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22

Physical Activity and Fitness

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Co-Lead Agencies:

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Centers for Disease Control and Prevention
President’s Council on Physical Fitness and Sports

[Note: The Healthy People 2010 Information Access Project has provided direct PubMed search links for available references in this chapter to make information and evidence-based strategies related to the chapter easier to find.]

Contents

GoalPage 22-3

Overview. Page 22-3

spacerIssues and Trends. Page 22-3

spacerDisparities. Page 22-4

spacerOpportunities. Page 22-6

Interim Progress Toward Year 2000 Objectives. Page 22-6

Healthy People 2010—Summary of Objectives. Page 22-7

Healthy People 2010 Objectives. Page 22-8

spacerPhysical Activity in Adults. Page 22-8

spacerMuscular Strength/Endurance and Flexibility. Page 22-13

spacerPhysical Activity in Children and Adolescents. Page 22-17

spacerAccess. Page 22-25

Related Objectives From Other Focus Areas. Page 22-33

Terminology. Page 22-35

References. Page 22-36

 



Goal

Improve health, fitness, and quality of life through daily physical activity.

Overview

The 1990s brought a historic new perspective to exercise, fitness, and physical activity by shifting the focus from intensive vigorous exercise to a broader range of health-enhancing physical activities. Research has demonstrated that virtually all individuals will benefit from regular physical activity.[1] A Surgeon General’s report on physical activity and health concluded that moderate physical activity can reduce substantially the risk of developing or dying from heart disease, diabetes, colon cancer, and high blood pressure.1 Physical activity also may protect against lower back pain and some forms of cancer (for example, breast cancer), but the evidence is not yet conclusive.[2], [3]

Issues and Trends

On average, physically active people outlive those who are inactive.[4], [5], [6], [7], [8] Regular physical activity also helps to maintain the functional independence of older adults and enhances the quality of life for people of all ages.[9], [10], [11]

The role of physical activity in preventing coronary heart disease (CHD) is of particular importance, given that CHD is the leading cause of death and disability in the United States. Physically inactive people are almost twice as likely to develop CHD as persons who engage in regular physical activity. The risk posed by physical inactivity is almost as high as several well-known CHD risk factors, such as cigarette smoking, high blood pressure, and high blood cholesterol. Physical inactivity, though, is more prevalent than any one of these other risk factors. People with other risk factors for CHD, such as obesity and high blood pressure, may particularly benefit from physical activity.

Regular physical activity is especially important for people who have joint or bone problems and has been shown to improve muscle function, cardiovascular function, and physical performance.[12] However, people with arthritis (20 percent of the adult population) are less active than those without arthritis.[13] People with osteoporosis, a chronic condition affecting more than 25 million people in the United States, may respond positively to regular physical activity, particularly weight-bearing activities, such as walking,[14] and especially when combined with appropriate drug therapy and calcium intake. Increased bone mineral density has been positively associated with aerobic fitness, body composition, and muscular strength.[15]

Although vigorous physical activity is recommended for improved cardiorespiratory fitness, increasing evidence suggests that moderate physical activity also can have significant health benefits, including a decreased risk of CHD. For people who are inactive, even small increases in physical activity are associated with measurable health benefits. In addition, moderate physical activity is more readily adopted and maintained than vigorous physical activity.[16] As research continues to illustrate the links between physical activity and selected health outcomes, people will be able to choose physical activity patterns optimally suited to individual preferences, health risks, and physiologic benefits.

For individuals who do not engage in any physical activity during their leisure time, taking the first step toward developing a pattern of regular physical activity is important. Unfortunately, few individuals engage in regular physical activity despite its documented benefits. Only about 23 percent of adults in the United States report regular, vigorous physical activity that involves large muscle groups in dynamic movement for 20 minutes or longer 3 or more days per week. Only 15 percent of adults report physical activity for 5 or more days per week for 30 minutes or longer, and another 40 percent do not participate in any regular physical activity.

Public education efforts need to address the specific barriers that inhibit the adoption and maintenance of physical activity by different population groups. Older adults, for example, need information about safe walking routes. Persons with foot problems need to learn about proper foot care and footwear in order to reach appropriate activity levels. People with CHD and other chronic conditions must understand the importance of regular physical activity to maintain physical function. Each person should recognize that starting out slowly with an activity that is enjoyable and gradually increasing the frequency and duration of the activity are central to the adoption and maintenance of physical activity behavior. Along with the public education efforts, public programs in a variety of settings (recreation centers, worksites, health care settings, and schools) need to be developed, evaluated, and shared as potential models. The availability of group activities in the community is important for many.

Disparities

Disparities in levels of physical activity exist among population groups. The proportion of the population reporting no leisure-time physical activity is higher among women than men, higher among African Americans and Hispanics than whites, higher among older adults than younger adults, and higher among the less affluent than the more affluent. Participation in all types of physical activity declines strikingly as age or grade in school increases. In general, persons with lower levels of education and income are least active in their leisure time. Adults in North Central and Western States tend to be more active than those in the Northeastern and Southern States. People with disabilities and certain health conditions are less likely to engage in moderate or vigorous physical activity than are people without disabilities. Health promotion efforts need to identify barriers to physical activity faced by particular population groups and develop interventions that address these barriers.1


Physical Activity graph

Data demonstrate that major decreases in vigorous physical activity occur during grades 9 through 12. This decrease is more profound for girls than for boys, whether the measure is engaging in vigorous physical activity in general or in team sports. The President’s Council on Physical Fitness and Sports concluded that because of the physical health and emotional benefits of physical activity, it should have an increasingly important role in the lives of girls.[17] Adolescents’ interest and participation in physical activity differ by gender.17 Therefore, strategies to increase the amount of physical activity for boys and girls must address these differences and must begin before the disparities in levels of physical activity manifest themselves. Compared to boys, girls are less likely to participate in team sports but more likely to participate in aerobics or dance. Often girls and boys perceive different benefits from physical activity, with boys viewing such activity as competition and girls as weight management. These factors must be considered in developing programs to address the needs of girls. Because boys are more likely than girls to have higher self-esteem and greater physical strength, programs addressing the needs of girls should provide instruction and experiences that increase their confidence and their opportunities to participate in activities, as well as social environments that support involvement in a range of physical activities.17

Opportunities

The Healthy People 2010 objectives offer opportunities to ensure that physical activity and fitness become part of regular healthy behavioral patterns. Encouraging any type or amount of physical activity in leisure time can provide important health benefits, compared to a sedentary lifestyle.

