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## Complete Summary

#### GUIDELINE TITLE

Physical activity and public health in older adults: recommendation from
the American College of Sports Medicine and the American Heart
Association.

#### BIBLIOGRAPHIC SOURCE(S)

Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera
CA, Castaneda-Sceppa C, American College of Sports Medicine, American
Heart Association. Physical activity and public health in older adults:
recommendation from the American College of Sports Medicine and the
American Heart Association. Circulation 2007 Aug 28;116(9):1094-105.
\[67 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17671236)

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Pate RR, Pratt M, Blair SN,
Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King
AC, et al. Physical activity and public health. A recommendation from
the Centers for Disease Control and Prevention and the American College
of Sports Medicine. JAMA. 1995 Feb 1;273(5):402-7.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

General health

#### GUIDELINE CATEGORY

Counseling\
Prevention

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Geriatrics\
Internal Medicine\
Preventive Medicine\
Sports Medicine

#### INTENDED USERS

Patients\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

-   To issue a recommendation on the types and amounts of physical
    activity needed to improve and maintain health in older adults

-   To explain and clarify the additions and modifications made to the
    ACSM/AHA recommendation for adults

-   To discuss the promotion of physical activity in older adults so as
    to provide guidance about appropriate types and amounts of physical
    activity

#### TARGET POPULATION

All adults aged 65+ years, and adults aged 50 to 64 with clinically
significant chronic conditions or functional limitations that affect
movement ability, fitness, or physical activity

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Moderate-intensity exercise (e.g., brisk walk)

2.  Vigorous-intensity exercise (e.g., jogging)

3.  Light-intensity exercise (self care, cooking, casual walking,
    shopping)

4.  Muscle strengthening exercise

5.  Duration of exercise

#### MAJOR OUTCOMES CONSIDERED

-   Metabolic equivalent energy expenditure

-   Morbidity and mortality

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The expert panel reviewed existing consensus statements and relevant
evidence from primary research articles and reviews of the literature.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

A.  Data derived from multiple randomized clinical trials

B.  Data derived from a single randomized trial or from nonrandomized
    studies

C.  Consensus opinion of experts

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

In 1999, an expert panel was convened with the assistance and support of
the International Life Sciences Institute
([http://www.ilsi.org](http://www.ilsi.org/)). The panel had expertise
in public health, behavioral science, epidemiology, exercise science,
medicine, and gerontology. The panel was initially charged with issuing
a comprehensive preventive recommendation on physical activity for older
adults that addressed aerobic, muscle-strengthening, flexibility, and
balance activities, as well as the promotion of physical activity. The
panel was instructed to base its recommendations on a review of primary
research articles, literature reviews, existing preventive
recommendations, and therapeutic recommendations.

Panel members wrote background papers addressing components of the
proposed recommendation, using their judgment to develop a strategy for
locating and analyzing relevant evidence. The panelists relied as
appropriate on earlier reviews of evidence, without repeating them. The
panel did not undertake a full review of the evidence of the benefits of
aerobic activity in the older population, because previous
evidence-based recommendations for aerobic activity applied to all
adults. But the panel considered whether modifications or clarifications
were needed when applying these recommendations to older adults who
commonly have chronic diseases, low fitness levels and/or functional
limitations. Recommendations for muscle-strengthening exercises, which
applied to older adults, had also been issued by the 1990s. In 2001, a
consensus statement dealt with the role of balance exercise in
preventing falls among older adults. In that same year, an extensive
evidence summary and consensus statement was published from a Centers
for Disease Control and Prevention(CDC)/Health Canada Expert Panel
meeting entitled \"Dose-Response Aspects of Physical Activity and
Health.\" Three years earlier, the American College of Sports Medicine
(ACSM) had published positions stands for older adults and for healthy
adults, and ACSM regularly updated its guidelines for exercise
prescription. Late in the process, the panel had access to draft
conclusions of an expert panel convened by the University of Illinois at
Chicago that had reviewed the evidence on the health effects of physical
activity in older adults.

The background papers developed by the expert panel were discussed and
critiqued by all members of the panel. In 2001, following regular
discussions, the panel completed a draft of a preventive recommendation.
Shortly thereafter, ACSM/American Heart Association (AHA) agreed to
update the 1995 CDC/ACSM recommendation for adults. Issuing a separate
older adult recommendation had the risk of causing confusion, if it was
not consistent with the updated adult recommendation. Hence, the panel
was given a revised charge of issuing an older adult recommendation,
which was consistent with the updated recommendation for adults. Both
recommendations were to be issued simultaneously.

