CHAPTER 2

HISTORICAL BACKGROUND, TERMINOLOGY,

EVOLUTION OF RECOMMENDATIONS,
AND MEASUREMENT

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Western Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Early Promotion of Physical Activity for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Associating Physical Inactivity with Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Health, Physical Education, and Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Exercise Physiology Research and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Terminology of Physical Activity, Physical Fitness, and Health . . . . . . . . . . . . . . . . . . . . . . . . 20

Evolution of Physical Activity Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Summary of Recent Physical Activity Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Measurement of Physical Activity, Fitness, and Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Measuring Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Measures Based on Self-Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Measures Based on Direct Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Measuring Intensity of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Measuring Physical Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Endurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Muscular Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Body Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Validity of Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Contents, continued

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Appendix A: Healthy People 2000 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Appendix B: NIH Consensus Conference Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

 CHAPTER 2
HISTORICAL BACKGROUND, TERMINOLOGY,
EVOLUTION OF RECOMMENDATIONS,
AND MEASUREMENT

Introduction intact today confirm that physical capability was not

just a grim necessity for success at gathering food and
The exercise boom is not just a fad; it is a return providing shelter and safety (Eaton, Shostak, Konner
to ‘natural’ activity—the kind for which our 1988). Physical activity was enjoyed throughout every-
bodies are engineered and which facilitates the day prehistoric life, as an integral component of
proper function of our biochemistry and physi- religious, social, and cultural expression. Food sup-
ology. Viewed through the perspective of evolu- plies for the most part were plentiful, allowing ample
tionary time, sedentary existence, possible for time for both rest and recreational physical endeavors.
great numbers of people only during the last Eaton, Shostak, and Konner (1988) describe a
century, represents a transient, unnatural aber- “Paleolithic rhythm” (p. 32) observed among con-
ration. (Eaton, Shostak, Konner 1988, p. 168) temporary hunters and gatherers that seems to
mirror the medical recommendations for physical
T his chapter examines the historical development
of physical activity promotion as a means to
improve health among entire populations. The chap-
activity in this report. This natural cycle of regu-
larly intermittent activity was likely the norm for
ter focuses on Western (i.e., Greco-Roman) history, most of human existence. Sustenance preoccupa-
because of the near-linear development of physical tions typically were broken into 1- or 2-day periods
activity promotion across those times and cultures of intense and strenuous exertion, followed by 1- or
leading to current American attitudes and guidelines 2-day periods of rest and celebration. During these
regarding physical activity. These guidelines are rest days, however, less intense but still strenuous
discussed in detail in the last half of the chapter. To exertion accompanied 6- to 20-mile round-trip vis-
flesh out this narrow focus on Western traditions, as its to other villages to see relatives and friends and
well as to provide a background for the promotional to trade with other clans or communities. There or
emphasis of the chapter, this chapter begins by at home, dancing and cultural play took place.
briefly outlining both anthropological and historical As the neolithic Agricultural Revolution allowed
evidence of the central, “natural” role of physical more people to live in larger group settings and
activity in prehistoric cultures. Mention is also made cities, and as the specialization of occupations re-
of the historical prominence of physical activity in duced the amount and intensity of work-related
non-Greco-Roman cultures, including those of China, physical activities, various healers and philosophers
India, Africa, and precolonial America. began to stress that long life and health depended on
Archaeologists working in conjunction with medi- preventing illnesses through proper diet, nutrition,
cal anthropologists have established that our ances- and physical activity. Such broad prescriptions for
tors up through the beginning of the Industrial health, including exercise recommendations, long
Revolution incorporated strenuous physical activity predate the increasingly specific guidelines of classi-
as a normal part of their daily lives—and not only for cal Greek philosophy and medicine, which are the
the daily, subsistence requirements of their “work” predominant historical focus of this chapter.
lives. Investigations of preindustrial societies still
Physical Activity and Health

In ancient China as early as 3000 to 1000 B.C., hunt. Running was also a means for diverse Ameri-
the classic Yellow Emperor’s Book of Internal Medicine can Indian cultures to enact their myths and thereby
(Huang Ti 1949) first described the principle that construct a tangible link between themselves and
human harmony with the world was the key to both the physical and metaphysical worlds. Among
prevention and that prevention was the key to long the Indian peoples Nabokov cites are the Mesquakie
life (Shampo and Kyle 1989). These principles grew of Iowa, the Chemeheuvi of California, the Inca of
into concepts that became central to the 6th century Peru, the Zuni and other Pueblo peoples of the
Chinese philosophy Taoism, where longevity through American Southwest, and the Iroquois of the Ameri-
simple living attained the status of a philosophy that can East, who also developed the precursor of mod-
has guided Chinese culture through the present day. ern-day lacrosse. Even today, the Tarahumarahe of
tai chi chuan, an exercise system that teaches graceful northern Mexico play a version of kickball that
movements, began as early as 200 B.C. with Hua T’o involves entire villages for days at a time (Nabokov
and has recently been shown to decrease the incidence 1981; Eaton, Shostak, Konner 1988).
of falls in elderly Americans (Huard and Wong 1968;
see Chapter 4).
In India, too, proper diet and physical activity Western Historical Perspective
were known to be essential principles of daily Besides affecting the practice of preventive hygiene
living. The Ajur Veda, a collection of health and (as is discussed throughout this section), the ancient
medical concepts verbally transmitted as early as Greek ideals of exercise and health have influenced
3000 B.C., developed into Yoga, a philosophy that the attitudes of modern western culture toward
included a comprehensively elaborated series of physical activity. The Greeks viewed great athletic
stretching and flexibility postures. The principles achievement as representing both spiritual and
were first codified in 600 B.C. in the Upanishads and physical strength rivaling that of the gods (Jaeger
later in the Yoga Sutras by Patanjali sometime be- 1965). In the classical-era Olympic Games, the Greeks
tween 200 B.C. and 200 A.D. Yoga philosophies viewed the winners as men who had the character
also asserted that physical suppleness, proper breath- and physical prowess to accomplish feats beyond the
ing, and diet were essential to control the mind and capability of most mortals. Although participants in
emotions and were prerequisites for religious ex- the modern Olympic Games no longer compete with
perience. In both India and China during this the gods, today’s athletes inspire others to be physi-
period, the linking of exercise and health may cally active and to realize their potential—an inspi-
have led to the development of a medical subspe- ration as important for modern peoples as it was for
cialty that today would find its equivalent in sports the ancient Greeks.
medicine (Snook 1984).
Though less directly concerned with physical Early Promotion of
health than with social and religious attainment, Physical Activity for Health
physical activity played a key role in other ancient
Throughout much of recorded western history, phi-
non-Greco-Roman cultures. In Africa, systems of
losophers, scientists, physicians, and educators have
flexibility, agility, and endurance training not only
promoted the idea that being physically active con-
represented the essence of martial arts capability
tributes to better health, improved physical func-
but also served as an integral component of reli-
tioning, and increased longevity. Although some of
gious ritual and daily life. The Samburu and the
these claims were based on personal opinions or
Masai of Kenya still feature running as a virtue of
clinical judgment, others were the result of system-
the greatest prowess, linked to manhood and social
atic observation.
stature.
Among the ancient Greeks, the recognition that
Similarly, in American Indian cultures, running
proper amounts of physical activity are necessary for
was a prominent feature of all major aspects of life
healthy living dates back to at least the 5th century
(Nabokov 1981). Long before the Europeans in-
B.C. (Berryman 1992). The lessons found in the
vaded, Indians ran to communicate, to fight, and to

12
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

“laws of health” taught during the ancient period Whether by sailing, riding on horseback, or driving,
sound familiar to us today: to breathe fresh air, eat or via cradles, swings, and arms, everyone, even
proper foods, drink the right beverages, take plenty infants, Galen said, needed exercise (Green 1951
of exercise, get the proper amount of sleep, and trans., p. 25). He further stated:
include our emotions when analyzing our overall
The uses of exercise, I think, are twofold, one
well-being.
for the evacuation of the excrements, the other
Western historians agree that the close connec-
for the production of good condition of the firm
tion between exercise and medicine dates back to
parts of the body. For since vigorous motion is
three Greek physicians—Herodicus (ca. 480 B.C.),
exercise, it must needs be that only these three
Hippocrates (ca. 460–ca. 377 B.C.), and Galen
things result from it in the exercising body—
(A.D. 129–ca. 199). The first to study therapeutic
hardness of the organs from mutual attrition,
gymnastics—or gymnastic medicine, as it was often
increase of the intrinsic warmth, and acceler-
called—was the Greek physician and former exer-
ated movement of respiration. These are fol-
cise instructor, Herodicus. His dual expertise united
lowed by all the other individual benefits which
the gymnastic with the medical art, thereby prepar-
accrue to the body from exercise; from hardness
ing the way for subsequent Greek study of the health
of the organs, both insensitivity and strength
benefits of physical activity.
for function; from warmth, both strong attrac-
Although Hippocrates is generally known as the
tion for things to be eliminated, readier me-
father of preventive medicine, most historians credit
tabolism, and better nutrition and diffusion of
Herodicus as the influence behind Hippocrates’ in- all substances, whereby it results that solids are
terest in the hygienic uses of exercise and diet (Cyriax
softened, liquids diluted, and ducts dilated.
1914; Precope 1952; Licht 1984; Olivova 1985).
And from the vigorous movement of respira-
Regimen, the longer of Hippocrates’ two works deal-
tion the ducts must be purged and the excre-
ing with hygiene, was probably written sometime
ments evacuated. (p. 54)
around 400 B.C. In Book l, he writes:
The classical notion that one could improve
Eating alone will not keep a man well; he must
one’s health through one’s own actions—for ex-
also take exercise. For food and exercise, while ample, through eating right and getting enough sleep
possessing opposite qualities, yet work together
and exercise—proved to be a powerful influence on
to produce health. For it is the nature of exer-
medical theory as it developed over the centuries.
cise to use up material, but of food and drink to Classical medicine had made it clear to physicians
make good deficiencies. And it is necessary, as
and the lay public alike that responsibility for disease
it appears, to discern the power of various and health was not the province of the gods. Each
exercises, both natural exercises and artificial,
person, either independently or in counsel with his
to know which of them tends to increase flesh
or her physician, had a moral duty to attain and
and which to lessen it; and not only this, but preserve health. When the Middle Ages gave way to
also to proportion exercise to bulk of food, to
the Renaissance, with its individualistic perspective
the constitution of the patient, to the age of the and its recovery of classical humanistic influences,
individual, to the season of the year, to the
this notion of personal responsibility acquired even
changes in the winds, to the situation of the
greater emphasis. Early vestiges of a “self-help”
region in which the patient resides, and to the movement arose in western Europe in the 16th
constitution of the year. (1953 reprint, p. 229)
century. As that century progressed, “laws of bodily
Hippocrates was a major influence on the career health were expressed as value prescriptions” (Burns
of Claudius Galenus, or Galen, the Greek physician 1976, p. 208).
who wrote numerous works of great importance to More specifically, “orthodox Greek hygiene,”
medical history during the second century. Of these as Smith (1985, p. 257) called it, flourished as part
works, his book entitled On Hygiene contains the of the revival of Galenic medicine as early as the
most information on the healthfulness of exercise. 13th century. The leading medical schools of the

13
Physical Activity and Health

world—Italy’s Salerno, Padua, and Bologna—taught not be given exercise that might aggravate existing
hygiene to their students as part of general instruc- conditions; special exercises should be prescribed on
tion in the theory and practice of medicine . The an individual basis for convalescent, weak, and older
works of Hippocrates and Galen dominated a sys- patients; people who lead sedentary lives need ex-
tem whereby “the ultimate goal was to be able to ercise urgently; each exercise should preserve the
practise medicine in the manner of the ancient existing healthy state; exercise should not disturb
physicians” (Bylebyl 1979, p. 341). the harmony among the principal humors; exercise
Hippocrates’ Regimen also became important should be suited to each part of the body; and all
during the Renaissance in a literature that Gruman healthy people should exercise regularly.
(1961) identified as “prolongevity hygiene” and de- Although Galenism and the humoral theory of
fined as “the attempt to attain a markedly increased medicine were displaced by new ideas, particularly
longevity by means of reforms in one’s way of life” through the study of anatomy and physiology, the
(p. 221). Central to this literature was the belief that Greek principles of hygiene and regimen continued
persons who decided to live a temperate life, espe- to flourish in 18th century Europe. For some 18th
cially by reforming habits of diet and exercise, could century physicians, such nonintervention tactics were
significantly extend their longevity. Beginning with practical alternatives to traditional medical therapies
the writings of Luigi Cornaro in 1558, the classic that employed bloodletting and heavy dosing with
Greek preventive hygiene tradition achieved increas- compounds of mercury and drugs—“heroic” medi-
ing attention from those wishing to live longer and cine (Warner 1986), in which the “cure” was often
healthier lives. worse than the disease.
Christobal Mendez, who received his medical George Cheyne’s An Essay of Health and Long Life
training at the University of Salamanca, was the was published in London in 1724. By 1745, it had
author of the first printed book devoted to exercise, gone through 10 editions and various translations.
Book of Bodily Exercise (1553). His novel and com- Cheyne recommended walking as the “most natural”
prehensive ideas preceded developments in exercise and “most useful” exercise but considered riding on
physiology and sports medicine often thought to be horseback as the “most manly” and “most healthy”
unique to the early 20th century. The book consists (1734 reprint, p. 94). He also advocated exercises in
of four treatises that cover such topics as the effects the open air, such as tennis and dancing, and recom-
of exercise on the body and on the mind. Mendez mended cold baths and the use of the “flesh brush”
believed, as the humoral theorists did, that the phy- to promote perspiration and improve circulation.
sician had to clear away excess moisture in the body. John Wesley’s Primitive Physic, first published in
Then, after explaining the ill effects of vomiting, 1747, was influenced to a large degree by George
bloodletting, purging, sweating, and urination, he Cheyne. In his preface, Wesley noted that “the power
noted that “exercise was invented and used to clean of exercise, both to preserve and restore health, is
the body when it was too full of harmful things. It greater than can well be conceived; especially in
cleans without any of the above-mentioned inconve- those who add temperance thereto” (1793 reprint,
nience and is accompanied by pleasure and joy (as p. iv). William Buchan’s classic Domestic Medicine,
we will say). If we use exercise under the conditions written in 1769, prescribed proper regimen for im-
which we will describe, it deserves lofty praise as a proving individual and family health. The book
blessed medicine that must be kept in high esteem” contained rules for the healthy and the sick and
(1960 reprint, p. 22). stressed the importance of exercise for good health in
In 1569, Hieronymus Mercurialis’ The Art of both children and adults.
Gymnastics Among the Ancients was published in During the 19th century, both the classical Greek
Venice. Mercurialis quoted Galen extensivly and tradition and the general hygiene movement were
provided a descriptive compilation of ancient mate- finding their way into the United States through
rial from nearly 200 works by Greek and Roman American editions of western European medical
authors. In general, Mercurialis established the fol- treatises or through books on hygiene written by
lowing exercise principles: people who are ill should American physicians. The “self-help” era was also in