Activities that promote strength and flexibility are important because they may protect against disability, enhance functional independence, and encourage regular physical activity participation. These benefits are particularly important for older people—a good quality of life means being functionally independent and being able to perform the activities of daily living.

Young people are at particular risk for becoming sedentary as they grow older. Therefore, encouraging moderate and vigorous physical activity among youth is important. Because children spend most of their time in school, the type and amount of physical activity encouraged in schools are important components of a fitness program and a healthy lifestyle.

The major barriers most people face when trying to increase physical activity are time, access to convenient facilities, and safe environments in which to be active. Counseling by primary care providers about the need to participate in physical activity also is an important way to change behavior. In addition, facilities need to be accessible to people with disabilities.

Interim Progress Toward Year 2000 Objectives

Of the 13 physical activity and fitness objectives, 1 has been met—increasing worksite fitness programs. Four objectives show solid gains, indicating that the message about increased physical activity is reaching some segments of the population. The message that a sedentary lifestyle plays a role in both overweight and weight loss needs to be addressed better, as does the role primary care providers can play in counseling individuals to increase their daily activities. Both the quantity and quality of school physical education have slipped. Data to evaluate access and availability of community fitness facilities are not available.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Healthy People 2010—Summary of Objectives

Physical Activity and Fitness

Goal: Improve health, fitness, and quality of life through daily physical activity.

Number

Objective Short Title

Physical Activity in Adults

22-1

No leisure-time physical activity

22-2

Moderate physical activity

22-3

Vigorous physical activity

Muscular Strength/Endurance and Flexibility

22-4

Muscular strength and endurance

22-5

Flexibility

Physical Activity in Children and Adolescents

22-6

Moderate physical activity in adolescents

22-7

Vigorous physical activity in adolescents

22-8

Physical education requirement in schools

22-9

Daily physical education in schools

22-10

Physical activity in physical education class

22-11

Television viewing

Access

22-12

School physical activity facilities

22-13

Worksite physical activity and fitness

22-14

Community walking

22-15

Community bicycling

 


Healthy People 2010 Objectives

Physical Activity in Adults

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22-1.

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Reduce the proportion of adults who engage in no leisure-time physical activity.

Target: 20 percent.

Baseline: 40 percent of adults aged 18 years and older engaged in no leisure-time physical activity in 1997 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

Adults Aged 18 Years and Older, 1997

No Leisure-Time Physical Activity

Percent

TOTAL

40

Race and ethnicity

American Indian or Alaska Native

46

Asian or Pacific Islander

42

Asian

42

Native Hawaiian and other
Pacific Islander

41

Black or African American

52

White

38

 

Hispanic or Latino

54

Not Hispanic or Latino

38

Black or African American

52

White

36

Gender

Female

43

Male

36

Education level (aged 25 years and older)

Less than 9th grade

73

Grades 9 through 11

59

High school graduate

46

Some college or AA degree

35

College graduate or above

24

Geographic location

Urban

39

Rural

43

Disability status

Persons with disabilities

56

Persons without disabilities

36

Select populations

Age groups

18 to 24 years

31

25 to 44 years

34

45 to 64 years

42

65 to 74 years

51

75 years and older

65

Persons with arthritis symptoms

43

Persons without arthritis symptoms

38

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

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22-2.

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Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day.

Target: 30 percent.

Baseline: 15 percent of adults aged 18 years and older engaged in moderate physical activity for at least 30 minutes 5 or more days per week in 1997 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.


Adults Aged 18 Years and Older, 1997

22-2.
30 Minutes of
Activity 5 or More
Days per Week

20 Minutes of
Activity 3 or More
Days per Week*

Percent

TOTAL

15

31

Race and ethnicity

American Indian or Alaska Native

13

25

Asian or Pacific Islander

15

30

Asian

15

30

Native Hawaiian and other Pacific
Islander

11

31

Black or African American

10

23

White

15

32

 

Hispanic or Latino

11

23

Not Hispanic or Latino

15

32

Black or African American

10

22

White

16

33

Gender

Female

13

30

Male

16

31

Education level (aged 25 years and older)

Less than 9th grade

7

13

Grades 9 through 11

11

21

High school graduate

14

28

Some college or AA degree

17

34

College graduate or above

17

38

Geographic location

Urban

15

31

Rural

15

30

Disability status

Persons with disabilities

12

23

Persons without disabilities

16

33

Select populations

Age groups

18 to 24 years

17

36

25 to 44 years

15

31

45 to 64 years

14

30

65 to 74 years

16

31

75 years and older

12

23

Persons with arthritis symptoms

15

29

Persons without arthritis symptoms

15

32

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*Data for 20 minutes of activity 3 or more days per week are displayed to further characterize the issue.

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22-3

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Increase the proportion of adults 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.

Target: 30 percent.

