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Integrating the 2008 Physical Activity Guidelines for American s 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

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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


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Objectives

  • Why evidence-base?

  • Discuss evidence from 2008 Guidelines

  • Identify evidence from the Community Guide

  • Identify potential strategies to include in adventure programs


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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


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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


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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


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Common components

  • Specific target population

  • Specific, measurable goals

  • Proven benefits

  • Defined program (structure, timeframe, reasoning)

  • Support (staffing skills, facility, equipment)


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Summary

  • Evidence-based concepts includes: planning, implementing and evaluating

  • Many advantages and disadvantages

  • Multiple evidence-based components to consider


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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


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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


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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


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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



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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


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2008 Physical Activity Guidelines for Americans (PA)

  • 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


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2005 Dietary Guidelines (PA)

2008 Physical Activity Guidelines

www.health.gov/DietaryGuidelines

www.health.gov/paguidelines


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3 Phases & Products (PA)

  • Evidence review (managed by CDC)

    • Database

  • Advisory committee report (expert panel)

    • Federal Advisory Report

  • Writing process (appointed panel)

    • 2008 Physical Activity Guidelines for Americans


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CDC triaged 14,472 abstracts (PA)

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


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Phase I (PA)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)


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Initial research questions (PA)

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]?





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Phase II (PA)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


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Phase II (PA)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


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Phase II (PA)Advisory Committee

Reviewed existing scientific literature to identify sufficient evidence to develop a comprehensive set of specific physical activity recommendations


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Phase III (PA) Writing Committee


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Phase III (PA) Writing Process

  • Strong reliance upon Advisory Committee Report

  • Final product - 8 chapters

  • Fact sheet, toolkits, PowerPoint presentation


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Children and Adolescents (PA)(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


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Examples of moderate-intensity aerobic activities (PA)

  • 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


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Examples of vigorous-intensity (PA)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


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Children and Adolescents (PA)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


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Examples of muscle strengthening activities (PA)

  • 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


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Examples of bone strengthening activities (PA)

  • Children

    • Games (hopscotch)

    • Jumping rope

    • Gymnastics, basketball, volleyball

  • Adolescents

    • Running

    • Hopping, skipping, jumping

    • Jumping rope

    • Gymnastics, basketball, volleyball


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Principle = (PA)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


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Muscle strengthening (PA)

3 days per week

Bone strengthening

3 days per week

Muscle & bone strengthening principles

As part of the daily 60 minutes to include:


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Key Guidelines (PA)– 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


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Key Guidelines (PA)– 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)


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Key Guidelines (PA)– 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 l.jpg

Principle = (PA)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


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Flexibility in meeting minimal aerobic 2008 Guideline (PA)

Intensity Duration Frequency

Moderate

or ≥ 150 minutes Week

Vigorous

or ≥ 75 minutes Week

Equivalent

Combination ≥ 150 minutes Week


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Summary (PA)

  • 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


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Summary (PA)

  • 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


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Resources (PA)

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


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QUIZ (PA)

  • 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


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QUIZ (PA)

  • 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


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QUIZ (PA)

  • 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


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Overview of the Task Force on Community Preventive Services (TFCP) Recommendations

AKA: Community Guide


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The (TFCP) RecommendationsCommunity 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


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The (TFCP) RecommendationsCommunity 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


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Physical Activity (TFCP) RecommendationsConceptual Framework

Behavioral

Outcomes

Modifiable

Determinants

Intermediate

Physiological

Outcomes

Health

Outcomes

Interventions


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6,238 screened (TFCP) Recommendations

849

retrieved

253 candidates

94 evaluated

Search strategy


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What are some strengths of the (TFCP) RecommendationsCommunity Guide?

  • Systematic review

  • Credible

  • Evidence of effectiveness

  • Sometimes cost effectiveness

  • A good starting point….


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What are some limitations of the (TFCP) RecommendationsCommunity 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


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5 Recommended strategies (TFCP) Recommendations

  • Recommended, strong evidence:

  • Community wide campaigns

  • Individually-adapted health behavior change programs

  • School-based physical education

  • Social support interventions in community contexts

  • Creation of/enhanced access to places for PA combined with informational outreach


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What is the (TFCP) RecommendationsGuide 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


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Promoting PA: Environmental and Policy Approaches (TFCP) Recommendations

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)


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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


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Results from the Systematic Reviews informational outreach

  • 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)


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Results continued informational outreach

  • 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


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Resources informational outreach

  • 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.


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QUIZ informational outreach

  • 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


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QUIZ informational outreach

  • 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


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Implications informational outreach

  • 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


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Wrap up informational outreach

  • 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?


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For more information informational outreach

Websites:

www.thecommunityguide.org

http://www.health.gov/paguidelines/

www.cdc.gov/nccdphp/dnpa/physical


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For more information informational outreach

  • Websites

    www.thecommunityguide.org

    http://www.health.gov/paguidelines/

    www.cdc.gov/nccdphp/dnpa/physical


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