14
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

full bloom during antebellum America. Early ves- the beneficial consequences in the cure of many
tiges of a self-help movement had arisen in western diseases would be very great indeed” (p. 113).
Europe in the 16th century. As that century pro-
gressed, “laws of bodily health were expressed as Associating Physical Inactivity with Disease
value prescriptions” (Burns 1976, p. 208). Classical Throughout history, numerous health professionals
Greek preventive hygiene was part of formal medical have observed that sedentary people appear to suffer
training through the 18th century and continued on from more maladies than active people. An early
in the American health reform literature for most of example is found in the writings of English physician
the 19th century. During the latter period, an effort Thomas Cogan, author of The Haven of Health (1584);
was made to popularize the Greek laws of health, to he recommended his book to students who, because
make each person responsible for the maintenance of their sedentary ways, were believed to be most
and balance of his or her health. Individual reform susceptible to sickness.
writers thus wrote about self-improvement, self- In his 1713 book Diseases of Workers, Bernar-
regulation, the responsibility for personal health, dino Ramazzini, an Italian physician considered the
and self-management (Reiser 1985). If people ate too father of occupational medicine, offered his views on
much, slept too long, or did not get enough exercise, the association between chronic inactivity and poor
they could only blame themselves for illness. By the health. In the chapter entitled “Sedentary Workers
same token, they could also determine their own and Their Diseases,” Ramazzini noted that “those
good health (Cassedy 1977; Numbers 1977; who sit at their work and are therefore called ‘chair-
Verbrugge 1981; Morantz 1984). workers,’ such as cobblers and tailors, suffer from
A.F.M. Willich’s Lectures on Diet and Regimen their own particular diseases.” He concluded that
(1801) emphasized the necessity of exercise within “these workers . . . suffer from general ill-health and
the bounds of moderation. He included information an excessive accumulation of unwholesome humors
on specific exercises, the time for exercise, and the caused by their sedentary life,” and he urged them to
duration of exercise. The essential advantages of at least exercise on holidays “so to some extent
exercise included increased bodily strength, improved counteract the harm done by many days of sedentary
circulation of the blood and all other bodily fluids, life” (1964 trans., pp. 281–285).
aid in necessary secretions and excretions, help in Shadrach Ricketson, a New York physician, wrote
clearing and refining the blood, and removal of the first American text on hygiene and preventive
obstructions. medicine (Rogers 1965). In his 1806 book Means of
John Gunn’s classic Domestic Medicine, Or Poor Preserving Health and Preventing Diseases, Ricketson
Man’s Friend, was first published in 1830. His section explained that “a certain proportion of exercise is not
entitled “Exercise” recommended temperance, exer- much less essential to a healthy or vigorous constitu-
cise, and rest and valued nature’s way over tradi- tion, than drink, food, and sleep; for we see that
tional medical treatment. He also recommended people, whose inclination, situation, or employ-
exercise for women and claimed that all of the ment does not admit of exercise, soon become pale,
“diseases of delicate women” like “hysterics and feeble, and disordered.” He also noted that “exercise
hypochondria, arise from want of due exercise in the promotes the circulation of the blood, assists diges-
open, mild, and pure air” (1986 reprint, p. 109). tion, and encourages perspiration” (pp. 152–153).
Finally, in an interesting statement for the 1830s if Since the 1860s, physicians and others had
not the 1990s, Gunn recommended a training sys- been attempting to assess the longevity of runners
tem for all: “The advantages of the training systems and rowers. From the late 1920s (Dublin 1932;
are not confined to pedestrians or walkers—or to Montoye 1992) to the landmark paper by Morris
pugilists or boxers alone; or to horses which are and colleagues (1953), observations that prema-
trained for the chase and the race track; they extend ture mortality is lower among more active persons
to man in all conditions; and were training intro- than sedentary persons began to emerge and were
duced into the United States, and made use of by later replicated in a variety of settings (Rook 1954;
physicians in many cases instead of medical drugs,

15
Physical Activity and Health

Brown et al. 1957; Pomeroy and White 1958; Zukel in 1834 gained him national recognition. Caldwell
et al. 1959). The hypothesis that a sedentary lifestyle defined physical education as “that scheme of train-
leads to increased mortality from coronary heart ing, which contributes most effectually to the devel-
disease, as well as the later hypothesis that inactiv- opment, health, and perfection of living matter. As
ity leads to the development of some other chronic applied to man, it is that scheme which raises his
diseases, has been the subject of numerous studies whole system to its summit of perfection. . . . Physical
that provide the major source of data supporting education, then, in its philosophy and practice, is of
the health benefits of exercise (see Chapter 4). great compass. If complete, it would be tantamount
to an entire system of Hygeiene. It would embrace
Health, Physical Education, and Fitness every thing, that, by bearing in any way on the
The hygiene movement found further expression in human body, might injure or benefit it in its health,
19th century America through a new literature de- vigor, and fitness for action” (pp. 28–29).
voted to “physical education.” In the early part of the During the first half of the 19th century, systems
century, many physicians began using the term in of gymnastic and calisthenic exercise that had been
journal articles, speeches, and book titles to describe developed abroad were brought to the United States.
the task of teaching children the ancient Greek “laws The most influential were exercises advanced by Per
of health.” As Willich explained in his Lectures on Diet Henrik Ling in Sweden in the early 1800s and the
and Regimen (1801), “by physical education is meant “German system” of gymnastic and apparatus exer-
the bodily treatment of children; the term physical cises that was based on the work of Johan Christoph
being applied in opposition to moral” (p. 60). In his GutsMuths and Friedrich Ludwig Jahn. Also, Ameri-
section entitled “On the Physical Education of Chil- cans like Catharine Beecher (1856) and Dioclesian
dren,” he continued to discuss stomach ailments, Lewis (1883) devised their own extensive systems of
bathing, fresh air, exercise, dress, and diseases of the calisthenic exercises intended to benefit both women
skin, among other topics. Physical education, then, and men. By the 1870s, American physicians and
implied not merely exercising the body but also educators frequently discussed exercise and health.
becoming educated about one’s body. For example, physical training in relation to health
These authors were joined by a number of early was a regular topic in the Boston Medical and Surgical
19th century educators. For example, an article Journal from the 1880s to the early 1900s.
entitled “Progress of Physical Education” (1826), Testing of physical fitness in physical education
which appeared in the first issue of American Journal began with the extensive anthropometric documen-
of Education, declared that “the time we hope is tation by Edward Hitchcock in 1861 at Amherst
near, when there will be no literary institution College. By the 1880s, Dudley Sargent at Harvard
unprovided with the proper means to healthful University was also recording the bodily measure-
exercise and innocent recreation, and when literary ments of college students and promoting strength
men shall cease to be distinguished by a pallid testing (Leonard and Affleck 1947). During the early
countenance and a wasted body” (pp. 19–20). Both 1900s, the focus on measuring body parts shifted to
William Russell, who was the journal’s editor, and tests of vital working capacity. These tests included
Boston educator William Fowler believed that girls measures of blood pressure (McCurdy 1901;
as well as boys should have ample outdoor exercise. McKenzie 1913), pulse rate (Foster 1914), and fa-
Knowledge about one’s body also was deemed cru- tigue (Storey 1903). As early as 1905, C. Ward
cial to a well-educated and healthy individual by Crampton, former director of physical training and
several physicians who, as Whorton has suggested, hygiene in New York City, published the article “A
“dedicated their careers to birthing the modern Test of Condition” in Medical News. Attempts to
physical education movement” (p. 282). assess physical fitness had constituted a significant
Charles Caldwell held a prominent position in aspect of the work of turn-of-the-century physical
Lexington, Kentucky’s, Transylvania University educators, many of whom were physicians.
Medical Department. Although he wrote on a variety Allegations that American conscripts during
of medical topics, his Thoughts on Physical Education World War I were inadequately fit to serve their

16
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

country helped shift the emphasis of physical educa- better nation now than we were in 1917,” but he
tion from health-related exercise to performance out- cautioned Americans not to believe “we have at-
comes. Public concern stimulated legislation to make tained an optimum in physical fitness” (p. 54). He
physical education a required subject in schools. But realized the magnitude of the fitness problem when
the financial austerities of the Great Depression had a he noted that the poor results of physical examina-
negative effect on education in general, including tions reported by the Selective Service Boards were “a
physical education (Rogers 1934). At the same time, challenge to the medical profession, to the social
the combination of increased leisure time for many scientists, the physical educators, the public health
Americans and a growing national interest in college officials, and all those concerned in the United States
and high school sports shifted the emphasis on physi- with the physical improvement of our population”
cal education away from the earlier aim of enhancing (p. 55). The goals most frequently cited for physical
performance and health to a new focus on sports- education between 1941 and 1945 were resistance to
related skills and the worthy use of leisure time. disease, muscular strength and endurance, cardio-
Physical efficiency was a term widely used in respiratory endurance, muscular growth, flexibility,
the literature of the 1930s. Another term, physical speed, agility, balance, and accuracy (Larson and
condition, also found its way into research reports. Yocom 1951).
In 1936, Arthur Steinhaus published one of the After World War II concluded, a continuing
earliest articles on “physical fitness” in the Journal interest in physical fitness convinced other key mem-
of Health, Physical Education, and Recreation; in bers of the medical profession and the American
1938, C. H. McCloy’s article “Physical Fitness and Medical Association to continue studying exercise.
Citizenship” appeared in the same journal. Much of this interest can be attributed to the pioneer-
As the United States entered World War II, the ing work of Thomas K. Cureton, Jr., and his Physical
federal government showed increasing interest in Fitness Research Laboratory at the University of Illinois
physical education, especially toward physical fit- (Shea 1993). Cardiologists, health education special-
ness testing and preparedness. In October 1940, ists, and physicians in preventive medicine were be-
President Franklin Roosevelt named John Kelly, a coming aware of the contributions of exercise to the
former Olympic rower, to the new position of overall health and efficiency of the heart and circula-
national director of physical training. The follow- tory system. In 1946, the American Medical
ing year, Fiorella La Guardia, the Mayor of New Association’s Bureau of Health Education designed
York City and the director of civilian defense for the and organized the Health and Fitness Program to
Federal Security Agency, appointed Kelly as assis- provide “assistance to local organizations throughout
tant in charge of physical fitness; tennis star Alice the nation in the development of satisfactory health
Marble was also chosen to promote physical fitness education programs” (Fishbein 1947, p. 1009). The
among girls and women (Park 1989; Berryman program became an important link among physical
1995). educators, physicians, and physiologists.
In 1943, Arthur Steinhaus chaired a committee The event that attracted the most public attention
appointed by the Board of Directors of the American to physical fitness, including that of President Dwight
Medical Association to review the nature and role of D. Eisenhower, was the publication of the article
exercise in physical fitness (Steinhaus et al. 1943), “Muscular Fitness and Health” in the December 1953
and C. Ward Crampton chaired a committee on issue of the Journal of Health, Physical Education,
physical fitness under the direction of the Federal and Recreation. The authors, Hans Kraus and Ruth
Security Agency. Crampton and his 73-member Hirschland of the Institute of Physical Medicine
advisory council were charged with developing physi- and Rehabilitation at the New York University
cal fitness in the civilian population (Crampton 1941; Bellevue Medical Center, stated that 56.6 per-
Park 1989). cent of the American schoolchildren tested “failed
In 1941, Morris Fishbein, editor of the Journal of to meet even a minimum standard required for
the American Medical Association, stated that “from health” (p. 17). When this rate was compared with
the point of view on physical fitness we are a far the 8.3 percent failure rate for European children, a

17
Physical Activity and Health

call for reform went out. Kraus and Hirschland 1975, AAHPER stated it was time to differentiate
labeled the lack of sufficient exercise “a serious physical fitness related to health from performance
deficiency comparable with vitamin deficiency” and related to athletic ability (Blair, Falls, Pate 1983).
declared “an urgent need” for its remedy (pp. 17–19). Accordingly, AAHPER commissioned the develop-
John Kelly, the former national director of physical ment of the Health Related Physical Fitness Test. This
fitness during World War II, notified Pennsylvania move in youth fitness paralleled the adoption of the
Senator James Duff of these startling test results. aerobic concept, which promoted endurance-type
Duff, in turn, brought the research to the attention of exercise among the public (Cooper 1968).
President Eisenhower, who invited several athletes
and exercise experts to a meeting in 1955 to examine Exercise Physiology Research and Health
this issue in more depth. A President’s Conference The study of the physiology of exercise in a modern
on Fitness of American Youth, held in June 1956, sense began in Paris, France, when Antoine Lavoisier
was attended by 150 leaders from government, physi- in 1777 and Lavoisier and Pierre de Laplace in 1780
cal education, medical, public health, sports, civic, developed techniques to measure oxygen uptake and
and recreational organizations. This meeting even- carbon dioxide production at rest and during exer-
tually led to the establishment of the President’s cise. During the 1800s, European scientists used and
Council on Youth Fitness and the President’s Citizens advanced these procedures to study the metabolic
Advisory Committee on the Fitness of American responses to exercise (Scharling 1843; Smith 1857;
Youth (Hackensmith 1966; Van Dalen and Bennett Katzenstein 1891; Speck 1889; Allen and Pepys
1971). 1809). The first major application of this research to
When John Kennedy became president in 1961, humans—Edward Smith’s study of the effects of
one of his first actions was to call a conference on “assignment to hard labor” by prisoners in London
physical fitness and young people. In 1963, the in 1857—was to determine if hard manual labor
President’s Council on Youth Fitness was renamed negatively affected the health and welfare of the
the President’s Council on Physical Fitness. In 1968, prisoners and whether it should be considered cruel
the word “sports” was added to the name, making it and unusual punishment.
the President’s Council on Physical Fitness and Sports William Byford published “On the Physiology of
(PCPFS). The PCPFS was charged with promoting Exercise” in the American Journal of Medical Sciences
physical activity, fitness, and sports for Americans of in 1855, and Edward Mussey Hartwell, a leading
all ages. physical educator, wrote a two-part article, “On the
During the 1960s, a number of educational and Physiology of Exercise,” for the Boston Medical and
public health organizations published articles and Surgical Journal in 1887. The first important book on
statements on the importance of fitness for children the subject, George Kolb’s Beitrage zur Physiologie
and youths. The American Association for Health, Maximaler Muskelarbeit Besonders des Modernen Sports,
Physical Education, and Recreation (AAHPER) ex- was published in 1887 (trans. Physiology of Sport,
panded its physical fitness testing program to in- 1893) (cited in Langenfeld 1988 and Park 1992). The
clude college-aged men and women. The association following year, Fernand Lagrange’sPhysiology of Bodily
developed new norms from data collected from more Exercise was published in France.
than 11,000 boys and girls 10–17 years old. The From the early 1900s to the early 1920s, several
AAHPER also joined with the President’s Council on works on exercise physiology began to appear. George
Physical Fitness to conduct the AAHPER Youth Fitz, who had established a physiology of exercise
Fitness Test, which had motivational awards. In laboratory during the early 1890s, published his
1966, President Lyndon Johnson’s newly created Principles of Physiology and Hygiene in 1908. R. Tait
Presidential Physical Fitness Award was incorpo- McKenzie’s Exercise in Education and Medicine (1909)
rated into the program. was followed by such works as Francis Benedict and
In the mid-1970s, the need to promote the health— Edward Cathcart’s Muscular Work, A Metabolic Study
rather than exclusively the performance—benefits of with Special Reference to the Efficiency of the Human
exercise and physical fitness began to reappear. In Body as a Machine (1913). The next year, a professor

