session or at a higher intensity),
but the relationship is not linear. Progressively larger
increases in frequency, duration, or intensity are needed
to induce a steady increase in cardiorespiratory fitness.
The frequency of musculoskeletal injury also rises with
more frequent, prolonged, and intense activity. 30
This objective is designed to encourage
vigorous physical participation for at least three times
per week. Unfortunately, those that meet the minimal
frequency and duration proposed in this objective may
secure a strong cardiorespiratory system, but they may
not achieve the weight control or physiologic benefits
secured by daily activity (see Objective 1.3). On the
other hand, daily vigorous physical activity performed
for 30 minutes per day will surely provide daily energy
expenditure, but there is also an increased injury risk.
30 Therefore, vigorous physical activity should be incorporated
into the daily activity pattern proposed in Objective
1.3 in a manner that will not result in injury.
Monitoring progress toward this objective
must take into account the decline in maximal cardiorespiratory
capacity with age. 6 A method for this has been developed
and used in surveys that obtain information about physical
activities performed without measuring pulse rates.
10
1.5 Reduce to no
more than 15 percent the proportion of people aged 6
and older who engage in no leisure-time physical activity.
(Baseline: 24 percent for people aged 18 and older in
1985)
Baseline data source: National
Health Interview Survey, CDC.
Although the protective effect of
a more active lifestyle is seen for both occupational
and leisure-time physical activity, the amount of physical
activity at work and in the home has declined steadily.
For most people, the greatest opportunity for physical
activity is during leisure.
Unfortunately, 24 percent of men and
women aged 18 and older report no leisure-time physical
activity. The prevalence of leisure-time sedentarism
increases with advancing age--33 percent of people aged
45 through 64 and 43 percent of those aged 65 and older
engage in no leisure-time physical activity. 9 People
with disabilities and lower-income individuals are also
more likely to be sedentary at leisure.
It is important for those who are
sedentary during their leisure-time to take the first
step towards developing a pattern of regular physical
activity. Public education efforts need to address the
specific barriers that inhibit the adoption of physical
activity by different population groups. Older adults,
for example, need information about safe walking routes,
appropriate foot care and footwear for those with foot
problems, appropriate levels of activity for those with
coronary heart disease and other chronic conditions,
and the availability of group activities in the community.
1.6 Increase to
at least 40 percent the proportion of people aged 6
and older who regularly perform physical activities
that enhance and maintain muscular strength, muscular
endurance, and flexibility. (Baseline data available
in 1991)
Muscular strength, muscular endurance,
and joint flexibility are excepted components of health-related
fitness although the type, frequency, duration, and
intensity of activities necessary for specific age and
gender groups remains to be determined. Regular participation
in home maintenance, yard work, gardening, and selected
occupational activities may satisfy this objective in
adults. Participation in games and other active childhood
pursuits may satisfy this objective in children. Satisfying
this objective may require combinations of activities
as not all activities will both increase muscular strength
and endurance and enhance flexibility.
Muscular strength and endurance describe
the ability of skeletal muscles to perform hard and/or
prolonged work. Strength and endurance greatly affect
the ability to perform the tasks of daily living without
undue physical stress and fatigue. Regular use of skeletal
muscles helps to improve and maintain strength and endurance.
14,47 Engaging in regular physical activity and engaging
in a variety of physical activities can help to satisfy
this objective. Although weight training (exercising
with free weights or weight machines) can increase muscle
strength and endurance, weight training is not necessary
to meet this objective and may not be appropriate for
all age groups and individuals. 46
Flexibility describes the range of
motion in a joint or sequence of joints. Those with
greater flexibility may have a lower risk of future
back injury. 7 Older adults with better joint flexibility
may be able to drive an automobile more safely. 45 Joint
movement through the full range of motion helps to improve
and maintain flexibility.
Stretching exercises and engaging
regularly in a variety of physical activities may help
to satisfy this objective.
Physical activities that improve muscular
strength, muscular endurance, and flexibility also improve
the ability to perform tasks of daily living. The performance
of routine daily activities is particularly important
to maintaining functional independence and social integration
in older adults. Increasing the public's awareness of
all of these potential benefits may help to encourage
the pursuit of activities that will promote muscular
strength, muscular endurance, and flexibility.
1.7* Increase to
at least 50 percent the proportion of overweight people
aged 12 and older who have adopted sound dietary practices
combined with regular physical activity to attain an
appropriate body weight.