Baseline: 23 percent of adults aged 18 years and older engaged in vigorous physical activity 3 or more days per week for 20 or more minutes per occasion in 1997 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

Adults Aged 18 Years and Older, 1997

Vigorous Physical Activity

Percent

TOTAL

23

Race and ethnicity

American Indian or Alaska Native

19

Asian or Pacific Islander

17

Asian

16

Native Hawaiian and other Pacific Islander

24

Black or African American

17

White

24

 

Hispanic or Latino

16

Not Hispanic or Latino

24

Black or African American

17

White

25

Gender

Female

20

Male

26

Education level (aged 25 years and older)

Less than 9th grade

6

Grades 9 through 11

12

High school graduate

18

Some college or AA degree

24

College graduate and above

32

Geographic location

Urban

24

Rural

21

Disability status

Persons with disabilities

13

Persons without disabilities

25

Select populations

Age groups

18 to 24 years

32

25 to 44 years

27

45 to 64 years

21

65 to 74 years

13

75 years and older

6

Persons with arthritis symptoms

21

Persons without arthritis symptoms

24

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

The adoption and maintenance of regular physical activity represent an important component of any health regime and provide multiple opportunities to improve and maintain health. Because the highest risk of death and disability is found among those who do no regular physical activity, engaging in any amount of physical activity is preferable to none. Physical activity should be encouraged as part of a daily routine. While moderate physical activity for at least 30 minutes a day 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 daily schedules. For even greater health benefits, vigorous physical activity is necessary. For most persons, the greatest opportunity for physical activity is associated with leisure time, because few occupations today provide sufficient vigorous or moderate physical activity to produce health benefits.

Engaging in moderate physical activity for at least 30 minutes per day will help ensure that sufficient calories are used to provide health benefits. A minimum level of intensity (for example, a brisk walk for 30 minutes per day) would, for most persons, result in an energy expenditure of about 600 to 1,100 calories per week.[18] If calorie intake remains constant, this expenditure translates into a weight loss of roughly one-sixth to one-third pound per week. Increases in daily activity to ensure a weekly expenditure of 1,000 calories would have significant individual and public health benefit for CHD prevention and deaths from all causes, especially for persons who are sedentary. Furthermore, this level of activity is feasible for most people even though the relative intensity of any activity will vary by age. Starting out slowly and gradually increasing the frequency and duration of physical activity is the key to successful behavior change. 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.”

Muscular Strength/Endurance and Flexibility

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22-4.

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Increase the proportion of adults who perform physical activities that enhance and maintain muscular strength and endurance.

Target: 30 percent.

Baseline: 18 percent of adults aged 18 years and older performed physical activities that enhance and maintain strength and endurance 2 or more days per week in 1998 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.


Adults Aged 18 Years and Older, 1998 (unless noted)

Strengthening and Endurance
Exercises

Percent

TOTAL

18

Race and ethnicity

American Indian or Alaska Native

18

Asian or Pacific Islander

17

Asian

17

Native Hawaiian and other Pacific Islander

19

Black or African American

16

White

18

 

Hispanic or Latino

13

Not Hispanic or Latino

18

Black or African American

15

White

19

Gender

Female

14

Male

21

Education level (aged 25 years and older)

Less than 9th grade

4

Grades 9 through 11

8

High school graduate

11

Some college or AA degree

19

College graduate and above

26

Geographic location

Urban

19

Rural

15

Disability status

Persons with disabilities

14 (1997)

Persons without disabilities

20 (1997)

Select populations

Age Groups

18 to 24 years (not age adjusted)

28

25 to 44 years (not age adjusted)

21

45 to 64 years (not age adjusted)

14

65 to 74 years (not age adjusted)

10

75 years and older (not age adjusted)

7

Persons with arthritis symptoms

18

Persons without arthritis symptoms

18

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

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22-5.

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Increase the proportion of adults who perform physical activities that enhance and maintain flexibility.

Target: 43 percent.

Baseline: 30 percent of adults aged 18 years and older did stretching exercises in the past 2 weeks in 1998 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

Adults Aged 18 Years and Older, 1998 (unless noted)

Stretching
Exercises

Percent

TOTAL

30

Race and ethnicity

American Indian or Alaska Native

26

Asian or Pacific Islander

34

Asian

34

Native Hawaiian and other Pacific Islander

42

Black or African American

26

White

30

 

Hispanic or Latino

22

Not Hispanic or Latino

31

Black or African American

27

White

31

Gender

Female

30

Male

30

Family income level

Below poverty

21

Near poverty

24

Middle/high income

34

Education level (aged 25 years and older)

Less than high school

16

High school graduate

23

At least some college

36

Geographic location

Urban

32

Rural

25

Disability status

Persons with activity limitations

29 (1995)

Persons without activity limitations

31 (1995)

Select populations

Age groups

18 to 24 years

36

25 to 44 years

32

45 to 64 years

28

65 to 74 years

24

75 years and older

22

Persons with arthritis symptoms

DNA

Persons without arthritis symptoms

DNA

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

All adults could benefit from physical activities designed to ensure functional independence throughout life. The specific physical fitness components that provide continued physical function as persons age include muscular strength/endurance and flexibility. Examples of these activities include weight training, resistance activities (using elastic bands or dumbbells), and stretching exercises (such as static stretching, yoga, or T’ai Chi Chuan).

Effective treatment of many chronic diseases and disorders has resulted in more years of life, but many of these extra years are spent with disabling conditions that prevent independent living and reduce the quality of life. Strengthening activities, while important for all age groups, are particularly important for older adults. Muscle strength declines with age, and there is a demonstrated relationship between muscle strength and physical function.[19] Age-related loss of strength may be lessened by strengthening exercises, enabling an individual to maintain a threshold level of strength necessary to perform basic weight-bearing activities, such as walking.[20], [21] Strength training also has been shown to preserve bone density in postmenopausal women.9

Physical activities that improve muscular strength/endurance and flexibility also improve the ability to perform tasks of daily living and may improve balance, thus preventing falls.1 Activities of daily living have been identified as a scale to measure dependencies in basic self-care and other functions important for independent living and to avoid institutionalization. The performance of routine daily activities is particularly important to maintaining functional independence and social integration in older adults.11

Although flexibility may appear to be a minor component of physical fitness, the consequence of rigid joints affects all aspects of life, including walking, stooping, sitting, avoiding falls, and driving a vehicle. Lack of joint flexibility may adversely affect quality of life and will lead to eventual disability.[22] Activities such as static stretching or T’ai Chi Chuan routines, which consist of slow, graceful movements with low impact, have great promise for maintaining flexibility and can be appropriate for adults of any age.[23] Increasing public awareness of all these potential benefits of muscle strengthening and flexibility activities—and developing and making quality programs available and accessible—may encourage the pursuit of activities that promote muscular strength/endurance and flexibility.