18
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

of physiology at the University of London, F.A. effects of different types, intensities, durations, or
Bainbridge, published a second edition of Physiology frequencies of exercise on performance capacity or
of Muscular Exercise (Park 1981). health-related outcomes.
In 1923, the year Archibald Hill was appointed Activities surrounding World War II greatly in-
Joddrell Professor of Physiology at University Col- fluenced the research in exercise physiology, and
lege, London, the physiology of exercise acquired several laboratories, including the Harvard Fatigue
one of its most respected researchers and staunchest Laboratory, began directing their efforts toward top-
supporters, for Hill had won the Nobel Prize in ics of importance to the military. The other national
Medicine and Physiology the year before. Hill’s 1925 concern that created much interest among physiolo-
presidential address on “The Physiological Basis of gists was the fear (discussed earlier in this chapter),
Athletic Records” to the British Association for the that American children were less fit than their Euro-
Advancement of Science appeared in The Lancet pean counterparts. Research was directed toward the
(1925a) and Scientific Monthly (1925b), and in 1926 concept of fitness in growth and development, ways
he published his landmark book Muscular Activity. to measure fitness, and the various components of
The following year, Hill published Living Machinery, fitness (Berryman 1995). Major advances were also
which was based largely on his lectures before audi- made in the 1940s and 1950s in developing the
ences at the Lowell Institute in Boston and the Baker components of physical fitness (Cureton 1947) and
Laboratory of Chemistry in Ithaca, New York. in determining the effects of endurance and strength
Several leading physiologists besides Hill were training on measures of performance and physi-
interested in the human body’s response to exercise ologic function, especially adaptations of the cardio-
and environmental stressors, especially activities vascular and metabolic systems. Also investigated
involving endurance, strength, altitude, heat, and were the effects of exercise training on health-related
cold. Consequently, they studied soldiers, athletes, outcomes, such as cholesterol metabolism (Taylor,
aviators, and mountain climbers as the best models Anderson, Keys 1957; Montoye et al. 1959).
for acquiring data. In the United States, such re- Starting in the late 1950s and continuing through
search was centered in the Boston area, first at the the 1970s, a rapidly increasing number of published
Carnegie Nutrition Laboratory in the 1910s and studies evaluated or compared different components
later at the Harvard Fatigue Laboratory, which was of endurance-oriented exercise training regimens.
established under the leadership of Lawrence For example, Reindell, Roskamm, and Gerschler
Henderson in 1927 (Chapman and Mitchell 1965; (1962) in Germany, Christensen (1960) in Denmark,
Dill 1967; Horvath and Horvath 1973). That year, and Yakovlev and colleagues (1961) in Russia
Henderson and colleagues first demonstrated that compared—and disagreed—about the relative ben-
endurance exercise training improved the efficiency efits of interval versus continuous exercise train-
of the cardiovascular system by increasing stroke ing in increasing cardiac stroke volume and
volume and decreasing heart rate at rest. Two years endurance capacity. Other investigators began to
later, Schneider and Ring (1929) published the evaluate the effects of different modes (Sloan and
results of a 12-week endurance training program on Keen 1959) and durations (Sinasalo and Juurtola
one person, demonstrating a 24-percent increase in 1957) of endurance-type training on physiologic
“crest load of oxygen” (maximal oxygen uptake). and performance measures.
Over the next 15 years, a limited number of exercise Karvonen and colleagues’ (1957) landmark paper
training studies were published that evaluated the that introduced using “percent maximal heart rate
response of maximal oxygen uptake or endurance reserve” to calculate or express exercise training in-
performance capacity to exercise training. These tensity was one of the first studies designed to com-
included noteworthy reports by Gemmill and col- pare the effects of two different exercise intensities on
leagues (1931), Robinson and Harmon (1941), and cardiorespiratory responses during exercise. Over the
Knehr, Dill, and Neufeld (1942) on endurance next 20 years, numerous investigators documented
training responses by male college students. How- the effects of different exercise training regimens on a
ever, none of those early studies compared the variety of health-related outcomes among healthy

19
Physical Activity and Health

men and women and among persons under medical either property. This situation has caused some
care (Bouchard, Shephard, Stephens 1994). Many of confusion. Typically, mechanical classification
these studies evaluated the effects of endurance or stresses whether the muscle contraction produces
aerobic exercise training on cardiorespiratory capac- movement of the limb: isometric (same length) or
ity and were initially summarized by Pollock (1973). static exercise if there is no movement of the limb, or
The American College of Sports Medicine (ACSM) isotonic (same tension) or dynamic exercise if there
(1975, 1978) and the American Heart Association is movement of the limb. Metabolic classification
(AHA) (1975) further refined the results of this re- involves the availability of oxygen for the contrac-
search (see the section on “Evolution of Physical tion process and includes aerobic (oxygen available)
Activity Recommendations,” later in this chapter). or anaerobic (oxygen unavailable) processes.
Over the past two decades, experts from numer- Whether an activity is aerobic or anaerobic depends
ous disciplines have determined that exercise training primarily on its intensity. Most activities involve
substantially enhances physical performance and have both static and dynamic contractions and aerobic
begun to establish the characteristics of the exercise and anaerobic metabolism. Thus, activities tend to
required to produce specific health benefits (Bouchard, be classified according to their dominant features.
Shephard, Stephens 1994). Also, behavioral scientists The physical activity of a person or group is
have begun to evaluate what determines physical frequently categorized by the context in which it
activity habits among different segments of the popu- occurs. Common categories include occupational,
lation and are developing strategies to increase physi- household, leisure time, or transportation. Leisure-
cal activity among sedentary persons (Dishman 1988). time activity can be further subdivided into catego-
The results of much of this research are cited in the ries such as competitive sports, recreational activities
other chapters of this report and were the focus of the (e.g., hiking, cycling), and exercise training.
various conferences, reports, and guidelines summa- Exercise (or exercise training). Exercise and
rized later in this chapter. physical activity have been used synonymously in
As the literature of exercise science has matured the past, but more recently, exercise has been used to
and recommendations have evolved, certain widely denote a subcategory of physical activity: “physical
agreed-on terms have emerged. Because a number of activity that is planned, structured, repetitive, and
these occur throughout the rest of this chapter and purposive in the sense that improvement or mainte-
report, they are presented and briefly defined in the nance of one or more components of physical fitness
following section. is the objective” (Caspersen, Powell, Christensen
1985). Exercise training also has denoted physical
activity performed for the sole purpose of enhancing
Terminology of Physical Activity, physical fitness.
Physical Fitness, and Health Physical fitness. Physical fitness has been de-
fined in many ways (Park 1989). A generally ac-
This section discusses four broad terms used frequently
cepted approach is to define physical fitness as the
in this report: physical activity, exercise (or exercise
ability to carry out daily tasks with vigor and alert-
training), physical fitness, and health. Also included is
ness, without undue fatigue, and with ample energy
a glossary (Table 2-1) of more specific terms and
to enjoy leisure-time pursuits and to meet unfore-
concepts crucial to understanding the material pre-
seen emergencies. Physical fitness thus includes car-
sented in later parts of this chapter and report.
diorespiratory endurance, skeletal muscular
Physical activity. Physical activity is defined as
endurance, skeletal muscular strength, skeletal mus-
bodily movement produced by the contraction of
cular power, speed, flexibility, agility, balance, reac-
skeletal muscle that increases energy expenditure
tion time, and body composition. Because these
above the basal level. Physical activity can be cat-
attributes differ in their importance to athletic
egorized in various ways, including type, intensity,
performance versus health, a distinction has been
and purpose.
made between performance-related fitness and
Because muscle contraction has both mechani-
health-related fitness (Pate 1983; Caspersen, Powell,
cal and metabolic properties, it can be classified by
Christensen 1985). Health-related fitness has been

20
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

Table 2-1. Glossary of terms

Aerobic training—Training that improves the efficiency of the Kilojoule (kjoule)—A measurement of energy. 4.184 kilojoules =
aerobic energy-producing systems and that can improve 4,184 joules = 1 Calorie = 1 kilocalorie.
cardiorespiratory endurance.* Maximal heart rate reserve—The difference between maximum
Agility—A skill-related component of physical fitness that relates heart rate and resting heart rate.*
to the ability to rapidly change the position of the entire body in Maximal oxygen uptake ( V̇O2 max )—The maximal capacity
space with speed and accuracy.† for oxygen consumption by the body during maximal exertion.
Anaerobic training—Training that improves the efficiency of the It is also known as aerobic power, maximal oxygen consumption,
anaerobic energy-producing systems and that can increase and cardiorespiratory endurance capacity.*
muscular strength and tolerance for acid-base imbalances during Maximal heart rate (HR max)—The highest heart rate value
high-intensity effort.* attainable during an all-out effort to the point of exhaustion.*
Balance—A skill-related component of physical fitness that Metabolic equivalent (MET)—A unit used to estimate the
relates to the maintenance of equilibrium while stationary or metabolic cost (oxygen consumption) of physical activity. One
moving.† MET equals the resting metabolic rate of approximately 3.5 ml
Body composition—A health-related component of physical O2 • kg-1 • min-1 .*
fitness that relates to the relative amounts of muscle, fat, bone, Muscle fiber—An individual muscle cell.*
and other vital parts of the body.†
Muscular endurance—The ability of the muscle to continue to
Calorimetry—Methods used to calculate the rate and quantity perform without fatigue.*
of energy expenditure when the body is at rest and during
exercise.* Overtraining—The attempt to do more work than can be
physically tolerated.*
Direct calorimetry—A method that gauges the body’s rate
and quantity of energy production by direct measurement of Physical activity—Bodily movement that is produced by the
the body’s heat production; the method uses a calorimeter, contraction of skeletal muscle and that substantially increases
which is a chamber that measures the heat expended by the energy expenditure.
body.* Physical fitness—A set of attributes that people have or achieve
Indirect calorimetry—A method of estimating energy that relates to the ability to perform physical activity.
expenditure by measuring respiratory gases. Given that the Power—A skill-related component of physical fitness that relates
amount of O2 and CO2 exchanged in the lungs normally to the rate at which one can perform work.
equals that used and released by body tissues, caloric
expenditure can be measured by CO2 production and O2 Relative perceived exertion (RPE)—A person’s subjective
consumption.* assessment of how hard he or she is working. The Borg scale is a
numerical scale for rating perceived exertion.*
Cardiorespiratory endurance (cardiorespiratory fitness)—A
health-related component of physical fitness that relates to the Reaction time—A skill-related component of physical fitness that
ability of the circulatory and respiratory systems to supply oxygen relates to the time elapsed between stimulation and the beginning
during sustained physical activity.† of the reaction to it.†
Coordination—A skill-related component of physical fitness that Resistance training—Training designed to increase strength,
relates to the ability to use the senses, such as sight and hearing, power, and muscle endurance.*
together with body parts in performing motor tasks smoothly Resting heart rate—The heart rate at rest, averaging 60 to 80
and accurately.† beats per minute.*
Detraining—Changes the body undergoes in response to a Retraining—Recovery of conditioning after a period of inactivity.*
reduction or cessation of regular physical training.*
Speed—A skill-related component of physical fitness that relates
Endurance training/endurance activities—Repetitive, aerobic to the ability to perform a movement within a short period of
use of large muscles (e.g., walking, bicycling, swimming).‡ time.†
Exercise (exercise training)—Planned, structured, and repetitive Strength—The ability of the muscle to exert force.*
bodily movement done to improve or maintain one or more
components of physical fitness. Training heart rate (THR)—A heart rate goal established by using
the heart rate equivalent to a selected training level (percentage
Flexibility—A health-related component of physical fitness that of V̇O 2 max ). For example, if a training level of 75 percent V̇O2
relates to the range of motion available at a joint.* max is desired, theV̇O2 at 75 percent is determined and the heart
Kilocalorie (kcal)—A measurement of energy. 1 kilocalorie = 1 rate corresponding to this VO2 is selected as the THR.*
Calorie = 4,184 joules = 4.184 kilojoules.

*From Wilmore JH, Costill DL. Physiology of sport and exercise . Champaign, IL: Human Kinetics, 1994.
† From Corbin CB, Lindsey R. Concepts in physical education with laboratories. 8th ed. Dubuque, IA: Times Mirror Higher Education Group, 1994.
‡ Adapted from Corbin CB, Lindsey R, 1994, and Wilmore JH, Costill DL, 1994.

21
Physical Activity and Health

said to include cardiorespiratory fitness, muscular exercise training of 3–5 days per week, an intensity
strength and endurance, body composition, and flex- of training of 60–90 percent of maximal heart rate
ibility. The relative importance of any one attribute (equivalent to 50–85 percent of maximal oxygen
depends on the particular performance or health goal. uptake or heart rate reserve), a duration of 15–60
Health. The 1988 International Consensus Con- minutes per training session, and the rhythmical and
ference on Physical Activity, Physical Fitness, and aerobic use of large muscle groups through such
Health (Bouchard et al. 1990) defined health as “a activities as running or jogging, walking or hiking,
human condition with physical, social, and psycho- swimming, skating, bicycling, rowing, cross-country
logical dimensions, each characterized on a con- skiing, rope skipping, and various endurance games
tinuum with positive and negative poles. Positive or sports (Table 2-2).
health is associated with a capacity to enjoy life and Between 1978 and 1990, most exercise recom-
to withstand challenges; it is not merely the absence mendations made to the general public were based
of disease. Negative health is associated with mor- on this 1978 position statement, even though it
bidity and, in the extreme, with premature mortal- addressed only cardiorespiratory fitness and body
ity.” Thus, when considering the role of physical composition. By providing clear recommendations,
activity in promoting health, one must acknowledge these guidelines proved invaluable for promoting
the importance of psychological well-being, as well cardiorespiratory endurance, although many people
as physical health. overinterpreted them as guidelines for promoting
overall health. Over time, interest developed in po-
tential health benefits of more moderate forms of
Evolution of Physical Activity physical activity, and attention began to shift to
Recommendations alternative physical activity regimens (Haskell 1984;
Blair, Kohl, Gordon 1992; Blair 1993).
In the middle of the 20th century, recommendations
In 1990, the ACSM updated its 1978 position
for physical activity to achieve fitness and health
statement by adding the development of muscular
benefits were based on systematic comparisons of
strength and endurance as a major objective (ACSM
effects from different profiles of exercise training
1990). The recommended frequency, intensity, and
(Cureton 1947; Karvonen, Kentala, Mustala 1957;
mode of exercise remained similar, but the duration
Christensen 1960; Yakolav et al. 1961; Reindell,
was slightly increased from 15–60 minutes to 20–60
Roskamm, Gerschler 1962). In the 1960s and 1970s,
minutes per session, and moderate-intensity resis-
expert panels and committees, operating under the
tance training (one set of 8–12 repetitions of 8–10
auspices of health- or fitness-oriented organizations,
different exercises at least 2 times per week) was
began to recommend specific physical activity pro-
suggested to develop and maintain muscular strength
grams or exercise prescriptions for improving physi-
and endurance (Table 2-2). These 1990 recommen-
cal performance capacity or health (President’s
dations also recognized that activities of moderate
Council on Physical Fitness 1965; AHA 1972, 1975;
intensity may have health benefits independent of
ACSM 1975). These recommendations were based
cardiorespiratory fitness:
on substantial clinical experience and on scientific
data available at that time. Since the original position statement was pub-
Pollock’s 1973 review of what type of exercise lished in 1978, an important distinction has
was needed to improve aerobic power and body been made between physical activity as it
composition subsequently formed the basis for a relates to health versus fitness. It has been
1978 position statement by the ACSM titled “The pointed out that the quantity and quality of
Recommended Quantity and Quality of Exercise for exercise needed to obtain health-related ben-
Developing and Maintaining Fitness in Healthy efits may differ from what is recommended
Adults.” This statement outlined the exercise that for fitness benefits. It is now clear that lower
healthy adults would need to develop and maintain levels of physical activity than recommended
cardiorespiratory fitness and healthy body composi- by this position statement may reduce the
tion. These guidelines recommended a frequency of risk for certain chronic degenerative diseases