Given drafts of an update to the 1995 recommendation for adults, in 2004
the panel on older adults synthesized a companion recommendation.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and effective
(should; is recommended; is indicated; is useful. effective, beneficial)

**Class II**: Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a procedure or
treatment

**IIa**: Weight of evidence/opinion is in favor of usefulness/efficacy
(is reasonable; can be useful, effective or beneficial; is probably
recommended or indicated)

**IIb**: Usefulness/efficacy is less well established by
evidence/opinion (may/might be considered, may/might be reasonable,
usefulness/effectiveness is unknown, unclear/uncertain or not well
established)

**Class III**: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective and in
some cases may be harmful (is not recommended; is not indicated; should
not; is not useful/effective, beneficial; may be harmful)

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

-   Manuscripts describing both adult and older adult recommendations
    were circulated for comments, revised, and edited for consistency,
    prior to review and approval by the American College of Sports
    Medicine (ACSM) and the American Heart Association (AHA).

-   This document was approved by the ACSM on January 5, 2007, and AHA
    Science Advisory and Coordinating Committee on March 24, 2007.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Levels of evidence (A-C) and classification of recommendations (I-III)
are defined at the end of the \"Major Recommendations\" field.

The following recommendation for older adults describes the amounts and
types of physical activity that promote health and prevent disease. The
recommendation applies to all adults aged 65+ years, and to adults aged
50 to 64 with clinically significant chronic conditions or functional
limitations that affect movement ability, fitness, or physical activity.
For the purposes of this recommendation, a chronic condition is
\"clinically significant\" if a person receives (or should receive)
regular medical care and treatment for it. A functional limitation is
\"clinically significant\" if it impairs the ability to engage in
physical activity. Thus, adults age 50 to 64 with chronic conditions
that do not affect their ability to be active (e.g., controlled
hypertension) would follow the adult recommendation. The parts of the
recommendation below that are not italicized repeat the recommendation
for adults, meaning these parts apply to all adults; the italicized
parts are specific for older adults.

*Regular physical activity, including aerobic activity and
muscle-strengthening activity, is essential for healthy aging. This
preventive recommendation specifies how older adults, by engaging in
each recommended type of physical activity, can reduce the risk of
chronic disease, premature mortality, functional limitations, and
disability.*

**Aerobic Activity**

To promote and maintain health, older adults need moderate-intensity
aerobic physical activity for a minimum of 30 min on five days each week
or vigorous-intensity aerobic activity for a minimum of 20 min on three
days each week. **\[I (A)\]** Also, combinations of moderate- and
vigorous-intensity activity can be performed to meet this
recommendation. **\[IIa (B)\]** *Moderate-intensity aerobic activity
involves a moderate level of effort relative to an individual\'s aerobic
fitness. On a 10-point scale, where sitting is 0 and all-out effort is
10, moderate-intensity activity is a 5 or 6 and produces noticeable
increases in heart rate and breathing. On the same scale,
vigorous-intensity activity is a 7 or 8 and produces large increases in
heart rate and breathing. For example, given the heterogeneity of
fitness levels in older adults, for some older adults a
moderate-intensity walk is a slow walk, and for others it is a brisk
walk.* This recommended amount of aerobic activity is in addition to
routine activities of daily living of light-intensity (e.g., self care,
cooking, casual walking or shopping) or moderate-intensity activities
lasting less than 10 min in duration (e.g., walking around home or
office, walking from the parking lot).

**Muscle-Strengthening Activity**

To promote and maintain health and physical independence, older adults
will benefit from performing activities that maintain or increase
muscular strength and endurance for a minimum of two days each week.
**\[IIa (A)\]** It is recommended that 8 to 10 exercises be performed on
two or more nonconsecutive days per week using the major muscle groups.
*To maximize strength development, a resistance (weight) should be used
that allows 10 to 15 repetitions for each exercise. The level of effort
for muscle-strengthening activities should be moderate to high. On a
10-point scale, where no movement is 0, and maximal effort of a muscle
group is 10, moderate-intensity effort is a 5 or 6 and high-intensity
effort is a 7 or 8.* Muscle-strengthening activities include a
progressive-weight training program, weight bearing calisthenics, and
similar resistance exercises that use the major muscle groups.