Physical Activity in Children and Adolescents

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22-6

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Increase the proportion of adolescents who engage in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days.

Target: 35 percent.

Baseline: 27 percent of students in grades 9 through 12 engaged in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days in 1999.

Target setting method: Better than the best.

Data source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP.

Students in Grades 9
Through 12, 1999 (unless noted)

Moderate Physical Activity

22-6.
Both
Genders

Females*

Males*

Percent

TOTAL

27

24

29

Race and ethnicity

American Indian or Alaska
Native

DSU

DSU

DSU

Asian or Pacific Islander

DSU

DSU

DSU

Asian

DSU

DSU

DSU

Native Hawaiian and other Pacific Islander

DSU

DSU

DSU

Black or African American

17

17

24

White

27

27

31

 

Hispanic or Latino

21

17

26

Not Hispanic or Latino

27

25

30

Black or African American

21

18

24

White

29

26

32

Parents’ education level

Less than high school

25 (1997)

25 (1997)

24 (1997)

High school graduate

21 (1997)

20 (1997)

21 (1997)

At least some college

20 (1997)

19 (1997)

20 (1997)

Select populations

Grade levels

9th grade

28

26

31

10th grade

26

25

27

11th grade

25

21

29

12th grade

27

24

29

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*Data for females and males are displayed to further characterize the issue.

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22-7.

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Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion.

Target: 85 percent.

Baseline: 65 percent of students in grades 9 through 12 engaged in vigorous physical activity 3 or more days per week for 20 or more minutes per occasion in 1999.

Target setting method: Better than the best.

Data source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP.



Students in Grades 9
Through 12, 1999 (unless noted)

Vigorous Physical Activity

22-7.
Both
Genders

Females*

Males*

Percent

TOTAL

65

57

72

Race and ethnicity

American Indian or Alaska
Native

DSU

DSU

DSU

Asian or Pacific Islander

DSU

DSU

DSU

Asian

DSU

DSU

DSU

Native Hawaiian and other Pacific Islander

DSU

DSU

DSU

Black or African American

56

49

64

White

68

60

75

 

Hispanic or Latino

61

50

72

Not Hispanic or Latino

65

58

73

Black or African American

56

47

65

White

67

60

75

Parents’ education level

Less than high school

50 (1997)

43 (1997)

60 (1997)

High school graduate

54 (1997)

45 (1997)

62 (1997)

At least some college

68 (1997)

57 (1997)

75 (1997)

Select populations

Grade Levels

9th grade

73

68

77

10th grade

65

56

73

11th grade

58

49

67

12th grade

61

52

71

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*Data for females and males are displayed to further characterize the issue.

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22-8

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Increase the proportion of the Nation's public and private schools that require daily physical education for all students.

Target and baseline:

Objective

Increase in Schools Requiring Daily Physical Activity for All Students

1994
Baseline

2010
Target

 

 

Percent

22-8a.

Middle and junior high schools

17

25

22-8b.

Senior high schools

2

5

Target setting method: 47 percent improvement for middle and junior high schools; 150 percent improvement for senior high schools.

Data source: School Health Policies and Programs Study (SHPPS), CDC, NCCDPHP.

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22-9

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Increase the proportion of adolescents who participate in daily school physical education.

Target: 50 percent.

Baseline: 29 percent of students in grades 9 through 12 participated in daily school physical education in 1999.

Target setting method: Better than the best.

Data source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP.

Students in Grades 9
Through 12, 1999 (unless noted)

Daily School Physical Education

22-9.
Both
Genders

Females*

Males*

Percent

TOTAL

29

26

32

Race and ethnicity

American Indian or Alaska
Native

DSU

DSU

DSU

Asian or Pacific Islander

DSU

DSU

DSU

Asian

DSU

DSU

DSU

Native Hawaiian and other Pacific Islander

DSU

DSU

DSU

Black or African American

28

25

33

White

28

26

31

 

Hispanic or Latino

40

36

45

Not Hispanic or Latino

28

25

30

Black or African American

29

26

33

White

28

26

31

Parents’ education level

Less than high school

29 (1997)

28 (1997)

30 (1997)

High school graduate

24 (1997)

22 (1997)

27 (1997)

At least some college

28 (1997)

25 (1997)

30 (1997)

Select populations

Grade levels

9th grade

42

40

44

10th grade

30

28

33

11th grade

20

17

24

12th grade

20

17

24

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*Data for females and males are displayed to further characterize the issue.

spacerspacerspacer

22-10.

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Increase the proportion of adolescents who spend at least 50 percent of school physical education class time being physically active.

Target: 50 percent.

Baseline: 38 percent of students in grades 9 through 12 were physically active in physical education class more than 20 minutes 3 to 5 days per week in 1999.


Target setting method: Better than the best.

Data source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP.

Students in Grades 9
Through 12, 1999 (unless noted)

Physically Active in Physical
Education Classes

22-10.
Both
Genders

Females*

Males*

Percent

TOTAL

38

32

45

Race and ethnicity

American Indian or Alaska
Native

DSU

DSU

DSU

Asian or Pacific Islander

DSU

DSU

DSU

Asian

DSU

DSU

DSU

Native Hawaiian and other Pacific Islander

DSU

DSU

DSU

Black or African American

32

24

41

White

40

33

46

 

Hispanic or Latino

41

35

47

Not Hispanic or Latino

38

31

45

Black or African American

32

25

37

White

40

33

45

Parents’ education level

Less than high school

28 (1997)

25 (1997)

32 (1997)

High school graduate

29 (1997)

24 (1997)

35 (1997)

At least some college

33 (1997)

27 (1997)

37 (1997)

Select populations

Grade levels

9th grade

55

48

62

10th grade

41

35

47

11th grade

29

24

35

12th grade

24

16

32

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*Data for females and males are displayed to further characterize the issue.