22
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

and yet may not be of sufficient quantity or and Pulmonary Rehabilitation has also published
quality to improve [maximal oxygen uptake]. guidelines for using physical activity for cardiac
ACSM recognizes the potential health benefits (1991, 1995) and pulmonary (1993) rehabilitation.
of regular exercise performed more frequently Some of these recommendations provide substantial
and for longer duration, but at lower intensi- advice to ensure that exercise programs are safe for
ties than prescribed in this position statement. people at increased risk for heart disease or for
patients with established disease.
In conjunction with a program to certify exercise
Between the 1970s and the mid-1990s, exercise
professionals at various levels of experience and
training studies conducted on middle-aged and older
competence, the ACSM has published five editions
persons and on patients with lower functional capac-
of Guidelines for Exercise Testing and Prescription
ity demonstrated that significant cardiorespiratory
(ACSM 1975, 1980, 1986, 1991, 1995b) that de-
performance and health-related benefits can be ob-
scribe the components of the exercise prescription
tained at more moderate levels of activity intensity
and explain how to initiate and complete a proper
than previously realized. In addition, population-
exercise training program (Table 2-2). The ACSM
based epidemiologic studies demonstrated dose-
has also published recommendations on the role
response gradients between physical activity and
of exercise for preventing and managing hyper-
health outcomes. As a result of these findings, the
tension (1993) and for patients with coronary
most recent CDC-ACSM guidelines recommend that
heart disease (1994) and has published a position
all adults perform 30 or more minutes of moderate-
stand on osteoporosis (1995a). For the most
intensity physical activity on most, and preferably
part, newer recommendations that focus on spe-
all, days—either in a single session or “accumulated”
cific health outcomes are consistent with the
in multiple bouts, each lasting at least 8–10 minutes
ACSM’s 1978 and 1990 position statements, but
(Pate et al. 1995). This guideline thus significantly
they generally expand the range of recommended
differs from the earlier ones on three points: it
activities to include moderate-intensity exercise.
reduces the minimum starting exercise intensity
Between the 1960s and 1990s, other U.S. health
from 60 percent of maximal oxygen uptake to 50
and fitness organizations published recommenda-
percent in healthy adults and to 40 percent in pa-
tions for physical activity. Because these organiza-
tients or persons with very low fitness; it increases
tions used the same scientific data as the ACSM, their
the frequency of exercise sessions from 3 days per
position statements and guidelines are similar. A
week to 5–7 days per week, depending on intensity
notable example is Healthy People 2000 (USDHHS
and session duration; and it includes the option of
1990), the landmark publication of the U.S. Public
accumulating the minimum of 30 minutes per day in
Health Service that lists various health objectives for
multiple sessions lasting at least 8–10 minutes (Pate
the nation. (The objectives for physical activity and
et al. 1995). This modification in advice acknowl-
fitness, as revised in 1995 [USDHHS 1995], are
edges that people who are sedentary and who do not
included as Appendix A of this chapter.) Other
enjoy, or are otherwise not able to maintain, a regi-
recommendations include specific exercise programs
men of regular, vigorous activity can still derive
developed for men and women by the President’s
substantial benefit from more moderate physical
Council on Physical Fitness (1965) and the YMCA
activity as long as it is done regularly.
(National Council YMCA 1989). The AHA (1972,
The NIH Consensus Development Conference
1975, 1992, 1993, 1994, 1995) has published for
Statement on Physical Activity and Cardiovascular
both health professionals and the public a series of
Health identifies physical inactivity as a major pub-
physical activity recommendations and position state-
lic health problem in the United States and issues a
ments directed at CHD prevention and cardiac reha-
call to action to increase physical activity levels
bilitation. In 1992, the AHA published a statement
among persons in all population groups. (See Ap-
identifying physical inactivity as a fourth major risk
pendix B for full text of the recommendations.) The
factor for CHD, along with smoking, high blood
core recommendations, similar to those jointly made
pressure, and high blood cholesterol (Fletcher et al.
by the CDC and the ACSM (Pate et al. 1995), call for
1992). The American Association of Cardiovascular

23
Physical Activity and Health

Table 2-2. Selected physical activity recommendations in the United States (1965–1996)
Source Objective Type/mode
PCPF (1965) Physical fitness General fitness
AHA Recommendations (1972) CHD prevention Endurance
YMCA (1973) General health and fitness Endurance, strength, flexibility
ACSM Guidelines (1975) Cardiorespiratory fitness Endurance, strength, flexibility

AHA Recommendations (1975) Secondary prevention in patients Endurance

with heart disease
ACSM Position Statement (1978) Cardiorespiratory fitness Endurance
and body composition

USDHEW–Healthy People (1979) Disease prevention/ Endurance

health promotion
ACSM Guidelines (1980) Cardiorespiratory fitness Endurance, strength, flexibility

ACSM Guidelines (1986) Cardiorespiratory fitness Endurance, strength, flexibility

USDHHS–Surgeon General’s Report Weight control Endurance

on Nutrition and Health (1988)
USPSTF (1989) Primary prevention in clinical practice Not specified, implied endurance
ACSM Position Stand (1990) Cardiorespiratory and muscular Endurance, strength
fitness

ACSM Guidelines (1991) Cardiorespiratory fitness Endurance, strength, flexibility

USHHS/USDA Dietary Health promotion/disease prevention, Not specified

Guidelines (1990) weight maintenance
AACVPR (1991) Cardiac rehabilitation Endurance, strength

DHHS-Healthy People 2000 (1991)* Disease prevention/health promotion Endurance, strength, flexibility

AHA Position Statement (1992) CVD prevention and rehabilitation Endurance

AHA Standards (1992 and 1995) CHD prevention and rehabilitation Endurance, strength

AACVPR (1993) Pulmonary rehabilitation Endurance

ACSM Position Statement (1993) Prevention and treatment Endurance, strength
of hypertension

24
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

Endurance Resistance training

Intensity Frequency Duration
Five levels 5 x week Approximately 30 minutes Selected calisthenics
70–85% MHR 3–7 x week 15–20 minutes Not addressed
80% V̇O2 max 3 x week 40–45 minutes Not specified
60–90% V̇O2 max 3 x week 20–30 minutes Not specified
60–90% HRR
70–85% MHR 3–4 x week 20–60 minutes Not addressed

50–85% V̇O2 max 3–5 x week 15–60 minutes Not addressed

50–85% HRR
60–90% MHR
Moderate/hard 3 x week 15–30 minutes Not addressed

50–85% V̇O2 max/HRR 3–5 x week 15–60 minutes Not specified

60–90% MHR
50–85% V̇O2 max/HRR 3–5 x week 15–60 minutes Not specified
60–90% MHR
Not specified ≥ 3 x week ≥ 20 minutes Not addressed

At least moderate Not specified Not specified Not addressed

50–85% V̇O2 max 3–5 x week 20–60 minutes 1 set, 8–12 repetitions
50–85% HRR 8–10 exercises
60–90% MHR 2 days x week
40–85% V̇O2 max 3–5 x week 15–60 minutes Not specified
55–90% MHR
RPE = 12–16
Not specified Not specified Not specified Not addressed

Exercise following ACSM 3–5 x week 15–60 minutes 1–3 sets, 12–15 repetitions
(1986) and AHA (1983) major muscle groups
recommendations 2–3 days x week
Light/moderate/vigorous 3–5 x week 20–30 minutes Not specified

> 50% V̇O2 max 3–4 x week 30–60 minutes Not addressed
50–60% V̇O2 max ≥ 3 x week ≥ 30 minutes 1 set, 10–15 repetitions
50–60% HR reserve 8–10 exercises,
2–3 days x week
60% HR reserve 3 x week 20–30 minutes Not addressed
40–70% V̇O2 max 3–5 x week 20–60 minutes Not specified

25
Physical Activity and Health

Table 2-2. Continued

Source Objective Type/mode
AHA Position CVD prevention Moderate intensity
Statement (1993) and rehabilitation (i.e., brisk walking) integrated
into daily routine
ACSM Position Stand (1994) Secondary prevention in patients Endurance, strength
with coronary heart disease

AHA Position Statement (1994) Cardiac rehabilitation Endurance and strength training
of moderate intensity following
other guidelines
Physical Activity Guidelines Lifetime health promotion Endurance
for Adolescents (1994)† for adolescents
AACVPR (1995) Cardiac rehabilitation Endurance, strength

ACSM Guidelines (1995) Cardiorespiratory fitness Endurance, strength

and muscular fitness

ACSM Position Stand (1995) Prevention of osteoporosis Strength, flexibility, coordination,

cardiorespiratory fitness
AHCPR (1995) Cardiac rehabilitation Endurance, strength

AMA Guidelines for Health promotion/ Endurance

Adolescent Preventive physical fitness
Services (GAPS) (1994)
CDC/ACSM (1995)‡ Health promotion Endurance

USHHS/USDA Dietary Health promotion/disease Endurance

Guidelines (1995) prevention, weight maintenance
NHLBI Consensus Conference CVD prevention for adults and Endurance
(1996) children and cardiac rehabilitation
USPSTF (1996) Primary prevention Endurance, strength, flexibility
in clinical practice

26
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

Endurance Resistance training

Intensity Frequency Duration
Not specified Not specified Not specified Not addressed

40–85% V̇O 2 max 3 x week, 20–40 minutes Not specified

40–85% HRR nonconsecutive days
55–90% MHR
Not specified Not specified Not specified Not specified

Moderate/vigorous 3 x week, vigorous ≥ 20 minutes, vigorous Not addressed

daily, moderate not specified, moderate
> 50% V̇O2 max 3–5 x week 30–45 minutes, 200–300 1 set, 10–15 repetitions,
RPE 12–14 kcal per session or major muscle groups
1,000–1,500 kcal per week 2–3 days x week
40–85% V̇O2 max/HRR 3-5 x week 12–15 minutes initially: 1 set, 8–12 repetitions
RPE 12–16 20–30 minutes for 8–10 exercises
conditioning and 2 days x week
maintaining
Not specified Not specified Not specified Not specified

70–85% MHR 3 x week 20–40 minutes Not specified

Moderate ≥ 3 x week 20–30 minutes Not addressed

Moderate/hard All or most days ≥ 30 minutes per day Not specified

in bouts of at least 8–10
minutes
Moderate All or most days ≥ 30 minutes per day Not addressed

Moderate/hard All or most days ≥ 30 minutes per day Not addressed

Moderate Most days 30 minutes Not specified

*See Appendix B for listing of objectives. †See Sallis and Patrick, 1994. ‡ See Pate et al., 1995.
Key to associations: AACVPR = American Association for Cardiovascular and Pulmonary Rehabilitation; ACSM = American College of Sports
Medicine; AHA = American Heart Association; AHCPR = Agency for Health Care Policy and Research; CDC = Centers for Disease Control and
Prevention; NHLBI = National Heart, Lung, and Blood Institute; PCPF = President’s Council on Physical Fitness; USDA = United States Department
of Agriculture; USDHEW = United States Department of Health, Education, and Welfare; USDHHS = United States Department of Health and
Human Services; USPSTF = United States Preventive Services Task Force; YMCA = Young Men’s Christian Association.
Key to abbreviations: CHD = coronary heart disease; CVD = cardiovascular disease; HRR = heart rate reserve; MHR = maximal heart rate;
RPE = rating of perceived exertion; V̇O2 max = maximal oxygen uptake.
Not addressed = not included in recommendations. Not specified = recommended but not quantified.

27
Physical Activity and Health

all children and adults to accumulate at least 30 Medical Association’s Guidelines for Adolescent
minutes per day of moderate-intensity physical Preventive Services (GAPS) (AMA 1994) recom-
activity. The recommendations also acknowledge mends that physicians provide annual physical ac-
that persons already achieving this minimum could tivity counseling to all adolescents.
experience greater benefits by increasing either the
duration or the intensity of activity. In addition, the
statement recommends more widespread use of car- Summary of Recent Physical
diac rehabilitation programs that include physical Activity Recommendations
activity.
Sedentary persons can increase their physical activ-
The consensus statement from the 1993 Inter-
ity in many ways. The traditional, structured ap-
national Consensus Conference on Physical Activ-
proach originally described by the ACSM and others
ity Guidelines for Adolescents (Sallis and Patrick
involved rather specific recommendations regard-
1994) emphasizes that adolescents should be physi-
ing type, frequency, intensity, and duration of ac-
cally active every day as part of general lifestyle
tivity. Recommended activities typically included
activities and that they should engage in 3 or more
fast walking, running, cycling, swimming, or aero-
20-minute sessions of moderate to vigorous exer-
bics classes. More recently, physical activity recom-
cise each week. The American Academy of Pediat-
mendations have adopted a lifestyle approach to
rics has issued several statements encouraging active
increasing activity (Pate et al. 1995). This method
play in preschool children, assessment of children’s
involves common activities, such as brisk walking,
activity levels, and evaluation of physical fitness
climbing stairs (rather than taking the elevator),
(1992, 1994). Both the consensus statement and
doing more house and yard work, and engaging in
the American Academy of Pediatrics’ statements
active recreational pursuits. Recent physical activity
emphasize active play, parental involvement, and
recommendations thus acknowledge both the struc-
generally active lifestyles rather than specific vigor-
tured and lifestyle approaches to increasing physical
ous exercise training. They also acknowledge the
activity. Either approach can be beneficial for a
need for appropriate school physical education
sedentary person, and individual interests and op-
curricula.
portunities should determine which is used. The
Recognizing the important interrelationship of
most recent recommendations cited agree on sev-
nutrition and physical activity in achieving a balance
eral points:
between energy consumed and energy expended, the
1988 Surgeon General’s Report on Nutrition and • All people over the age of 2 years should
Health (USDHHS 1988) recommended physical ac- accumulate at least 30 minutes of endurance-
tivities such as walking, jogging, and bicycling for at type physical activity, of at least moderate
least 20 minutes, 3 times per week. The 1995 Dietary intensity, on most—preferably all—days of
Guidelines for Americans greatly expanded physical the week.
activity guidance to maintain and improve weight. • Additional health and functional benefits of
The bulletin recommends that all Americans engage physical activity can be achieved by adding
in 30 minutes of moderate-intensity physical activity more time in moderate-intensity activity, or
on all, or most, days of the week (USDA/USDHHS by substituting more vigorous activity.
1995). • Persons with symptomatic CVD, diabetes, or
The U.S. Preventive Services Task Force other chronic health problems who would like
(USPSTF) has recommended that health care pro- to increase their physical activity should be
viders counsel all patients on the importance of evaluated by a physician and provided an
incorporating physical activities into their daily exercise program appropriate for their clinical
routines to prevent coronary heart disease, hyper- status.
tension, obesity, and diabetes (Harris et al. 1989;
USPSTF 1989, 1996). Similarly, the American