(Baseline: 30 percent of overweight
women and 25 percent of overweight men for people aged
18 and older in 1985)
Baseline data source: National
Health Interview Survey, CDC.
Overweight occurs when too few calories
are expended and too many consumed for individual metabolic
requirements. 29 The results of weight loss programs
focused on dietary restrictions alone have not been
encouraging. Physical activity burns calories, increases
the proportion of lean to fat body mass, and raises
the metabolic rate. 48 Therefore, a combination of both
caloric control and increased physical activity is important
for attaining a healthy body weight. 13
Neither frequent fluctuations in body
weight nor extreme restrictions in food intake are desirable.
Overweight people should increase their physical activity
and should avoid calorie-dense foods, especially those
high in fat. Diets that are lower in fat and higher
in vegetables, fruits, and grains can facilitate weight
reduction. Extremely low-calorie diets, cyclic weight
reduction, and fad weight-loss regimes of unscientific
merit should be avoided. Practices should be adopted
that are safe and that lead to long-term maintenance
of appropriate weight. Extreme behaviors as exhibited
in bulimia or anorexia nervosa should be medically treated.
Self-help groups and programs that
apply the principles of behavior modification (e.g.,
goal setting, self-monitoring, stimulus control, reinforcement)
may help overweight individuals to sustain the physical
activity and dietary practices needed to reach an appropriate
body weight.
The target for this objective is very
ambitious, but given the potential health benefits of
weight loss in the overweight person, this objective
deserves special priority. Attaining this objective
will help to reduce the prevalence of overweight in
the total population (see Objective 1.2). The prevention
of overweight among those not yet overweight is also
vitally important. Objectives 1.3, 1.4, and 1.5 in this
priority area and Objectives 2.5 and 2.6 in Nutrition
address the primary prevention of obesity.
*This objective also appears as Objective
2.7 in Nutrition .
Services and Protection Objectives
1.8 Increase to
at least 50 percent the proportion of children and adolescents
in 1st through 12th grade who participate in daily school
physical education.
(Baseline: 36 percent in 1984-86)
Baseline data sources: For
students in 5th through 12th grade, the National Children
and Youth Fitness Study 1, ODPHP; for students in 1st
through 4th grade, the National Children and Youth Fitness
Study II, ODPHP.
Participation in school physical education
assures a minimum amount of physical activity by children
and continued physical activity into adulthood. Findings
from the National Children and Youth Fitness Studies
I and II suggest that the quantity, and in particular
the quality, of school physical education programs have
a significant positive effect on the health-related
fitness of children and youth. 40,41 In addition, recent
reports suggest that physical education programs in
early childhood not only promote health and well-being,
but also contribute to academic achievement. 4
Concern about the amount and quality
of youth physical activity and school physical education
has been expressed by several groups, including the
American Academy of Pediatrics and the American College
of Sports Medicine. In 1987, both houses of Congress
passed a resolution (H. Con. Res. 97) encouraging state
and local educational agencies to provide high quality
daily physical education programs for all children in
kindergarten through 12th grade. Only one state, Illinois,
currently requires daily physical education as part
of the curriculum in kindergarten through 12th grade.
Although a quantity is not synonymous
with quality (see Objective 1.9), the proportion of
students receiving daily physical education in school
is one measure of the frequency of participation in
physical activity and the frequency of exposure to information
about how and why to partake in activity. Because time
spent engaged in regular, vigorous, and prolonged physical
activity outside of school physical education falls
off sharply during the fall and winter months, daily
school physical education programs can play an important
role in helping children and youth maintain a high level
of physical activity year-round.
In 1974-75, it was estimated that
roughly one-third of students in 5th through 12th grade
received physical education daily. As of 1984, the situation
had changed little, with only 36 percent of students
in 5th through 12th grade receiving physical education
daily. 40 In 1986, only 36 percent of students in 1st
through 4th grade received daily physical education.
41
Most children in the lower grades
are enrolled in school physical education but many receive
it fewer than 5 days per week. In the upper grades,
fewer children are enrolled but those who are more often
participate in daily physical education classes. Therefore,
to achieve this objective, physical education needs
to be more frequent for children in the lower grades,
whereas enrollment needs to be increased for children
in the upper grades.
To achieve this objective equitably
for all of America's children, daily adaptive physical
education programs should be available for children
with special needs. School physical education requirements
are also recommended for students in preschool and post
secondary programs.
1.9 Increase to
at least 50 percent the proportion of school physical
education class time that students spend being physically
active, preferably engaged in lifetime physical activities.