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22-11.

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Increase the proportion of adolescents who view television 2 or fewer hours on a school day.

Target: 75 percent.

Baseline: 57 percent of students in grades 9 through 12 viewed television 2 or fewer hours per school day in 1999.

Target setting method: Better than the best.

Data source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP.

Students in Grades 9 through 12, 1999

Television 2 or Fewer Hours
per School Day

Percent

TOTAL

57

Race and ethnicity

American Indian or Alaska Native

DSU

Asian or Pacific Islander

DSU

Asian

DSU

Native Hawaiian and other Pacific Islander

DSU

Black or African American

28

White

66

 

Hispanic or Latino

48

Not Hispanic or Latino

DNA

Black or African American

26

White

66

Gender

Female

59

Male

56

Parents’ education level

Less than high school

DNC

High school graduate

DNC

At least some college

DNC

Select populations

Grade levels

9th grade

49

10th grade

54

11th grade

62

12th grade

67

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

The health benefits of moderate and vigorous physical activity are not limited to adults. Physical activity among children and adolescents is important because of the related health benefits (cardiorespiratory function, blood pressure control, and weight management) and because a physically active lifestyle adopted early in life may continue into adulthood. Even among children aged 3 to 4 years, those who were less active tended to remain less active after age 3 years than most of their peers.[24] These findings highlight the need for parents, educators, and health care providers to become positive role models and to be involved actively in the promotion of physical activity and fitness in children and adolescents.

Many children are less physically active than recommended, and physical activity declines during adolescence.[25], [26] One study found that one-quarter of U.S. children spend 4 hours or more watching television daily.[27] Schools are an efficient vehicle for providing physical activity and fitness instruction because they reach most children and adolescents. Participation in school physical education ensures a minimum amount of physical activity and provides a forum to teach physical activity strategies and activities that can be continued into adulthood. Findings 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 adolescents by increasing their participation in moderate to vigorous activities.[28], [29]

Studies have shown that spending 50 percent of physical education class time on physical activity is an ambitious but feasible target. Being active for at least half of physical education class time on at least half of the school days would provide a substantial portion of the physical activity time recommended for adolescents.[30] To achieve the benefits of school-based physical education equitably for all children, daily adaptive physical education programs should be available for children with special needs. School physical education requirements also are recommended for students in preschool and postsecondary programs.[31]

Physical education is the primary source of physical activity and fitness instruction. Health education and other courses, however, can highlight the importance of physical activity as a component of a healthy lifestyle. A well-designed health education curriculum can help students develop the knowledge, attitudes, behavioral skills, and confidence needed to adopt and maintain physically active lifestyles.31 To maximize classroom time, instruction on physical activity also can be integrated into the lesson plans of other school subjects, such as mathematics, biology, and language arts. Programs that have included classroom instruction in physical activity have been effective in enhancing students’ physical activity-related knowledge,[32] attitudes,[33] behavior,[34] and physical fitness.[35] (See Focus Area 7. Educational and Community-Based Programs.)

Access

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(Developmental) Increase the proportion of the Nation’s public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours (that is, before and after the school day, on weekends, and during summer and other vacations).

Potential data source: School Health Policies and Programs Study (SHPPS), CDC, NCCDPHP.

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Increase the proportion of worksites offering employer-sponsored physical activity and fitness programs.

Target: 75 percent.

Baseline: 46 percent of worksites with 50 or more employees offered physical activity and/or fitness programs at the worksite or through their health plans in 1998–1999.

Worksite Size

Worksite or Health Plan

Health Plan

Worksite

Percent

Total (50 or more employees)

46

22

36

50 to 99 employees

38

21

24

100 to 249 employees

42

20

31

250 to 749 employees

56

25

44

750 or more employees

68

27

61

Less than 50 employees

Developmental

Target setting method: Better than the best.

Data source: National Worksite Health Promotion Survey, Association for
Worksite Health Promotion (AWHP).

Participation in regular physical activity depends, in part, on the availability and proximity of community facilities and on environments conducive to physical activity. Studies of adult participation in physical activity have found that use generally decreases as facility distance from a person’s residence increases.[36] People are unlikely to use community resources located more than a few miles away by car or more than a few minutes away by biking or walking.

One of the major barriers to youth participation in sports is lack of enough sports facilities.[37] Increased access to community physical activity facilities would, therefore, help increase youth physical activity. The availability of school facilities for physical activity programs also may be beneficial for crime and violence prevention and other social programs,37 because most juvenile crime is committed between 3 and 8 p.m.

Schools need to work with community coalitions and community-based physical activity programs to take maximum advantage of school facilities for the benefit of children and adolescents and the community as a whole. The needs of all community members, including senior citizens and people with disabilities, need to be considered.

Worksite physical activity and fitness programs provide a mechanism for reaching large numbers of adults and have at least short-term effectiveness in increasing the physical activity and fitness of program participants.[38] Such programs should be provided in a culturally and linguistically competent manner. Evidence that worksite programs are cost-effective is growing. Such programs may even reduce employer costs for insurance premiums, disability benefits, and medical expenses.[39] Additional benefits for employers include increased productivity, reduced absenteeism, reduced employee turnover, improved morale, enhanced company image, and enhanced recruitment. Including family members and retirees in worksite programs can further increase benefits to employers and the community.39

As purchasers of group health and life insurance plans, employers can design employee benefit packages that include coverage for fitness club membership fees and community-based fitness classes. Employers also can offer reduced insurance premiums and rebates for employees who participate regularly in worksite fitness programs or who can document participation in regular physical activity.


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Increase the proportion of trips made by walking.