28
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

• Previously inactive men over age 40, women (LaPorte, Montoye, Caspersen 1985; Caspersen
over age 50, and people at high risk for CVD 1989). Techniques used to gather this self-reported
should first consult a physician before em- information include diaries, logs, recall surveys,
barking on a program of vigorous physical retrospective quantitative histories, and global self-
activity to which they are unaccustomed. reports (Kannel, Wilson, Blair 1985; Wilson et al.
• Strength-developing activities (resistance train- 1986; Powell et al. 1987; Caspersen 1989). Surveys
ing) should be performed at least twice per are practical for assessing physical activity in large
week. At least 8–10 strength-developing exer- populations because they are not costly, are rela-
cises that use the major muscle groups of the tively easy to administer, and are generally accept-
legs, trunk, arms, and shoulders should be able to study participants (Montoye and Taylor 1984;
performed at each session, with one or two sets LaPorte, Montoye, Caspersen 1985; Caspersen 1989).
of 8–12 repetitions of each exercise. Information obtained from self-report instruments
has often been converted into estimates of energy
expenditure (i.e., kilocalories or kilojoules; meta-
Measurement of Physical Activity, bolic equivalents [METs]) or some other summary
measure that can be used to categorize or rank
Fitness, and Intensity persons by their physical activity level. This tech-
The ability to relate physical activity to health de- nique has also been used to convert job classifica-
pends on accurate, precise, and reproducible mea- tions into summary measures.
sures (Wilson et al. 1986; National Center for Health Diaries can detail virtually all physical activity
Statistics 1989). Measurement techniques have performed during a specified (usually short) period.
evolved considerably over the years (Park 1989), A summary index can be derived from a diary by
creating a shifting pattern of strength and weakness 1) summing the total duration of time spent in a
in the evidence supporting the assertion that physi- given activity multiplied by an estimated rate of
cal activity improves health (Ainsworth et al. 1994). energy expenditure for that activity, or 2) listing
The complexity is heightened by the different health accumulated time across all activities or time ac-
implications of measuring activity, gauging inten- crued within specific classes of activities. Compari-
sity, and assessing fitness. The tools currently in use sons with indirect calorimetry or with caloric intake
(Table 2-3) must be evaluated not only for their have shown that diaries are accurate indices of daily
efficacy in measuring an individual’s status, but also energy expenditure (Acheson et al. 1980). Because
for their applicability as instruments in larger-scale diaries are commonly limited to spans of 1–3 days,
epidemiologic research. These tools vary consider- they may not represent long-term physical activity
ably in the age groups to which they can be applied, patterns (LaPorte, Montoye, Caspersen 1985). Dia-
as well as in their cost, in their likelihood of affecting ries require intensive effort by the participant, and
the behavior they try to measure, and in their accept- their use may itself produce changes in the physical
ability. For example, many of the tools that are activities the participant does during the monitoring
appropriate for young and middle-aged persons are period (LaPorte, Montoye, Caspersen 1985;
less so for the elderly and may have no relevance at Caspersen 1989).
all for children. A brief review of these approaches Logs are similar to diaries but provide a record of
provides some insight into the current constellation participation in specific types of physical activity
of strengths and weaknesses on which epidemio- rather than in all activites (King et al. 1991). The
logic conclusions rest. time that activity was started and stopped may be
recorded, either soon after participation or at the end
Measuring Physical Activity of the day. Logs can be useful for recording partici-
Measures Based on Self-Report pation in an exercise training program. But as with
diaries, they can be inconvenient for the participant,
Physical activity is a complex set of behaviors most
and their use may itself influence the participant’s
commonly assessed in epidemiologic studies by ask-
behavior.
ing people to classify their level of physical activity

29
Physical Activity and Health

Table 2-3. Assessment procedures and their potential use in epidemiologic research
Use in Low Low
large Low Low subject subject Likely to Accep- Socially
Measurement Applicable scale $ time time effort influence table to accep- Activity
tool age groups studies cost cost cost cost behavior persons table specific
Surveying
Task specific diary adult, elderly yes yes yes no no yes ? yes yes
Recall questionnaire adult, elderly yes yes yes yes yes no yes yes yes
Quantitative history adult, elderly yes yes no no no no yes yes yes
Global self-report adult, elderly yes yes yes yes yes no yes yes no
Monitoring
Behavioral adult, elderly no no no no yes yes ? ? yes
observation
Job classification adult yes yes yes yes yes no yes yes yes
Heart rate monitor all no no no yes yes no yes yes no
Heart rate and
motion sensor all no no no yes yes no yes yes no
Electronic motion adult, elderly yes no yes yes yes no yes yes no
sensor
Pedometer adult, elderly yes yes yes yes yes no yes yes no
Gait assessment child, adult, no no yes yes yes no yes yes no
elderly
Accelerometers all yes yes yes yes yes no yes yes no
Horizontal time child, adult, no no yes yes yes no yes yes no
monitor elderly
Stabilometers infant no no yes yes yes no yes yes no
Direct calorimetry all no no no no no yes no no yes
Indirect calorimetry adult, elderly no no no no no yes no no yes
Doubly labeled child, adult, yes no no yes yes no yes yes no
water elderly
Modified from LaPorte, Montoye, Caspersen. Public Health Reports, 1985.
Note that most tests that are applicable for adults can be used in adolescents as well. Few tests can be applied to the pediatric age groups;
among infants, only direct calorimetry, accelerometers, heart rate monitoring, and stabilometers can be used with accuracy.

Recall surveys are less likely to influence behav- activity or more general estimates of usual or typical
ior and generally require less effort by the respon- participation. The recall survey is the method used
dent than either diaries or logs, although some for the national and state-based information systems
participants have trouble remembering details of providing data for Chapter 5 of this report.
past participation in physical activity (Baranowski The retrospective quantitative history—the most
1985). Recall surveys of physical activity generally comprehensive form of physical activity recall survey
have been used for time frames of from 1 week to a —generally requires specific detail for time frames of
lifetime (Kriska et al. 1988; Blair et al. 1991). They up to 1 year (LaPorte, Montoye, Caspersen 1985). If
can ascertain either precise details about physical the time frame is long enough, the quantitative history

30
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

can adequately represent year-round physical activ- associated with specific activities, a summary estimate
ity. For example, the Minnesota Leisure-Time Physi- of caloric output can be obtained from such observa-
cal Activity Questionnaire and the Tecumseh tion. An important subtype of this approach is the
questionnaire obtained information on the average classification of work based on the amount of physical
frequency and duration of participation for a specific activity it requires. These approaches can be labor-
list of physical activities performed over the previous intensive (hence prohibitively expensive for large-
year (Montoye and Taylor 1984; Taylor et al. 1978). scale studies) but are usually well accepted by study
Unfortunately, obtaining this abundance of data is a participants.
heavy demand on the respondent’s memory, and the In the category of mechanical or electronic mea-
complexity of the survey generates additional ex- surement, various instruments have been used to
pense (LaPorte, Montoye, Caspersen 1985). monitor heart rate and thus provide a continuous
Global self-reports, another type of recall survey, recording of a physiologic process that reflects both
ask individuals to rate their physical activity rela- the duration and intensity of physical activity. Heart
tive to other people’s in general or to that of a rate is typically used to estimate daily energy expen-
similar age and sex group. This easy-to-use ap- diture (i.e., oxygen uptake) on physical activity; the
proach, which was employed for the National Health underlying assumption is that a linear relationship
Interview Survey (NCHS, Bloom 1982), tends to exists between heart rate and oxygen uptake. A
best represent participation in vigorous physical major disadvantage of heart rate monitoring is the
activity (Washburn, Adams, Haile 1987; Caspersen need to calibrate the heart rate–energy expenditure
and Pollard 1988; Jacobs et al. 1993). A weakness of curve for each individual. Another limitation is that
this approach is that persons reporting the same the relationship between heart rate and energy ex-
rating may have different actual physical activity penditure is variable for low-intensity physical ac-
profiles (Washburn, Adams, Haile 1987; Caspersen tivities. Most monitors have to be worn for extended
and Pollard 1988). periods by the participant, and they pose some dis-
Although survey approaches generally apply to comfort and inconvenience.
adults, adolescents, and the elderly, survey instru- Other approaches for using heart rate to measure
ments must often be tailored to the specific demo- physical activity include using the percentage of time
graphic requirements of the group under study. spent during daily activities in various ranges of
Recently, some researchers have suggested develop- heart rate (Gilliam et al. 1981), using the difference
ing special survey instruments for older persons between mean daily heart rate and resting heart rate
(Voorrips et al. 1991; Dipietro et al. 1993; Washburn (Sallis et al. 1990), and using the integration of the
et al. 1993) and adolescents or children (Noland et area under a heart rate versus time curve adjusted for
al. 1990; Sallis et al. 1993). resting heart rate (Freedson 1989). Heart rate alone
may not be a suitable surrogate for determining the
Measures Based on Direct Monitoring level of physical activity, given that other factors,
The major alternative to surveys is to directly mea- such as psychological stress or changes in body
sure physical activity through behavioral observa- temperature, can significantly influence heart rate
tion, mechanical or electronic devices, or throughout the day.
physiologic measurements (Table 2-3). Such ap- A variety of sensors have been developed to
proaches eliminate the problems of poor memory measure physical activity by detecting motion. Pe-
and biased self-reporting but are themselves lim- dometers, perhaps the earliest motion sensors, were
ited by high cost and the burden on participants designed to count steps and thus measure the dis-
and staff. Consequently, these measures have been tance walked or run. However, not all pedometers
used primarily in small-scale studies, though they are reliable enough for estimating physical activity in
have been used recently in some large-scale studies either laboratory or field research (Kashiwazaki et al.
(Lakka, Nyyssonen, Salonen 1994). 1986; Washburn, Janney, Fenster 1990). Electronic
Behavioral observation is the straightforward motion sensors tend to perform better than their
process of watching and recording what a person mechanical counterparts (Wong et al. 1981; Taylor
does. Using general guidelines for caloric expenditure et al. 1982; LaPorte et al. 1983). Their output has

31
Physical Activity and Health

been significantly correlated with energy expendi- Measuring Intensity of Physical Activity
ture assessed with indirect calorimetry in controlled Common terms used to characterize the intensity
laboratory conditions using graded treadmill exer- of physical activity include light or low, moderate
cise (Balogun, Amusa, Onyewadume 1988; Haskell or mild, hard or vigorous, and very hard or strenu-
et al. 1993; Montoye et al. 1996), under short-term ous (Table 2-4). A frequent approach to classify-
controlled activity (e.g., walking or cycling over a ing intensity has been to express it relatively—that
measured course) for heart rate during laboratory is, in relation to a person’s capacity for a specific
and daily activities, and for observed behavior in a type of activity. For example, the intensity pre-
controlled setting (Klesges and Klesges 1987; Rogers scribed for aerobic exercise training usually is ex-
et al. 1987; Freedson 1989; Sallis et al. 1990; pressed in relation to the person’s measured
Washburn, Janney, Fenster 1990). Direct validation cardiorespiratory fitness (ACSM 1990). Because
has shown reasonable correlation with physical ac- heart rate during aerobic exercise is highly associ-
tivity records completed over a year (Richardson et ated with the increase in oxygen uptake, the per-
al. 1995). Recording simultaneously both the heart centage of maximal heart rate is often used as a
rate and the motion from sensors on several parts of surrogate for estimating the percentage of maximal
the body and then calibrating each individual’s heart oxygen uptake (ACSM 1990). Exercise intensity
rate and motion sensor output versus oxygen uptake can also be expressed in absolute terms, such as a
for various activities can accurately estimate the specific type of activity with an assigned intensity
energy expended from physical activity (Haskell et (for example, walking at 4 miles per hour or jogging
al. 1993). Several other devices (e.g., accelerometers, at 6 miles per hour). Such quanta of work can also
stabilometers) are of lesser value for large-scale stud- be described in absolute terms as METs, where one
ies, and their use is limited to small physiologic MET is about 3.5 ml O2 • kg-1 • min-1, corresponding
investigations. to the body at rest. The workloads in the just-
Methods for physiologically monitoring energy quoted example are equivalent to 4 and 10 METs,
expenditure include direct calorimetry (requiring the respectively. The number of METs associated with
participant to remain in a metabolic chamber) and a wide range of specific activities can be estimated
indirect calorimetry (requiring the participant to wear from aggregated laboratory and field measurements
a mask and to carry equipment for analyzing expired (Ainsworth, Montoye, Leon 1994).
air). Both methods are too expensive and complicated The process of aging illustrates an important
for use in large-scale studies. Another physiologic relationship between absolute and specific mea-
measurement, the use of doubly labeled water, offers sures. As people age, their maximal oxygen uptake
researchers special opportunities to assess energy ex- decreases. Activity of a given MET value (an abso-
penditure. By using two stable isotopes (2H2O and lute intensity) therefore requires a greater percent-
H218O) measured every few days or weeks in the urine, age of their maximal oxygen uptake (a relative
researchers can calculate the rate of carbon dioxide intensity). The aforementioned walk at 4 miles per
production—a reflection of the rate of energy produc- hour (4 METs) may be light exercise for a 20-year-
tion in humans over time. According to their body old, moderate for a 60-year-old, and vigorous for an
weight, study participants drink a specified amount of 80-year-old.
these isotopes. A mass spectrometer is used to track Most exercise training studies have used relative
the amount of unmetabolized isotope in the urine. intensity to evaluate specific exercise training regi-
Although this technique obtains objective data with mens. On the other hand, observational studies relat-
little effort on the part of participants, two disadvan- ing physical activity to morbidity or mortality usually
tages are its relatively high cost and its inability to report absolute intensity or total amount of physical
distinguish between types of activities performed. The activity estimated from composite measures that in-
technique has been proven accurate when compared clude intensity, frequency, and duration. It is thus
with indirect calorimetry (Klein et al. 1984; Westerterp difficult to compare the intensity of activity that
et al. 1988; Edwards et al. 1990). improves physiologic markers with the intensity of
activity that may reduce morbidity and mortality.