(Baseline: Students spent an estimated 27 percent of
class time being physically active in 1983)
Note: Lifetime activities are activities
that may be readily carried into adulthood because they
generally need only one or two people. Examples include
swimming, bicycling, jogging, and racquet sports. Also
counted as lifetime activities are vigorous social activities
such as dancing. Competitive group sports and activities
typically placed only to young children such as group
games are excluded.
Baseline data source: Siedentop
1983.
Results from the National Children
and Youth Fitness Studies I and II revealed that although
enrollment in physical education positively affects
fitness, the nature of the program is of even greater
importance. 40,41 The intent of this objective is to
encourage the implementation of high quality physical
education programs that will enhance the fitness of
children and youth and encourage life-long physical
activity.
Although school physical education
can help to assure a minimum amount of physical activity
for children and youth, studies indicate that only 27
percent of class time is spent in actual physical activity;
26 percent of time is spent in instruction, 22 percent
is spent in administrative tasks, and 25 percent is
spent waiting. 38 The target of 50 percent is attainable
if waiting time is trimmed to less than 5 percent of
class time.
Many physical educators stress the
importance of dedicating a major portion of the physical
education curriculum to lifetime physical activities,
especially as the student approaches adulthood. Despite
the acknowledged importance of lifetime physical activities
outside the physical education class (60 percent) than
within it. 40 The portion of the physical education
curriculum devoted to lifetime fitness in 5th through
12th grade is only 48 percent, 45 percent for boys and
50 percent for girls. The average student is exposed
to 5.6 different lifetime activities over a year's time.
To a large extent, relays and informal games for younger
students and competitive sports for older students are
still the mainstay of the physical education program.
More class time should be spent engaged in lifetime
activities and more emphasis given to developing the
knowledge, attitudes, cognitive skills, and physical
skills students need to remain physically active throughout
life.
1.10 Increase
the proportion of worksites offering employer-sponsored
physical activity and fitness programs as follows:
Worksite Size |
1985 Baseline |
2000 Target |
50-99 employees |
14% |
20% |
100-249 employees |
23% |
35% |
250-749 employees |
32% |
50% |
750 employees |
54% |
80% |
Baseline data source:
National Survey of Worksite Health Promotion Activities,
ODPHP.
Worksite physical activity and fitness
programs provide a mechanism for reaching large numbers
of adults. Examples of such programs include onsite
exercise facilities and exercise classes, reimbursable
membership fees in health clubs and Ys, informal walking
clubs, formal fitness challenges and campaigns, and
flexible health benefits that include exercise-related
activities. Employer-sponsored programs can be offered
on site or in conjunction with community organizations.
Smaller worksites may prefer to align themselves with
a community recreation facility in order to meet this
objective.
Although varied, worksite fitness
programs can increase the physical activity and fitness
of program participants and improve employee health.
17 Evidence that worksite programs are cost-effective
is also growing. Such programs may even reduce employer
costs for insurance premiums, disability benefits, and
medical expenses. 37 Additional benefits for employers
include increased productivity, reduced absenteeism,
reduced employee turnover, improved morale, enhanced
company image, and enhanced recruitment. Benefits to
employers and the community can be further increased
by including family members and retirees in worksite
programs.
High levels of participation can be
achieved by offering a variety of physical activities,
maximizing convenience, permitting employees to exercise
on company time, or giving employees flexible time for
use of the facilities. A promotion and education campaign
can aid in recruitment. Incentives and awards for regular
participation or achievement can help motivate people
to continue. Employee involvement in planning and managing
the program may also be important to program success.
Special effort should be made to target sedentary and
high-risk employees. Optimally, efforts to promote physical
activity and fitness at the worksite should be part
of a comprehensive health promotion program (see Objective
10.12 in Occupational Safety and Health and Objectives
8.6 and 8.7 in Educational and Community-Based Programs)
.
In 1985, a national survey of worksites
found that activities to promote physical activity and
fitness were present at 22 percent of worksites with
50 or more employees. 26 Of these, the majority offered
information (65 percent) or group classes or workshops
(59 percent). Far fewer offered equipment or facilities
(22 percent), special events or competition (26 percent),
or subsidized memberships (27 percent). Of worksites
offering exercise equipment or facilities, 89 percent
set aside an area specifically for fitness activities,
76 percent had a locker room with showers, 74 percent
had stationary bicycles or other aerobic exercise equipment,
62 percent had weight training equipment, 53 percent
reported other major exercise facilities or equipment
(e.g., swimming pools, running tracks, or racquetball,
tennis, or squash courts), and 22 percent had a fitness
course.