Target and baseline:

Objective

Increase in Trips
Made by Walking

Length of Trip

1995
Baseline*

2010
Target

                               Percent

22-14a.

Adults aged 18 years and older

Trips of 1 mile
or less

17

25

22-14b.

Children and adolescents
aged 5 to15 years

Trips to school of
1 mile or less

31

50

*Age adjusted to the year 2000 standard population.

Target setting method: 47 percent improvement for 22-14a and 68 percent improvement for 22-14b. (Better than the best will be used when data are available.)

Data source: Nationwide Personal Transportation Survey (NPTS), DOT.

Adults Aged 18 Years and Older, 1995

22-14a.
Trips of 1 Mile or Less Made by Walking

Percent

TOTAL

17

Race and ethnicity

American Indian or Alaska Native

DNC

Asian or Pacific Islander

DNC

Asian

DNC

Native Hawaiian and other Pacific Islander

DNC

Black or African American

DNC

White

DNC

 

Hispanic or Latino

DNC

Not Hispanic or Latino

DNC

Black or African American

DNC

White

DNC

Gender

Female

17

Male

16

Education level

Less than high school

20

High school graduate

14

At least some college

18

Geographic location

Urban

18

Rural

9

Select populations

Age groups

18 to 24 years

22

25 to 44 years

17

45 to 64 years

14

65 to 74 years

16

75 years and older

19

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Children and Adolescents Aged 5 to 15 Years, 1995

22-14b.
Trips to School of 1 Mile or Less Made by Walking

Percent

TOTAL

31

Race and ethnicity

American Indian or Alaska Native

DNC

Asian or Pacific Islander

DNC

Asian

DNC

Native Hawaiian and other Pacific Islander

DNC

Black or African American

DNC

White

DNC

 

Hispanic or Latino

DNC

Not Hispanic or Latino

DNC

Black or African American

DNC

White

DNC

Gender

Female

27

Male

35

Parents’ education level

Less than high school

DNC

High school graduate

DNC

At least some college

DNC

Geographic location

Urban

32

Rural

27

Select populations

Age groups

5 to 9 years

27

10 to 15 years

35

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Walking is a very popular form of physical activity in the United States; however, people need the opportunity to walk safely. Over 75 percent of all trips less than 1 mile were made by automobile in 1995.[40] In addition, the number of walking trips as a percentage of all trips taken (of any distance) has declined over the years. Walking trips made by adults dropped from 9.3 percent in 1977 to 7.2 percent in 1990 and again to 5.4 percent in 1995. Walking has declined even more sharply for children.40 These declines have negative implications for the health of adults and children.


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Increase the proportion of trips made by bicycling.

Target and baseline:

Objective

Increase in Trips
Made by Bicycling

Activity

1995
Baseline*

2010
Target

                          Percent

22-15a.

Adults aged 18 years and older

Trips of 5 miles
or less

0.6

2.0

22-15b.

Children and adolescents
aged 5 to15 years

Trips to school of
2 miles or less

2.4

5.0

*Age adjusted to the year 2000 standard population.

Target setting method: 233 percent improvement for 22-15a and 108 percent improvement for 22-15b. (Better than the best will be used when data are available.)

Data source: Nationwide Personal Transportation Survey (NPTS), DOT.

Adults Aged 18 Years and Older, 1995

22-15a.
Trips of 5 Miles or Less Made by
Bicycling

Percent

TOTAL

0.6

Race and ethnicity

American Indian or Alaska Native

DNC

Asian or Pacific Islander

DNC

Asian

DNC

Native Hawaiian and other Pacific Islander

DNC

Black or African American

DNC

White

DNC

 

Hispanic or Latino

DNC

Not Hispanic or Latino

DNC

Black or African American

DNC

White

DNC

Gender

Female

0.3

Male

0.9

Education level

Less than high school

0.6

High school graduate

0.5

At least some college

0.6

Geographic location

Urban

0.6

Rural

0.3

Age groups

18 to 24 years

1.4

25 to 44 years

0.6

45 to 64 years

0.3

65 to 74 years

0.3

75 years and older

0.1

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.



Children and Adolescents Aged 5 to 15 Years, 1995

22-15b.
Trips to School of 2 Miles or Less Made by Bicycling

Percent

TOTAL

2.4

Race and ethnicity

American Indian or Alaska Native

DNC

Asian or Pacific Islander

DNC

Asian

DNC

Native Hawaiian and other Pacific Islander

DNC

Black or African American

DNC

White

DNC

 

Hispanic or Latino

DNC

Not Hispanic or Latino

DNC

Black or African American

DNC

White

DNC

Gender

Female

1.7

Male

3.2

Parents’ education level

Less than high school

DNC

High school graduate

DNC

At least some college

DNC

Geographic location

Urban

2.6

Rural

1.1

Select populations

Age groups

5 to 9 years

1.6

10 to 15 years

3.0

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Bicycling is another form of transportation that may be used by both children and adults for distances that may not be feasible, practical, or efficient to cover by walking. If the environment does not provide safe opportunities for physical activities such as walking and bicycling, adults and children likely will spend more time engaging in sedentary activities indoors. (See Focus Area 8. Environmental Health.) Sedentary activities such as watching television, playing video games, and using personal computers have contributed to increases in the cases of overweight individuals.27

Related Objectives From Other Focus Areas

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1.

Access to Quality Health Services

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2.

Arthritis, Osteoporosis, and Chronic Back Conditions

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3.

Cancer

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4.

Chronic Kidney Disease

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5.

Diabetes

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6.

Disability and Secondary Conditions

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7.

Educational and Community-Based Programs

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8.

Environmental Health

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9.

Family Planning

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11.

Health Communication

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12.

Heart Disease and Stroke

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15.

Injury and Violence Prevention

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16.

Maternal, Infant, and Child Health

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17.

Medical Product Safety

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18.

Mental Health and Mental Disorders

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19.