32
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

Table 2-4. Classification of physical activity intensity, based on physical activity lasting up to 60 minutes
Strength-type
Endurance-type activity exercise
Absolute intensity (METs) Relative
Relative intensity in healthy adults (age in years) intensity*
Maximal
V̇O 2 max (%) Maximal Middle- Very voluntary
heart rate heart Young aged Old old contraction
Intensity reserve (%) rate (%) RPE† (20–39) (40–64) (65–79) (80+) RPE (%)
Very light <25 <30 <9 <3.0 <2.5 <2.0 ≤1.25 <10 <30
Light <25–44 <30–49 <9–10 <3.0–4.7 <2.5–4.4 <2.0–3.5 <1.26–2.2 <10–11 <30–49
Moderate <45–59 <50–69 <11–12 <4.8–7.1 <4.5–5.9 <3.6–4.7 <2.3–2.95 <12–13 50–69
Hard <60–84 <70–89 <13–16 <7.2–10.1 <6.0–8.4 <4.8–6.7 <3.0–4.25 <14–16 70–84
Very hard ≥85 ≥90 >16 ≥10.2 ≥8.5 ≥6.8 ≥4.25 <17–19 >85
Maximal‡ <100 <100 <20 <12.0 <10.0 <8.0 <5.0 <20 <100
Table 2-4 provided courtesy of Haskell and Pollock.
*Based on 8–12 repetitions for persons under age 50 years and 10–15 repetitions for persons aged 50 years and older.
† Borg rating of Relative Perceived Exertion 6–20 scale (Borg 1982).
‡ Maximal values are mean values achieved during maximal exercise by healthy adults. Absolute intensity (METs) values are approximate mean

values for men. Mean values for women are approximately 1–2 METs lower than those for men.

Recent public health guidelines and research physiologic equivalents can be estimated. This type
reports have used absolute intensity to define ap- of subjective scale furnishes a convenient way to
propriate levels of physical activity, but the term monitor performance.
“absolute” may convey a misplaced sense of preci-
sion. For example, the CDC-ACSM guidelines (Pate Measuring Physical Fitness
et al. 1995) use absolute intensity to classify brisk Perhaps the most highly developed measurement
walking as moderate physical activity. In contrast, area is the assessment of physical fitness, since it
Healthy People 2000 objective 1.3 defines brisk rests on physiologic measurements that have good
walking as “light to moderate” intensity and takes to excellent accuracy and reliability. The major foci
into account the age- and sex-related variability in of fitness measurements are endurance (or cardio-
maximal capacity (USDHHS 1990). One solution to respiratory fitness), muscular fitness, and body
this inconsistency in terminology is to create con- composition.
sistent categories that equate a variety of measures
to the same adjective (Table 2-4). Using such a Endurance
rubric, the observations of Spelman and colleagues Cardiorespiratory fitness, also referred to as cardio-
(1993) that brisk walking for healthy adults aged respiratory capacity, aerobic power, or endurance
22–58 years demands 40–60 percent of their aerobic fitness, is largely determined by habitual physical
power suggests a correspondence with 3–5 METs activity. However, other factors influence cardio-
and a classification of moderate intensity. Those respiratory fitness, including age, sex, heredity,
prescribing an exercise pattern for adults can use and medical status (Bouchard, Shepard, Stevens
the rating of perceived exertion (RPE) scale (ACSM 1994).
1991). An RPE of 10–11 corresponds to light inten- The best criterion of cardiorespiratory fitness is
sity, 12–13 to moderate intensity, and 14–16 to maximal oxygen uptake or aerobic power (V̇O2 max).
hard intensity (Table 2-4), and the approximate Measured in healthy persons during large muscle,

33
Physical Activity and Health

dynamic activity (e.g., walking, running, or cycling), In another approach to assessing cardiorespi-
V̇O2 max is primarily limited by the oxygen transport ratory fitness, participants usually walk, jog, or
capacity of the cardiovascular system (Mitchell and run a specified time or distance, and their perfor-
Blomqvist 1971).V̇O2 max is most accurately deter- mance is converted to an estimate of V̇O 2 max
mined by measuring expired air composition and (Cooper 1968). These procedures have been fre-
respiratory volume during maximal exertion. This quently used to test the cardiorespiratory fitness
procedure requires relatively expensive equipment, of children, of young adults, or of groups that have
highly trained technicians, and time and coopera- occupation-related physical fitness requirements,
tion from the participant, all of which usually limit such as military and emergency service personnel.
its use in large epidemiologic studies (Montoye et al. In many cases, these tests require maximal or
1970; King et al. 1991). near-maximal effort by the participant and thus
Because the individual variation in mechanical have not been used for older persons or those at
and metabolic efficiency is for activities that do not increased risk for CVD. The advantage is that large
require much skill—such as walking or running on a numbers of participants can be tested rapidly at low
motor-driven treadmill, cycling on a stationary bi- cost. However, to obtain an accurate evaluation,
cycle ergometer, or climbing steps—oxygen uptake participants must be willing to exert themselves
can be quite accurately estimated from the rate of and know how to set a proper pace.
work (Siconolfi et al. 1982). Thus, V̇O2 max can be
estimated from the peak exercise workload during a Muscular Fitness
maximal exercise test without measuring respiratory Common measures of muscular fitness are muscular
gases. Such procedures require an accurately cali- strength, muscular endurance, flexibility, and bal-
brated exercise device, careful adherence to a spe- ance, agility, and coordination. Muscular strength
cific protocol, and good cooperation by the can be measured during performance of either static
participant. They have been used in numerous exer- or dynamic muscle contraction (NCHS, Wilmore
cise training studies for evaluating the effects of 1989). Because muscular strength is specific to the
exercise on cardiovascular risk factors and perfor- muscle group, the testing of one group does not
mance, in secondary prevention trials for patients provide accurate information about the strength of
after hospitalization for myocardial infarction, and other muscle groups (Clarke 1973). Thus, for a
in some large-scale observational studies (Blair et al. comprehensive assessment, strength testing must
1989; Sidney et al. 1992). involve at least several major muscle groups, includ-
Any maximal test to assess cardiorespiratory ing the upper body, trunk, and lower body. Standard
fitness imposes a burden on both the participant tests have included the bench press, leg extension,
and the examiner. To reduce this burden, several and biceps curl using free weights. The heaviest
submaximal exercise testing protocols have been weight a person can lift only one time through the
developed. With these protocols, the heart rate full range of motion for a particular muscle group is
response to a specified workload is used to predict considered the person’s maximum strength for that
the V̇O2 max. The underlying assumption (besides specific muscle group.
the linear relationship between heart rate and oxy- Muscular endurance is specific to each muscle
gen uptake) is that the participant’s maximal heart group. Most tests for use in the general population do
rate can be estimated accurately. Both assumptions not distinguish between muscular endurance and
are adequately met when a standardized protocol is muscular strength. Tests of muscular endurance and
used to test a large sample of healthy adults. In some strength, which include sit-ups, push-ups, bent-arm
cases, no extrapolation to maximal values is per- hangs, and pull-ups, must be properly administered
formed, and an individual’s cardiorespiratory fit- and may not discriminate well in some populations
ness is expressed as the heart rate at a set workload (e.g., pull-ups are not a good test for many popula-
(e.g., heart rate at 5 kilometers/hour or at 100 tions because a high percentage of those tested will
watts) or at the workload required to reach a spe- have 0 scores). Few laboratory tests of muscular
cific submaximal heart rate (workload at a heart endurance have been developed, and such tests usu-
rate of 120 beats/minute). ally involve having the participant perform a series of

34
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

contractions at a set percentage of maximal strength method lacks accuracy in some populations, includ-
and at a constant rate until the person can no longer ing older persons and children (Lohman 1986).
continue at that rate. The total work performed or Anthropometric measurements (i.e., girths, diam-
the test duration is used as a measure of muscular eters, and skinfolds) used to calculate the percentage
endurance. of body fat have varying degrees of accuracy and
Flexibility is difficult to measure accurately and reliability (Wilmore and Behnke 1970).
reliably. Because it is specific to the joint being Data now suggest that the distribution of body
tested, no one measure provides a satisfactory index fat, especially accumulation in the abdominal area,
of an individual’s overall flexibility (Harris 1969). and total body fat are significant risk factors for CVD
Field testing of flexibility frequently has been lim- and diabetes (Bierman and Brunzell 1992; Blumberg
ited to the sit-and-reach test, which is considered to and Alexander 1992). Researchers have determined
be a measure of lower back and hamstring flexibility. the magnitude of this abdominal or central obesity
The criterion method for measuring flexibility in the by calculating the waist-to-hip circumference ratio
laboratory is goniometry, which is used to measure or by using new electronic methods that can image
the angle of the joint at both extremes in the range of regional fat tissue. New technologies that measure
motion (NCHS, Wilmore 1989). body composition include total body electrical con-
Balance, agility, and coordination are especially ductivity (Segal et al. 1985), bioelectrical impedance
important among older persons, who are more prone (Lukaski et al. 1986), magnetic resonance imaging
to fall and, as a result, suffer fractures due to reduced (Lohman 1984), and dual-energy x-ray absorptio-
bone mineral density. Field methods for measuring metry (DEXA) (Mazess et al. 1990). These new
balance, agility, and coordination have included procedures have substantial potential to provide
various balance stands (e.g., one-foot stand with new information on how changes in physical activity
eyes open and with eyes closed; standing on a narrow affect body composition and fat distribution.
block) and balance walks on a narrow line or rail
(Tse and Bailey 1992). In the laboratory, computer- Validity of Measurements
based technology is now being used to evaluate Health behaviors are difficult to measure, and this is
balance measured on an electronic force platform or certainly true for the behavior of physical activity. Of
to analyze a videotape recording of the participant particular concern is how well self-reported physical
walking (Lehmann et al. 1990). Agility or coordina- activity accurately represents a person’s habitual
tion are measured most frequently by using a field activity status. Factors that interfere with obtaining
test, such as an agility walk or run (Cureton 1947). accurate assessments include incomplete recall, ex-
In the laboratory, coordination or reaction/move- aggeration of amount of activity, and nonrepresenta-
ment time are determined by using electronic signal- tive sampling of time intervals during which activity
ing and timing devices (Spirduso 1975). More is assessed.
development is needed to establish norms using One of the principal difficulties in establishing the
standardized tests for measuring balance, agility, validity of a physical activity measure is the lack of a
and coordination, especially of older persons. suitable “gold-standard” criterion measure for com-
parison. In the absence of a true criterion measure,
Body Composition cardiorespiratory fitness has often been used as a
In most population-based studies that have provided validation standard for physical activity surveys. Al-
information on the relationship between physical though habitual physical activity is a major determi-
activity and morbidity or mortality, body composi- nant of cardiorespiratory fitness, other factors, such as
tion has been estimated by measuring body height genetic inheritance, also play a role. Therefore, a
and weight and calculating body mass index (weight/ perfect correlation between physical activity report-
height2). The preferred method for determining ing and cardiorespiratory fitness would not be ex-
amount of body fat and lean body mass in exercise pected. Nonetheless, correlations of reported physical
training studies has been hydrostatic or underwater activity with measured cardiorespiratory fitness have
weighing (NCHS, Wilmore 1989); however, this been examined. Table 2-5 shows results from studies

35
Physical Activity and Health

Table 2-5. Correlation of two survey instruments with physiologic measures of caloric exchange
Study Sample Physiologic test Correlation coefficient
Minnesota Leisure-Time Physical Activity Questionnaire
Taylor et al. (1978) 175 men Treadmill endurance 0.45
Skinner et al. (1966) 54 men Submaximal treadmill text 0.13 NS
Leon et al. (1981) 175 men Treadmill 0.41
Submaximal heart rate 0.59
DeBacker et al. (1981) 1,513 men Submaximal treadmill test 0.10
Jacobs et al. (1993) 64 men V̇O 2 max 0.43
& women Submaximal heart rate 0.45
Richardson et al. (1995) 78 men V̇O 2 max 0.47
& women
Albanes et al. (1990) 21 men Resting caloric intake 0.17 NS
Montoye et al. (1996) 28 men Doubly labeled water 0.26 NS

College Alumni Study Survey

Siconolfi et al. (1985) 36 men V̇O 2 max 0.29
32 women V̇O 2 max 0.46
Jacobs et al. (1993) 64 men
& women V̇O 2 max 0.52
Submaximal heart rate 0.52
Albanes et al. (1990) 21 men Resting caloric intake 0.32 NS
Montoye et al. (1996) 28 men Doubly labeled water 0.39
Energy intake, 7 days 0.44
NS = nonsignificant correlation coefficient; all others were statistically significant.

in which questionnaire data from the Minnesota not be perfectly correlated with cardiorespiratory
Leisure-Time Physical Activity Questionnaire (Taylor fitness, but it may be the predominant predictive
et al. 1978) and the College Alumni Study survey factor.
(Paffenbarger et al. 1993) are compared with physi- Because misclassification of physical activity, as
ological measures, in most cases cardiorespiratory could occur by using an invalid measure, would tend
fitness. Although most correlation coefficients (e.g., to bias studies towards finding no association, the
Pearson’s r) are statistically significant, they exhibit consistently found associations between physical ac-
considerable variability (range 0.10 to 0.59), and the tivity and lower risk of several diseases (as is discussed
overall central tendency (median, 0.41) suggests in Chapter 4) suggest that the measure has at least
only moderate external validity. However, in a some validity. Moreover, they suggest that a more
study of predictors of cardiorespiratory fitness precise measure of physical activity would likely yield
among adults (Blair et al. 1989), in all age and sex even stronger associations with health. Thus, although
subgroups, self-reported physical activity was the measurement of physical activity by currently avail-
principal contributor to the predictive models that able methods may be far from ideal, it has provided a
also included weight, resting heart rate, and current means to investigate and demonstrate important health
smoking. Thus, self-reported physical activity may benefits of physical activity.

36
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

Chapter Summary 3. Recommendations from experts agree that for

better health, physical activity should be per-
The assertion that frequent participation in physical
formed regularly. The most recent recommenda-
activity contributes to better health has been a recur-
tions advise people of all ages to include a
ring theme in medicine and education throughout
minimum of 30 minutes of physical activity of
much of Western history. Early empirical observa-
tions and case studies suggesting that a sedentary life moderate intensity (such as brisk walking) on
most, if not all, days of the week. It is also
was not healthy have been supported by rigorous
acknowledged that for most people, greater health
scientific investigation that has evolved over the past
benefits can be obtained by engaging in physical
century. In recent decades, a number of experimental
activity of more vigorous intensity or of longer
and clinical specialties have contributed substan-
tially to an emerging field that may accurately be duration.
described as exercise science. This field includes 4. Experts advise previously sedentary people em-
disciplines ranging from exercise physiology and barking on a physical activity program to start
biomechanics to physical activity epidemiology, ex- with short durations of moderate-intensity activ-
ercise psychology, clinical sports medicine, and pre- ity and gradually increase the duration or inten-
ventive medicine. Research findings from these sity until the goal is reached.
specialties provide the basis for this first Surgeon
5. Experts advise consulting with a physician before
General’s report on physical activity and health.
beginning a new physical activity program for
Numerous expert panels, committees, and confer-
people with chronic diseases, such as CVD and
ences have been convened over the years to evaluate
diabetes mellitus, or for those who are at high risk
the evidence relating physical activity and health.
for these diseases. Experts also advise men over
These gatherings have laid a solid foundation for the
age 40 and women over age 50 to consult a
current consensus that for optimal health, people of
physician before they begin a vigorous activity
all ages should be physically active on most days.
program.
Specific exercise recommendations have empha-
sized only vigorous activity for cardiorespiratory 6. Recent recommendations from experts also
fitness until recently, when the benefits of moderate- suggest that cardiorespiratory endurance ac-
intensity physical activity have been recognized tivity should be supplemented with strength-
and promoted as well. developing exercises at least twice per week
for adults, in order to improve musculoskel-
etal health, maintain independence in per-
Conclusions forming the activities of daily life, and reduce
1. Physical activity for better health and well-being the risk of falling.
has been an important theme throughout much
of western history.
2. Public health recommendations have evolved
from emphasizing vigorous activity for cardiores-
piratory fitness to including the option of moder-
ate levels of activity for numerous health benefits.