As purchasers of group health and
life insurance plans, employers can also design employee
benefit packages that include coverage for fitness club
membership fees and community-based fitness classes
or reduced insurance premiums and rebates for employees
who participate regularly in worksite fitness programs
or who can document regular physical activity.
1.11 Increase
community availability and accessibility of physical
activity and fitness facilities as follows:
Facility |
1986 Baseline |
2000 Target |
Hiking, biking,
and fitness trail miles |
1 per 71,000 people |
1 per 10,000 people |
Public swimming
pools |
1 per 53,000 people |
1 per 25,000 people |
Acres of park and
recreation open space |
1.8 per 1,000 people
(553 people per managed care) |
4 per 1,000 people
(250 people per managed care) |
Baseline data source:
McDonald and Cordell 1988.
Participation in regular physical
activity depends in part on the availability and proximity
of community facilities and conducive environments.
As facility distance from residence increases, use generally
decreases. People are unlikely to use community resources
located more than a few miles away by car or more than
a few minutes away by bike or on foot. In a recent national
survey, 51 percent of adults agreed that greater availability
of exercise facilities would help them become more involved
in regular exercise. 15
The National Recreation and Park Association
(NRPA) has established recreation, park, and open space
standards and guidelines that recommend, at a minimum,
6.25 to 10.5 acres of developed open space per 1,000
people (or 1 managed acre for every 95 to 160 people).
19 A 1986 survey of municipal and county park and recreation
departments found that the average number of citizens
per managed acre was 553, well over the standard of
95 to 160. 25 The average for small, medium, and large
communities were 345, 1,147, and 312 citizens per acre,
respectively. (Small communities were defined as fewer
than 25,000 people, medium as 25,000 to 100,000 people,
and large as more than 100,000 people.)
Trails in particular are unavailable
in most communities. Only 46 percent of municipal and
county park and recreation departments provide fitness
trails, 29 percent provide hiking trails, 21 percent
provide bicycle trails, and 15 percent provide snow
trails. For departments with trails, the average number
of miles for all trail types combined is 23, but the
median is only 6 miles. Where trails are provided, the
average number of citizens per trail mile ranges from
17,107 for hiking trails to 19,129 for biking trails
to 28,941 for fitness trails. Including areas without
trails yields national estimates of roughly 1 hiking
trail mile per 59,000 citizens, 1 biking trail mile
per 91,000 citizens, and 1 fitness trail mile per 63,000
citizens.
Additional miles of convenient and
accessible trails for biking, jogging, hiking, and cross-country
skiing are very much needed.
The NRPA standard recommends 1 community
swimming pool per 20,000 people within a service radius
of 15 to 30 minutes travel time. Only 56 percent of
municipal and county park and recreation departments
provide one or more community swimming pools. The median
number of pools per department is one. For small, medium,
and large communities, the medians are 1, 2, and 4 pools,
respectively. For departments providing pools, the nunmber
of citizens per pool averages 29,850. Including areas
served by departments that do not provide pools yields
a national estimate of roughly 1 public pool per 53,000
people.
Other facilities conducive to physical
activity are also in inadequate supply. For example,
the median number of tennis courts per park and recreation
department is only 8. For small, medium, and large communities,
the medians are 5, 12, and 32 courts, respectively.
For departments providing tennis courts, the number
of citizens per court averages 6,817. Nationally, the
number of citizens per court is estimated to be about
8,000. In contrast, the recommended standard for tennis
courts is 1 court per 2,000 people within a service
radius of 0.25 to 0.5 miles. Similarly, four is the
median number of basketball courts per park and recreation
department. For small, medium, and large communities,
the medians are 2, 5, and 14, respectively. For departments
providing basketball courts, the number of citizens
per court averages 12,551. Nationally, the estimate
is about 15,500. The recommended standard for basketball
courts, however, is 1 court per 5,000 people within
a service radius of 0.25 to 0.5 miles. Numerous other
facilities including sport playing fields, community
recreation centers, and community golf courses also
fall short of recommended standards.
1.12 Increase
to at least 50 percent the proportion of primary care
providers who routinely assess and counsel their patients
regarding the frequency, duration, type, and intensity
of each patient's physical activity practices. (Baseline:
Physicians provided exercise counseling for about 30
percent of sedentary patients in 1988)
Baseline data sources: American
College of Physicians (in press); Lewis 1988.