Nutrition and Overweight

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20.

Occupational Safety and Health

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23.

Public Health Infrastructure

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24.

Respiratory Diseases

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25.

Sexually Transmitted Diseases

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26.

Substance Abuse

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27.

Tobacco Use

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28.

Vision and Hearing

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Terminology

(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)

Aerobic: Conditions or processes that occur in the presence of, or requiring, oxygen.[41]

Energy expenditure: The energy cost to the body of physical activity, usually measured in kilocalories.41

Functional independence: The ability to perform successfully and safely activities related to a daily routine with sufficient energy, strength/endurance, flexibility, and coordination.

Physical activity: Bodily movement that is produced by the contraction of skeletal muscle and that substantially increases energy expenditure.1

Moderate physical activity: Activities that use large muscle groups and are at least equivalent to brisk walking. In addition to walking, activities may include swimming, cycling, dancing, gardening and yardwork, and various domestic and occupational activities.

Vigorous physical activity: Rhythmic, repetitive physical activities that use large muscle groups at 70 percent or more of maximum heart rate for age. An exercise heart rate of 70 percent of maximum heart rate for age is about 60 percent of maximal cardiorespiratory capacity and is sufficient for cardiorespiratory conditioning. Maximum heart rate equals roughly 220 beats per minute minus age. Examples of vigorous physical activities include jogging/running, lap swimming, cycling, aerobic dancing, skating, rowing, jumping rope, cross-country skiing, hiking/backpacking, racquet sports, and competitive group sports (for example, soccer and basketball).

Physical fitness: A set of attributes that persons have or achieve that relates to the ability to perform physical activity.1 Performance-related components of fitness include agility, balance, coordination, power, and speed.[42] Health-related components of physical fitness include body composition, cardiorespiratory function, flexibility, and muscular strength/endurance.41

Agility: Ability to start, stop, and move the body quickly and in different directions.

Balance: Ability to maintain a certain posture or to move without falling.

Body composition: The relative amount of body weight that is fat and nonfat.

Cardiorespiratory function: A health-related component of physical fitness that relates to the ability of the circulatory and respiratory systems to supply oxygen during physical activity.

Coordination: Ability to do a task integrating movements of the body and different parts of the body.

Exercise (exercise training): Planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness.

Flexibility: Ability to move a joint through the full range of motion without discomfort or pain.

Muscular endurance: Ability of the muscle to perform repetitive contractions over a prolonged period of time.

Muscular strength: Ability of the muscle to generate the maximum amount of force.

Power: Ability to exert muscular strength quickly.

Speed: Ability to move the whole body quickly.

Sedentary: Denotes a person who is relatively inactive and has a lifestyle characterized by a lot of sitting.41

References


[1] U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, 1996.

[2] Frost, H.; Moffett, J.A.K.; Moser, J.S.; et al. Randomized controlled trial for evaluation of fitness programme for patients with chronic low back pain. British Medical Journal 310:151-154, 1995. PubMed; PMID 7833752

[3] McTiernan, A.; Stanford, J.L.; Weiss, N.S.; et al. Occurrence of breast cancer in relation to recreational exercise in women age 50-64 years. Epidemiology 7(6):598-604, 1996. PubMed; PMID 8899385

[4] Kujala, U.M.; Kaprio, J.; Sarna, S.; et al. Relationship of leisure-time physical activity and mortality: The Finnish twin cohort. Journal of the American Medical Association 279(6):440-444, 1998. PubMed; PMID 9466636

[5] Paffenbarger, R.S.; Hyde, R.T.; Wing, A.L.; et al. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. New England Journal of Medicine 328(8):538-545, 1993. PubMed; PMID 8426621

[6] Sherman, S.E.; DAgostino, R.B.; Cobb, J.L.; et al. Physical activity and mortality in women in the Framingham Heart Study. American Heart Journal 128(5):879-884, 1994. PubMed; PMID 7942478

[7] Kaplan, G.A.; Strawbridge, W.J.; Cohen, R.D.; et al. Natural history of leisure-time physical activity and its correlates: Associations with mortality from all causes and cardiovascular disease over 28 years. American Journal of Epidemiology 144(8):793-797, 1996. PubMed; PMID 8857282

[8] Kushi, L.H.; Fee, R.M.; Folsom, A.R.; et al. Physical activity and mortality in postmenopausal women. Journal of the American Medical Association 277:1287-1292, 1997. PubMed; PMID 9109466

[9] Nelson, M.E.; Fiatarone, M.A.; Morganti, C.M.; et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures: A randomized controlled trial. Journal of the American Medical Association 272(24):1909-1914, 1994. PubMed; PMID 7990242

[10] LaCroix, A.Z.; Guralnik, J.M.; Berkman, L.F.; et al. Maintaining mobility in late life. II. Smoking, alcohol consumption, physical activity, and body mass index. American Journal of Epidemiology 137(8):858-869, 1993. PubMed; PMID 8484377

[11] Buchner, D.M. Preserving mobility in older adults. Western Journal of Medicine 167(4):258-264, 1997. PubMed; PMID 9348757

[12] Stenstrom, C.H. Home exercise in rheumatoid arthritis functional class II: Goal setting versus pain attention. Journal of Rheumatology 21(4):627-634, 1994. PubMed; PMID 8035384

[13] CDC. Prevalence of leisure-time physical activity among persons with arthritis and other rheumatic conditions—United States, 1990–91. Morbidity and Mortality Weekly Report 46(18):389-393, 1997. PubMed; PMID 9157272

[14] National Institutes of Health. Optimal calcium intake. In: NIH Consensus Statement 12(4):1-31, 1994.

[15] Snow-Harter, C.; Shaw, J.M.; and Matkin, C.C. Physical activity and risk of osteoporosis. In: Marcus, R.; Feldman, D.; and Kelsey, J., eds. Osteoporosis. San Diego, CA: Academic Press, 1996, 511-528.