37
Physical Activity and Health

Appendix A: Healthy People 2000 Objectives

The nation’s public health goals for the 1990s and beyond, as presented in Healthy People 2000 (USDHHS 1990),
aim to increase the span of healthy life for all Americans, to reduce health disparities among Americans, and to
achieve access to preventive services for all Americans. Reproduced here are the Healthy People 2000 objectives
for physical activity and fitness as revised in 1995 (USDHHS 1995).
Duplicate objectives that appear in two or more priority areas are marked with an asterisk alongside the
objective number.

Physical Activity and Fitness

Health Status Objectives

1.1* Reduce coronary heart disease deaths to no more than 100 per 100,000 people.
Special Population Target
Coronary Deaths (per 100,000) 2000 Target
1.1a Blacks 115
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 12–19.

Special Population Target

Overweight Prevalence 2000 Target
1.2a Low-income women aged 20 and older 25%
1.2b Black women aged 20 and older 30%
1.2c Hispanic women aged 20 and older 25%
1.2d American Indians/Alaska Natives 30%
1.2e People with disabilities 25%
1.2f Women with high blood pressure 41%
1.2g Men with high blood pressure 35%
1.2h Mexican-American men 25%

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 12–14, 24.3 for males aged 15–17, 25.8 for males aged 18–19, 23.4 for females aged
12–14, 24.8 for females aged 15–17, and 25.7 for females aged 18–19. The values for adults are the gender-specific 85th percentile values of the 1976–80 National
Health and Nutrition Examination Survey (NHANES II), reference population 20–29 years of age. For adolescents, overweight was defined using BMI cutoffs
based on modified age- and gender-specific 85th percentile values of the NHANES II. 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.

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.

Special Population Targets

Moderate Physical Activity 2000 Target
1.3a Hispanics aged 18 and older 25 %
5 or more times per week

Note: Light to moderate physical activity requires sustained, rhythmic 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 yardwork, various domestic and occupational activities, and games and other childhood pursuits.

38
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

1.4 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 6–17 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.

Special Population Targets

Vigorous Physical Activity 2000 Target
1.4a Lower-income people aged 18 and older 12%
(annual family income <$20,000)
1.4b Blacks aged 18 years and older 17%
1.4c Hispanics aged 18 years and older 17%

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 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.

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.

Special Population Targets

No Leisure-Time Physical Activity 2000 Target
1.5a People aged 65 and older 22%
1.5b People with disabilities 20%
1.5c Lower-income people (annual family 17%
income <$20,000)
1.5d Blacks aged 18 and older 20%
1.5e Hispanics aged 18 and older 25%
1.5f American Indians/Alaska Natives aged 18 and older 21%

Note: For this objective, people with disabilities are people who report any limitation in activity due to chronic conditions.

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.
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.

Special Population Targets

Adoption of Weight-Loss Practices 2000 Target
1.7a Overweight Hispanic males 24%
aged 18 and older
1.7b Overweight Hispanic females 22%
aged 18 and older

Services and Protection Objectives

1.8 Increase to at least 50 percent the proportion of children and adolescents in 1st–12th grade who
participate in daily school physical education.
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.

39
Physical Activity and Health

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 played only by young children such as group games are excluded.

1.10 Increase the proportion of worksites offering employer-sponsored physical activity and fitness
programs as follows:

Worksite Size 2000 Target

50–99 employees 20%
100–249 employees 35%
250–749 employees 50%
>750 employees 80%

1.11 Increase community availability and accessibility of physical activity and fitness facilities as follows:

Facility 2000 Target

Hiking, biking, and fitness trail miles 1 per 10,000 people
Public swimming pools 1 per 25,000 people
Acres of park and recreation open space 4 per 1,000 people
(250 people per managed acre)

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.

Health Status Objective

1.13* Reduce to no more than 90 per 1,000 people the proportion of all people aged 65 and older who have
difficulty in performing two or more personal care activities thereby preserving independence.

Special Population Targets

Difficulty Performing
Self Care (per 1,000) 2000 Target
1.13a People aged 85 and older 325
1.13b Blacks aged 65 and older 98

Note: Personal care activities are bathing, dressing, using the toilet, getting in and out of bed or chair, and eating.

40
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

Appendix B: NIH Consensus comment. Thereafter, the panel resolved conflict-

ing recommendations and released a revised state-
Conference Statement
ment at the end of the conference. The panel
In Press (3/18/96) finalized the revisions within a few weeks after the
National Institutes of Health conference.
Consensus Development Conference Statement Conclusions. All Americans should engage in
Physical Activity and Cardiovascular Health regular physical activity at a level appropriate to
December 18–20, 1995 their capacity, needs, and interest. Children and
NIH Consensus Statements are prepared by a adults alike should set a goal of accumulating at
nonadvocate, non-Federal panel of experts, based on least 30 minutes of moderate-intensity physical
(1) presentations by investigators working in areas activity on most, and preferably, all days of the
relevant to the consensus questions during a 2-day week. Most Americans have little or no physical
public session; (2) questions and statements from activity in their daily lives, and accumulating evi-
conference attendees during open discussion peri- dence indicates that physical inactivity is a major
ods that are part of the public session; and (3) closed risk factor for cardiovascular disease. However,
deliberations by the panel during the remainder of moderate levels of physical activity confer signifi-
the second day and morning of the third. This cant health benefits. Even those who currently
statement is an independent report of the panel and meet these daily standards may derive additional
is not a policy statement of the NIH or the Federal health and fitness benefits by becoming more physi-
Government. cally active or including more vigorous activity. For
those with known cardiovascular disease, cardiac
rehabilitation programs that combine physical ac-
Abstract
tivity with reduction in other risk factors should be
Objective. To provide physicians and the general more widely used.
public with a responsible assessment of the relation-
ship between physical activity and cardiovascular
Introduction
health.
Participants. A non-Federal, nonadvocate, 13- Over the past 25 years, the United States has experi-
member panel representing the fields of cardiology, enced a steady decline in the age- adjusted death toll
psychology, exercise physiology, nutrition, pediat- from cardiovascular disease (CVD), primarily in
rics, public health, and epidemiology. In addition, 27 mortality caused by coronary heart disease and stroke.
experts in cardiology, psychology, epidemiology, Despite this decline, coronary heart disease remains
exercise physiology, geriatrics, nutrition, pediatrics, the leading cause of death and stroke the third
public health, and sports medicine presented data to leading cause of death. Lifestyle improvements by
the panel and a conference audience of 600. the American public and better control of the risk
Evidence. The literature was searched through factors for heart disease and stroke have been major
Medline and an extensive bibliography of references factors in this decline.
was provided to the panel and the conference audi- Coronary heart disease and stroke have many
ence. Experts prepared abstracts with relevant cita- causes. Modifiable risk factors include smoking,
tions from the literature. Scientific evidence was high blood pressure, blood lipid levels, obesity, dia-
given precedence over clinical anecdotal experience. betes, and physical inactivity. In contrast to the
Consensus Process. The panel, answering pre- positive national trends observed with cigarette smok-
defined questions, developed their conclusions ing, high blood pressure, and high blood cholesterol,
based on the scientific evidence presented in open obesity and physical inactivity in the United States
forum and the scientific literature. The panel com- have not improved. Indeed automation and other
posed a draft statement that was read in its entirety technologies have contributed greatly to lessening
and circulated to the experts and the audience for physical activity at work and home.

41
Physical Activity and Health

The purpose of this conference was to examine developed and tested. Different environments such
the accumulating evidence on the role of physical as schools, worksites, health care settings, and the
activity in the prevention and treatment of CVD and home can play a role in promoting physical activity.
its risk factors. These community-level factors also need to be better
Physical activity in this statement is defined as understood.
“bodily movement produced by skeletal muscles To address these and related issues, the NIH’s
that requires energy expenditure” and produces National Heart, Lung, and Blood Institute and Office
healthy benefits. Exercise, a type of physical activity, of Medical Applications of Research convened a
is defined as “a planned, structured, and repetitive Consensus Development Conference on Physical
bodily movement done to improve or maintain one Activity and Cardiovascular Health. The conference
or more components of physical fitness.” Physical was cosponsored by the NIH’s National Institute of
inactivity denotes a level of activity less than that Child Health and Human Development, National
needed to maintain good health. Institute on Aging, National Institute of Arthritis and
Physical inactivity characterizes most Ameri- Musculoskeletal and Skin Diseases, National Insti-
cans. Exertion has been systematically engineered tute of Diabetes and Digestive and Kidney Diseases,
out of most occupations and lifestyles. In 1991, 54 National Institute of Nursing Research, Office of
percent of adults reported little or no regular leisure Research on Women’s Health, and Office of Disease
physical activity. Data from the 1990 Youth Risk Prevention, as well as the Centers for Disease Con-
Behavior Survey show that most teenagers in grades trol and Prevention and the President’s Council on
9-12 are not performing regular vigorous activity. Physical Fitness and Sports.
About 50 percent of high school students reported The conference brought together specialists in
they are not enrolled in physical education classes. medicine, exercise physiology, health behavior, epi-
Physical activity protects against the develop- demiology, nutrition, physical therapy, and nursing
ment of CVD and also favorably modifies other CVD as well as representatives from the public. After a day
risk factors, including high blood pressure, blood and a half of presentations and audience discussion,
lipid levels, insulin resistance, and obesity. The type, an independent, non-Federal consensus panel
frequency, and intensity of physical activity that are weighed the scientific evidence and developed a
needed to accomplish these goals remain poorly draft statement that addressed the following five
defined and controversial. questions.
Physical activity is also important in the treat- • What is the health burden of a sedentary lifetyle
ment of patients with CVD or those who are at on the population?
increased risk for developing CVD, including pa-
• What type, what intensity, and what quantity of
tients who have hypertension, stable angina, or pe-
physical activity are important to prevent car-
ripheral vascular disease, or who have had a prior
diovascular disease?
myocardial infarction or heart failure. Physical activ-
ity is an important component of cardiac rehabilita- • What are the benefits and risks of different
tion, and people with CVD can benefit from types of physical activity for people with car-
participation. However, some questions remain re- diovascular disease?
garding benefits, risks, and costs associated with • What are the successful approaches to adopting
becoming physically active. and maintaining a physically active lifestyle?
Many factors influence adopting and maintaining • What are the important questions for future
a physically active lifestyle, such as socioeconomic research?
status, cultural influences, age, and health status.
Understanding is needed on how such variables in- 1. What Is the Health Burden of a Sedentary
fluence the adoption of this behavior at the individual Lifestyle on the Population?
level. Intervention strategies for encouraging indi-
Physical inactivity among the U.S. population is now
viduals from different backgrounds to adopt and
widespread. National surveillance programs have
adhere to a physically active lifestyle need to be
documented that about one in four adults (more

42
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

women than men) currently have sedentary lifestyles that the addition of physical activity to dietary en-
with no leisure time physical activity. An additional ergy restriction can increase and help to maintain
one-third of adults are insufficiently active to achieve loss of body weight and body fat mass.
health benefits. The prevalence of inactivity varies by Middle-aged and older men and women who
gender, age, ethnicity, health status, and geographic engage in regular physical activity have significantly
region but is common to all demographic groups. higher high-density lipoprotein (HDL) cholesterol
Change in physical exertion associated with occupa- levels than do those who are sedentary. When exercise
tion has declined markedly in this century. training has extended to at least 12 weeks, beneficial
Girls become less active than do boys as they grow HDL cholesterol level changes have been reported.
older. Children become far less active as they move Most studies of endurance exercise training of
through adolescence. Obesity is increasing among individuals with normal blood pressure and those
children, at least in part related to physical inactivity. with hypertension have shown decreases in systolic
Data indicate that obese children and adolescents and diastolic blood pressure. Insulin sensitivity is
have a high risk of becoming obese adults, and obesity also improved with endurance exercise.
in adulthood is related to coronary artery disease, A number of factors that affect thrombotic
hypertension, and diabetes. Thus, the prevention of function—including hematocrit, fibrinogen, plate-
childhood obesity has the potential of preventing let function, and fibrinolysis—are related to the risk
CVD in adults. At age 12, 70 percent of children report of CVD. Regular endurance exercise lowers the risk
participation in vigorous physical activity; by age 21 related to these factors.
this activity falls to 42 percent for men and 30 percent The burden of CVD rests most heavily on the
for women. Furthermore, as adults age, their physical least active. In addition to its powerful impact on the
activity levels continue to decline. cardiovascular system, physical inactivity is also
Although knowledge about physical inactivity as associated with other adverse health effects, includ-
a risk factor for CVD has come mainly from investiga- ing osteoporosis, diabetes, and some cancers.
tions of middle-aged, white men, more limited evi-
dence from studies in women minority groups and the 2. What Type, What Intensity, and What
elderly suggests that the findings are similar in these Quantity of Physical Activity Are Important
groups. On the basis of current knowledge, we must to Prevent Cardiovascular Disease?
note that physical inactivity occurs disproportion-
Activity that reduces CVD risk factors and confers
ately among Americans who are not well educated and
many other health benefits does not require a struc-
who are socially or economically disadvantaged.
tured or vigorous exercise program. The majority of
Physical activity is directly related to physical
benefits of physical activity can be gained by per-
fitness. Although the means of measuring physical
forming moderate-intensity activities. The amount
activity have varied between studies (i.e., there is no
or type of physical activity needed for health benefits
standardization of measures), evidence indicates that
or optimal health is a concern due to limited time and
physical inactivity and lack of physical fitness are
competing activities for most Americans. The amount
directly associated with increased mortality from
and types of physical activity that are needed to
CVD. The increase in mortality is not entirely ex-
prevent disease and promote health must, therefore,
plained by the association with elevated blood pres-
be clearly communicated, and effective strategies
sure, smoking, and blood lipid levels.
must be developed to promote physical activity to
There is an inverse relationship between mea-
the public.
sures of physical activity and indices of obesity in
The quantitative relationship between level of
most U.S. population studies. Only a few studies
activity or fitness and magnitude of cardiovascular
have examined the relationship between physical
benefit may extend across the full range of activity. A
activity and body fat distribution, and these suggest
moderate level of physical activity confers health
an inverse relationship between levels of physical
benefits. However, physical activity must be per-
activity and visceral fat. There is evidence that in-
formed regularly to maintain these effects.
creased physical activity facilitates weight loss and