Physicians and other health care providers
are viewed as respected sources of information about
preventive as well as curative medicine. An estimated
80 percent of the population sees a physician at least
once during a given year, and 54 percent of all encounters
are with primary care physicians (e.g., general practitioners,
family physicians, internists, pediatricians, obstetrician/gynecologists).
43 Other primary care providers with whom patients have
frequent contact include physician assistants, nurse
practitioners, and nurses.
Most patients seen by primary care
providers could benefit from encouragement and advice
on physical activity, and 85 percent of adults say that
a doctor's recommendation would help them get more involved
in regular exercise. 15 However, physical activity assessment
and counseling is not yet routine practice for most
primary care providers. In 1983, less than half of primary
care physicians were found to "routinely"
inquire about their patients' exercise habits. 44 A
more recent national survey of internists found that
although 66 percent routinely obtained and recorded
the patterns of exercise for patients new to their practice,
exercise counseling was provided to fewer than one-third
of all sedentary patients. 1 Furthermore, when exercise
was discussed with patients, less than three minutes
typically was spent on the subject. A meta-analysis
of 7 physician surveys (including 2 national surveys
of family practitioners), 1 chart audit study, and 2
consumer surveys also estimated that physicians provide
exercise counseling for roughly 30 percent of sedentary
patients. 22
Though few studies have evaluated
the effectiveness of physical activity counseling by
primary care physicians or other providers, 36 percent
of the patients at one intervention site where physicians
were trained to counsel had begun a program of regular
physical activity compared to 28 percent at a control
site. 24 Additional support for the effectiveness of
physical activity counseling in clinical settings comes
from cardiac rehabilitation programs where exercise
compliance rates of 50 percent at 6 months are typically
observed. 12 Because of the potential benefit, the U.S.
Preventive Services Task Force recommended that clinicians
counsel all patients to engage in a program of regular
physical activity tailored to their health status and
personal lifestyle. 42 Clinicians who are unable to
design an effective program should refer patients to
a preventive medicine specialist, a certified exercise
specialist, or an accredited fitness center.
Surveys suggest that many physicians
are uncomfortable about their ability to properly counsel
and advise patients about physical activity. A standardized
set of questions, prescriptions, and counseling protocols
would facilitate attainment of this objective as would
training in physical activity assessment and counseling
through professional preparation curricula and continuing
education programs. Efforts to involve primary care
providers personally in physical activity may also be
effective in increasing counseling by providers. Several
studies have shown that the activity levels of physicians
are associated with their physical activity counseling
practices. 23 Primary care providers may further extend
their influence by serving as visible role models and,
as community leaders, can encourage schools to provide
daily school physical education (see Objectives 1.8
and 1.9).
Personnel Needs
Priorities for ensuring an adequate
supply of personnel to achieve the physical activity
and fitness objectives over the next decade include
the following:
Establish the number and types of
health professionals, including allied/associated public
health fields, who are needed to accomplish the practice,
educational, and research aspects of the physical activity
and fitness objectives.
Provide sufficient, appropriate curricular
content in physical activity and fitness in all schools
and programs preparing students for careers in the health,
education, and recreation professions, including allied/associated
public health fields, and ensure that all graduates
of such schools and programs can demonstrate knowledge
of these subjects.
Increase the provision of continuing
education on physical activity and fitness by national
professional associations whose members have roles in
promoting physical activity and fitness.
Surveillance and Data Needs
Availability of Future Data
- Annual data from existing surveys
are available to tract Objective 1.1.
- Periodic surveys and/or supplements
to existing surveys can help to tract Objective 1.2,
1.3, 1.4, 1.5, 1.6, and 1.7.
- New surveillance systems are needed
to tract Objectives 1.8, 1.9, 1.10, 1.11, and 1.12.
High Priority Needs
- Expanded surveillance of physical
activity is needed to provide periodic information
on the activity patterns of children and youth, racial
and ethnic minorities, and people with disabilities.
- Information is needed about the
health-related physical fitness levels of able-bodied
and disabled populations aged 6 and older according
to age, gender, race, and ethnicity. Periodic assessment
of national fitness levels is important because fitness
levels reflect changes in physical activity patterns.
Although a single national estimate of the health-related
physical fitness levels of children aged 6 through
17 was provided by the National Children and Youth
Fitness Studies I and II, no national estimates of
the health-related fitness of U.S. adults are available.
- Information about the availability
and use of community physical activity programs, facilities,
and special events is also very much needed.
- State and local surveillance systems
are needed to provide state and local estimates for
all of the above.