[16] Pate, R.R.; Pratt, M.; Blair, S.N.; et al. Physical activity and public health: A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Journal of the American Medical Association 273(5):402-407, 1995. PubMed; PMID 7823386

[17] Presidents Council on Physical Fitness and Sports. Physical Activity & Sport in the Lives of Girls. Washington, DC: The Presidents Council on Physical Fitness and Sports, 1997.

[18] Stofan, J.R.; DiPietro, L.; Davis, D.; et al. Physical activity patterns associated with cardiorespiratory fitness and reduced mortality: The Aerobics Center Longitudinal Study. American Journal of Public Health 88(12):1807-1813, 1998. PubMed; PMID 9842378

[19] Brown, M.; Sinacore, D.R.; and Host, H.H. The relationship of strength to function in the older adult. Journal of Gerontology 50A:55-59, 1995. PubMed; PMID 7493219

[20] Tseng, B.S.; Marsh, D.R.; Hamilton, M.T.; et al. Strength and aerobic training attenuate muscle wasting and improve resistance to the development of disability with aging. Journal of Gerontology 50A:113-119, 1995. PubMed; PMID 7493203

[21] Evans, W.J. Effects of exercise on body composition and functional capacity of the elderly. Journal of Gerontology 50A:147-150, 1995. PubMed; PMID 7493209

[22] Cunningham, D.A.; Paterson, D.H.; Hinmann, J.E.; et al. P.A. Determinants of independence in the elderly. Canadian Journal of Applied Physiology 18(3):243-254, 1993. PubMed; PMID 8242004

[23] Lan, C.; Lai, J.S.; Chen, S.Y; et al. 12-month Tai Chi training in the elderly: Its effect on health fitness. Medicine and Science in Sports and Exercise 30(3):345-351, 1997. PubMed; PMID 9526879

[24] Pate, R.R.; Baranowski, T.; Dowda, M.; et al. Tracking of physical activity in young children. Medicine and Science in Sports and Exercise 28(1):92-96, 1996. PubMed; PMID 8775360

[25] Pate, R.R.; Long, B.J.; and Heath, G. Descriptive epidemiology of physical activity in adolescents. Pediatric Exercise Science 6:434-447, 1994.

[26] CDC. Youth risk behavior surveillance—United States, 1997. Morbidity and Mortality Weekly Report 47(55-3):1-89, 1998. PubMed; PMID 9719790

[27] Anderson, R.E.; Crespo, C.J.; Bartlett, S.J.; et al. Relationship of physical activity and television watching with body weight and level of fatness among children: Results from the Third National Health and Nutrition Examination Survey. Journal of the American Medical Association 279:938-942, 1998.

[28] McKenzie, T.L.; Nader, P.R.; Strikmiller, P.K.; et al. School physical education: Effect of the child and adolescent trial for cardiovascular health. Preventive Medicine 25(4):423-431, 1996. PubMed; PMID 8818066

[29] Sallis, J.F.; McKenzie, T.L.; Alcaraz, J.E.; et al. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. American Journal of Public Health 87(8):1328-1334, 1997. PubMed; PMID 9279269

[30] Sallis, J.F., and Patrick, K. Physical activity guidelines for adolescents: Consensus statement. Pediatric Exercise Science 6:302-314, 1994.

[31] CDC. Guidelines for school and community programs to promote lifelong physical activity among young people. Morbidity and Mortality Weekly Report 46(RR-6):1-36, 1997. PubMed; PMID 9072670

[32] Killen, J.D.; Telch, M.J.; Robinson, T.N.; et al. Cardiovascular disease risk reduction for tenth graders: A multiple-factor school-based approach. Journal of the American Medical Association 260(12):1728-1733, 1988. PubMed; PMID 3411756

[33] Prokhorov, A.V.; Perry, C.L.; Kelder, S.H.; et al. Lifestyle values of adolescents: Results from Minnesota Heart Health Youth Program. Adolescence 28(111):637-647, 1993. PubMed; PMID 8237549

[34] Kelder, S.H.; Perry, C.L.; and Klepp, K.I. Community-wide youth exercise promotion: Long-term outcomes of the Minnesota Heart Health Program and the Class of 1989 study. Journal of School Health 63(5):218-223, 1993. PubMed; PMID 8336479

[35] Arbeit, M.L.; Johnson, C.C.; and Mott, D.S. The Heart Smart Cardiovascular School Health Promotion: Behavior correlates of risk factor change. Preventive Medicine 21(1):18-32, 1992. PubMed; PMID 1738766

[36] Sallis, J.F.; Hovell, M.F.; Hofstetter, C.R.; et al. Distance between homes and exercise facilities related to frequency of exercise among San Diego residents. Public Health Reports 105(2):179-185, 1990. PubMed; PMID 2108465

[37] Carnegie Council on Adolescent Development. A Matter of Time: Risk and Opportunity in the Out-of-School Hours. Recommendations for Strengthening Community Programs for Youth. New York, NY: Carnegie Corporation of New York, 1994.

[38] Cole, G.; Leonard, B.; Hammond, S.; et al. Using “stages of behavioral change” constructs to measure the short-term effects of a worksite-based intervention to increase moderate physical activity. Psychological Reports 82(2):615-618, 1998. PubMed; PMID 9621738

[39] Shephard, R.J. Employee health and fitness—state of the art. Preventive Medicine 12(5):644-653, 1983. PubMed; PMID 6419221

[40] U.S. Department of Transportation (DOT). National Bicycling and Walking Study: Transportation Choices for a Changing America. Pub. FH10A PD 94-023. Washington, DC: DOT, Federal Highway Administration, 1994.

[41] Kent, M. The Oxford Dictionary of Sports Science and Medicine. Oxford, England: Oxford University Press, 1994.

[42] Howley, E.T., and Franks, B.O. Health Fitness Instructors Handbook. 3rd ed. Champaign, IL: Human Kinetics, 1997.



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