43
Physical Activity and Health

Moderate=intensity activity performed by previously intensity or longer duration activity could be per-
sedentary individuals results in significant improve- formed approximately three times weekly and
ment in many health-related outcomes. These mod- achieve cardiovascular benefits, but low-intensity
erate intensity activities are more likely to be or shorter duration activities should be performed
continued than are high-intensity activities. more often to achieve cardiovascular benefits.
We recommend that all people in the United The appropriate type of activity is best deter-
States increase their regular physical activity to a mined by the individual’s preferences and what will
level appropriate to their capacities, needs, and inter- be sustained. Exercise, or a structured program of
est. We recommend that all children and adults activity, is a subset of activity that may encourage
should set a long-term goal to accumulate at least 30 interest and allow for more vigorous activity. People
minutes or more of moderate-intensity physical ac- who perform more formal exercise (i.e., structured
tivity on most, or preferably all, days of the week. or planned exercise programs) can accumulate this
Intermittent or shorter bouts of activity (at least 10 daily total through a variety of recreational or sports
minutes), including occupational, nonoccupational, activities. People who are currently sedentary or
or tasks of daily living, also have similar cardiovascu- minimally active should gradually build up to the
lar and health benefits if performed at a level of recommended goal of 30 minutes of moderate activ-
moderate intensity (such as brisk walking, cycling, ity daily by adding a few minutes each day until
swimming, home repair, and yardwork) with an reaching their personal goal to reduce the risk asso-
accumulated duration of at least 30 minutes per day. ciated with suddenly increasing the amount or inten-
People who currently meet the recommended mini- sity of exercise. (The defined levels of effort depend
mal standards may derive additional health and on individual characteristics such as baseline fitness
fitness benefits from becoming more physically ac- and health status.)
tive or including more vigorous activity. Developing muscular strength and joint flexibil-
Some evidence suggests lowered mortality with ity is also important for an overall activity program to
more vigorous activity, but further research is needed improve one’s ability to perform tasks and to reduce
to more specifically define safe and effective levels. the potential for injury. Upper extremity and resis-
The most active individuals have lower cardiovascu- tance (or strength) training can improve muscular
lar morbidity and mortality rates than do those who function, and evidence suggests that there may be
are least active; however, much of the benefit appears cardiovascular benefits, especially in older patients
to be accounted for by comparing the least active or those with underlying CVD, but further research
individuals to those who are moderately active. Fur- and guidelines are needed. Older people or those
ther increases in the intensity or amount of activity who have been deconditioned from recent inactivity
produce further benefits in some, but not all, param- or illness may particularly benefit from resistance
eters of risk. High-intensity activity is also associated training due to improved ability in accomplishing
with an increased risk of injury, discontinuation of tasks of daily living. Resistance training may contrib-
activity, or acute cardiac events during the activity. ute to better balance, coordination, and agility that
Current low rates of regular activity in Americans may help prevent falls in the elderly.
may be partially due to the mis-perception of many Physical activity carries risks as well as benefits.
that vigorous, continuous exercise is necessary to The most common adverse effects of activity relate to
reap health benefits. Many people, for example, fail musculoskeletal injury and are usually mild and self-
to appreciate walking as “exercise” or to recognize limited. The risk of injury increases with increased
the substantial benefits of short bouts (at least 10 intensity, frequency, and duration of activity and
minutes) of moderate-level activity. also depends on the type of activity. Exercise-related
The frequency, intensity, and duration of activ- injuries can be reduced by moderating these param-
ity are interrelated. The number of episodes of eters. A more serious but rare complication of activ-
activity recommended for health depends on the ity is myocardial infarction or sudden cardiac death.
intensity and/or duration of the activity: higher Although persons who engage in vigorous physical

44
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

activity have a slight increase in risk of sudden been associated with reductions in fatal cardiac events,
cardiac death during activity, the health benefits although the minimal or optimal level and duration
outweigh this risk because of the large overall risk of exercise required to achieve beneficial effects
reduction. remains uncertain. Data are inadequate to determine
In children and young adults, exertion-related whether stroke incidence is affected by physical
deaths are uncommon and are generally related to activity or exercise training.
congenital heart defects (e.g., hypertrophic cardi- The risk of death during medically supervised
omyopathy, Marfan’s syndrome, severe aortic valve cardiac exercise training programs is very low. How-
stenosis, prolonged QT syndromes, cardiac conduc- ever, those who exercise infrequently and have poor
tion abnormalities) or to acquired myocarditis. It is functional capacity at baseline may be at somewhat
recommended that patients with those conditions higher risk during exercise training. All patients
remain active but not participate in vigorous or with CVD should have a medical evaluation prior to
competitive athletics. participation in a vigorous exercise program.
Because the risks of physical activity are very low Appropriately prescribed and conducted exer-
compared with the health benefits, most adults do cise training programs improve exercise tolerance
not need medical consultation or pretesting before and physical fitness in patients with coronary heart
starting a moderate-intensity physical activity pro- disease. Moderate as well as vigorous exercise train-
gram. However, those with known CVD and men ing regimens are of value. Patients with low basal
over age 40 and women over age 50 with multiple levels of exercise capacity experience the most func-
cardiovascular risk factors who contemplate a pro- tional benefits, even at relatively modest levels of
gram of vigorous activity should have a medical physical activity. Patients with angina pectoris typi-
evaluation prior to initiating such a program. cally experience improvement in angina in associa-
tion with a reduction in effort-induced myocardial
3. What Are the Benefits and Risks of ischemia, presumably as a result of decreased myo-
Different Types of Physical Activity for cardial oxygen demand and increased work capacity.
People with Cardiovascular Disease? Patients with congestive heart failure also appear
to show improvement in symptoms, exercise capac-
More than 10 million Americans are afflicted with
ity, and functional well-being in response to exercise
clinically significant CVD, including myocardial in-
training, even though left ventricular systolic func-
farction, angina pectoris, peripheral vascular dis-
tion appears to be unaffected. The exercise program
ease, and congestive heart failure. In addition, more
should be tailored to the needs of these patients and
than 300,000 patients per year are currently sub-
supervised closely in view of the marked predisposi-
jected to coronary artery bypass surgery and a similar
tion of these patients to ischemic events and
number to percutaneous transluminal coronary
arrhythmias.
angioplasty. Increased physical activity appears to
Cardiac rehabilitation exercise training often
benefit each of these groups. Benefits include reduc-
improves skeletal muscle strength and oxidative
tion in cardiovascular mortality, reduction of symp-
capacity and, when combined with appropriate nu-
toms, improvement in exercise tolerance and
tritional changes, may result in weight loss. In addi-
functional capacity, and improvement in psycho-
tion, such training generally results in improvement
logical well-being and quality of life.
in measures of psychological status, social adjust-
Several studies have shown that exercise training
ment, and functional capacity. However, cardiac
programs significantly reduce overall mortality, as
rehabilitation exercise training has less influence on
well as death caused by myocardial infarction. The
rates of return to work than many nonexercise vari-
reported reductions in mortality have been highest—
ables, including employer attitudes, prior employ-
approximately 25 percent—in cardiac rehabilitation
ment status, and economic incentives. Multifactorial
programs that have included control of other cardio-
intervention programs, including nutritional changes
vascular risk factors. Rehabilitation programs using
and medication plus exercise, are needed to improve
both moderate and vigorous physical activity have
health status and reduce cardiovascular disease risk.

45
Physical Activity and Health

Cardiac rehabilitation programs have tradition- • Perceives a net benefit.

ally been institutional-based and group-centered (e.g., • Chooses an enjoyable activity.
hospitals, clinics, community centers). Referral and
• Feels competent doing the activity.
enrollment rates have been relatively low, generally
ranging from 10 to 25 percent of patients with CHD. • Feels safe doing the activity.
Referral rates are lower for women than for men and • Can easily access the activity on a regular basis.
lower for non-whites than for whites. Home-based • Can fit the activity into the daily schedule.
programs have the potential to provide rehabilitative • Feels that the activity does not generate financial
services to a wider population. Home-based pro- or social costs that he or she is unwilling to bear.
grams incorporating limited hospital visits with regu-
lar mail or telephone followup by a nurse case • Experiences a minimum of negative conse-
manager have demonstrated significant increases in quences such as injury, loss of time, negative
functional capacity, smoking cessation, and improve- peer pressure, and problems with self-identity.
ment in blood lipid levels. A range of options exists • Is able to successfully address issues of compet-
in cardiac rehabilitation including site, number of ing time demands.
visits, monitoring, and other services. • Recognizes the need to balance the use of labor-
There are clear medical and economic reasons saving devices (e.g., power lawn mowers, golf
for carrying out cardiac rehabilitation programs. carts, automobiles) and sedentary activities (e.g.,
Optimal outcomes are achieved when exercise train- watching television, use of computers) with
ing is combined with educational messages and activities that involve a higher level of physical
feedback about changing lifestyle. Patients who par- exertion.
ticipate in cardiac rehabilitation programs show a Other people in the individual’s social environ-
lower incidence of rehospitalization and lower ment can influence the adoption and maintenance of
charges per hospitalization. Cardiac rehabilitation is physical activity. Health care providers have a key
a cost-efficient therapeutic modality that should be role in promoting smoking cessation and other risk-
used more frequently. reduction behaviors. Preliminary evidence suggests
that this also applies to physical activity. It is highly
4. What Are the Successful Approaches to probable that people will be more likely to increase
Adopting and Maintaining a Physically their physical activity if their health care provider
Active Lifestyle? counsels them to do so. Providers can do this effec-
The cardiovascular benefits from and physiological tively by learning to recognize stages of behavior
reactions to physical activity appear to be similar change, to communicate the need for increased ac-
among diverse population subgroups defined by age, tivity, to assist the patient in initiating activity, and
sex, income, region of residence, ethnic background, by following up appropriately.
and health status. However, the behavioral and atti- Family and friends can also be important sources
tudinal factors that influence the motivation for and of support for behavior change. For example, spouses
ability to sustain physical activity are strongly deter- or friends can serve as “buddies,” joining in the
mined by social experiences, cultural background, physical activity; or a spouse could offer to take on a
and physical disability and health status. For ex- household task, giving his or her mate time to engage
ample, perceptions of appropriate physical activity in physical activity. Parents can support their
differ by gender, age, weight, marital status, family children’s activity by providing transportation, praise,
roles and responsibilities, disability, and social class. and encouragement, and by participating in activi-
Thus, the following general guidelines will need to ties with their children.
be further refined when one is planning with or Worksites have the potential to encourage in-
prescribing for specific individuals and population creased physical activity by offering opportunities,
groups, but generally physical activity is more likely reminders, and rewards for doing so. For example,
to be initiated and maintained if the individual an appropriate indoor area can be set aside to enable
walking during lunch hours. Signs placed near

46
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

elevators can encourage the use of the stairs instead. • Develop better methods for analysis and quan-
Discounts on parking fees can be offered to employ- tification of activity. These methods should be
ees who elect to park in remote lots and walk. applicable to both work and leisure time mea-
Schools are a major community resource for surements and provide direct quantitative esti-
increasing physical activity, particularly given the mates of activity.
urgent need to develop strategies that affect children • Conduct physiologic, biochemical, and genetic
and adolescents. As noted previously, there is now research necessary to define the mechanisms
clear evidence that U.S. children and adolescents by which activity affects CVD including changes
have become more obese. There is also evidence that in metabolism as well as cardiac and vascular
obese children and adolescents exercise less than effects. This will provide new insights into
their leaner peers. All schools should provide oppor- cardiovascular biology that may have broader
tunities for physical activities that implications than for other clinical outcomes.
• Are appropriate and enjoyable for children of • Examine the effects of physical activity and
all skill levels and are not limited to competitive cardiac rehabilitation programs on morbidity
sports or physical education classes. and mortality in elderly individuals.
• Appeal to girls as well as to boys, and to children • Conduct research on the social and psychologi-
from diverse backgrounds. cal factors that influence adoption of a more
• Can serve as a foundation for activities through- active lifestyle and the maintenance of that
out life. behavior change throughout life.
• Are offered on a daily basis. • Carry out controlled randomized clinical trials
Successful approaches may involve mass educa- among children and adolescents to test the
tion strategies or changes in institutional policies or effects of increased physical activity on CVD
community variables. In some environments (e.g., risk factor levels including obesity. The effects
schools, worksites, community centers), policy-level of intensity, frequency, and duration of in-
interventions may be necessary to enable people to creased physical activity should be examined in
achieve and maintain an adequate level of activity. such studies.
Policy changes that increase opportunities for physi-
cal activity can facilitate activity maintenance for
motivated individuals and increase readiness to Conclusions
change among the less motivated. As in other areas Accumulating scientific evidence indicates that physi-
of health promotion, mass communication strate- cal inactivity is a major risk factor for CVD. Moderate
gies should be used to promote physical activity. levels of regular physical activity confer significant
These strategies should include a variety of main- health benefits. Unfortunately, most Americans have
stream channels and techniques to reach diverse little or no physical activity in their daily lives.
audiences that acquire information through differ- All Americans should engage in regular physical
ent media (e.g., TV, newspaper, radio, Internet). activity at a level appropriate to their capacities,
needs, and interests. All children and adults should
5. What Are the Important Considerations set and reach a goal of accumulating at least 30
for Future Research? minutes of moderate-intensity physical activity on
most, and preferably all, days of the week. Those who
While much has been learned about the role of
currently meet these standards may derive additional
physical activity in cardiovascular health, there are
health and fitness benefits by becoming more physi-
many unanswered questions.
cally active or including more vigorous activity.
• Maintain surveillance of physical activity levels Cardiac rehabilitation programs that combine
in the U.S. population by age, sex, geographic, physical activity with reduction in other risk factors
and socioeconomic measures. should be more widely applied to those with known
CVD. Well-designed rehabilitation programs have

47
Physical Activity and Health

benefits that are lost because of these programs’ About the NIH Consensus
limited use.
Development Program
Individuals with CVD and men over 40 or women
over 50 years of age with multiple cardiovascular risk NIH Consensus Development Conferences are con-
factors should have a medical evaluation prior to vened to evaluate available scientific information
embarking on a vigorous exercise program. and resolve safety and efficacy issues related to a
Recognizing the importance of individual and biomedical technology. The resultant NIH Consen-
societal factors in initiating and sustaining regular sus Statements are intended to advance understand-
physical activity, the panel recommends the following: ing of the technology or issue in question and to be
useful to health professionals and the public.
• Development of programs for health care pro-
viders to communicate to patients the impor-
tance of regular physical activity.
• Community support of regular physical activ-
ity with environmental and policy changes at
schools, worksites, community centers, and
other sites.
• Initiation of a coordinated national campaign
involving a consortium of collaborating health
organizations to encourage regular physical
activity.
• The implementation of the recommendations
in this statement has considerable potential to
improve the health and well-being of American
citizens.

48
 Historical Background, Terminology, Evolution of Recommendations, and Measurement

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