Research Needs
Research is needed, especially for
population subgroups, to further define the relationships
between physical activity, physical fitness, and:
- The incidence of cardiovascular
disease;
- The incidence of colon cancer;
- The incidence of osteoporosis and
osteoporosis-related hip fractures;
- The incidence of and disability
from osteoarthritis; The incidence of low back pain,
injury, and disability; The incidence of injuries;
- The incidence of obesity and selected
types of body fat patterns;
- Nutritional patterns;
- The adoption of healthy behavior
patterns;
- The prevention and cessation of
cigarette smoking;
- The treatment of alcohol and drug
abuse;
- The incidence of depressive episodes
among depressed people;
- Improved mental well-being;
- The cognitive and functional ability
of older adults; and
- Quality of life.
Research on the determinants of regular
physical activity is also needed to identify the knowledge,
attitudes, and behavior and social skills associated
with a high probability of adopting and maintaining
a regular exercise program.
Related Objectives From Other Priority
Areas
Nutrition
2.20 Worksite nutrition/weight management
programs
Alcohol and Other Drugs
4.11 Anabolic steriod use
Mental Health and Mental Disorders
6.3 Mental disorders among children
and adolescents
6.4 Mental disorders among adults
6.5 Adverse health effects from stress
6.9 Taking steps to control stress
6.11 Worksite stress management programs
Educational and Community-Based
Programs
8.4 Quality school health education
8.6 Worksite health promotion activities
8.8 Health promotion programs for
older adults
8.10 Community health promotion programs
Unintentional Injuries
9.4 Fall-related deaths
9.7 Hip fractures among older adults
9.19 Protective equipment in sporting
and recreation events
Occupational Safety and Health
10.12 Worksite health and safety programs
10.13 Worksite back injury prevention
and rehabilitation programs
Heart Disease and Stroke
15.2 Stroke
15.4 Controlled high blood pressure
15.6 Mean serum cholesterol level
15.7 High blood cholesterol prevalence
15.8 Taking action to reduce blood
cholesterol
15.16 Worksite blood pressure/cholesterol
education
Cancer
16.5 Colorectal cancer
Diabetes and Chronic Disabling
Conditions
17.1 Years of healthy life
17.2 Disability due to chronic conditions
17.3 Preserving function in older
adults
17.5 Activity limitation due to chronic
back conditions
17.9 Diabetes-related deaths
Baseline Data Source References
American College of Physicians, Results
of the American College of Physicians Membership Survey
of Prevention Practices in Adult Medicine, to be published
in Annals of Internal Medicine .
Behavioral Risk Factor Surveillance
System, Centers for Disease Control, Public Health Service,
U.S. Department of Health and Human Services, Atlanta,
GA.
Hispanic Health and Nutrition Examination
Survey, National Center for Health Statistics, Centers
for Disease Control, Public Health Service, U.S. Department
of Health and Human Services, Hyattsville, MD.
Indian Health Service, Public Health
Service, U.S. Department of Health and Human Services,
Rockville, MD.
Lewis, C.E. Disease prevention and
health promotion practices of primary care physicians
in the United States. American Journal of Preventive
Medicine 4(4) Suppl:9-16, 1988.
McDonald, B.L. and Cordell, H.K.
Local Opportunities for Americans: Final Report of the
Municipal and County Park and Recreation Study, Alexandria,
VA: National Recreation and Park Association, 1988.
National Health Interview Survey,
National Center for Health Statistics, Centers for Disease
Control, Public Health Service, U.S. Department of Health
and Human Services, Hyattsville, MD.
National Health and Nutrition Examination
Survey (NHANES) II, National Center for Health Statistics,
Centers for Disease Control, Public Health Service,
U.S. Department of Health and Human Services, Hyattsville,
MD.
National Survey of Worksite Health
Promotion Activities, Office of Disease Prevention and
Health Promotion, Public Health Service, U.S. Department
of Health and Human Services, Washington, D.C.
National Vital Statistics System,
National Center for Health Statistics, Centers for Disease
Control, Public Health Service, U.S. Department of Health
and Human Services, Hyattsville, MD.
Siedentop, D. Developing Teaching
Skills in Physical Education . 2nd edition. Palo
Alto, CA: Mayfield, 1983. p.61.
U.S. Department of Health and Human
Services. National children and youth fitness study.
Journal of Physical Education, Recreation, and Dance
56:44-90, 1985.
U.S. Department of Health and Human
Services. National children and youth fitness study
II. Journal of Physical Education, Recreation, and
Dance 58:50-96, 1987.
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