**Benefits of Greater Amounts of Activity**

Participation in aerobic and muscle-strengthening activities above
minimum recommended amounts provides additional health benefits and
results in higher levels of physical fitness. **\[I (A)\]** *Older
adults should exceed the minimum recommended amounts of physical
activity if they have no conditions that preclude higher amounts of
physical activity, and they wish to do one or more of the following*;
(a) improve their personal fitness, *(b) improve management of an
existing disease where it is known that higher levels of physical
activity have greater therapeutic benefits for the disease*, and/or (c)
further reduce their risk for premature chronic health conditions and
mortality related to physical inactivity. In addition, to further
promote and maintain skeletal health, older adults should engage in
extra muscle strengthening activity and higher-impact weight-bearing
activities, as tolerated. **\[IIa (B)\]** To help prevent unhealthy
weight gain, some older adults may need to exceed minimum recommended
amounts of physical activity to a point that is individually effective
in achieving energy balance, while considering diet and other factors
that affect body weight. **\[IIa (B)\]**

**Flexibility Activity**

*To maintain the flexibility necessary for regular physical activity and
daily life, older adults should perform activities that maintain or
increase flexibility on at least two days each week for at least 10 min
each day.* **\[IIb (B)\]**

**Balance Exercise**

*To reduce risk of injury from falls, community-dwelling older adults
with substantial risk of falls (e.g., with frequent falls or mobility
problems) should perform exercises that maintain or improve balance.*
**\[IIa (A)\]**

**Integration of Preventive and Therapeutic Recommendations**

*Older adults with one or more medical conditions for which physical
activity is therapeutic should perform physical activity in the manner
that effectively and safely treats the condition(s).* **\[IIa (A)\]**
*So as to prevent other conditions from developing, older adults should
also perform physical activity in the manner recommended for prevention
as described herein. When chronic conditions preclude activity at
minimum recommended levels for prevention, older adults should engage in
regular physical activity according to their abilities and conditions so
as to avoid sedentary behavior.*

**Activity Plan**

*Older adults should have a plan for obtaining sufficient physical
activity that addresses each recommended type of activity*. **\[IIa
(C)\]** *In addition, to specifying each type of activity, care should
be taken to identify, how, when, and where each activity will be
performed. Those with chronic conditions for which activity is
therapeutic should have a single plan that integrates prevention and
treatment. For older adults who are not active at recommended levels,
plans should include a gradual (or stepwise) approach to increase
physical activity over time using multiple bouts of physical activity
([\>]{.underline}10 min) as opposed to continuous bouts when
appropriate. Many months of activity at less than recommended levels is
appropriate for some older adults (e.g., those with low fitness) as they
increase activity in a stepwise manner. Older adults should also be
encouraged to self-monitor their physical activity on a regular basis
and to re-evaluate plans as their abilities improve or as their health
status changes.*

**[Definitions]{.underline}**:

**Levels of Evidence**

A.  Data derived from multiple randomized clinical trials

B.  Data derived from a single randomized trial or from nonrandomized
    studies

C.  Consensus opinion of experts

**Classification of Recommendations**

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and effective
(should; is recommended; is indicated; is useful. effective, beneficial)

**Class II**: Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a procedure or
treatment

**IIa**: Weight of evidence/opinion is in favor of usefulness/efficacy
(is reasonable; can be useful, effective or beneficial; is probably
recommended or indicated)

**IIb**: Usefulness/efficacy is less well established by
evidence/opinion (may/might be considered, may/might be reasonable,
usefulness/effectiveness is unknown, unclear/uncertain or not well
established)

**Class III**: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective and in
some cases may be harmful (is not recommended; is not indicated; should
not; is not useful/effective, beneficial; may be harmful)

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is specifically stated for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   The benefits of regular physical activity in older adults are
    extensive. As noted in the adult recommendation, regular physical
    activity reduces risk of cardiovascular disease, thromboembolic
    stroke, hypertension, type 2 diabetes mellitus, osteoporosis,
    obesity, colon cancer, breast cancer, anxiety, and depression. Of
    particular importance to older adults, there is substantial evidence
    that physical activity reduces risk of falls and injuries from
    falls, prevents or mitigates functional limitations, and is
    effective therapy for many chronic diseases.

-   Clinical practice guidelines identify a substantial therapeutic role
    for physical activity in coronary heart disease, hypertension,
    peripheral vascular disease, type 2 diabetes, obesity, elevated
    cholesterol, osteoporosis, osteoarthritis, claudication, and chronic
    obstructive pulmonary disease.

-   Clinical practice guidelines identify a role for physical activity
    in the management of depression and anxiety disorders, dementia,
    pain, congestive heart failure, syncope, stroke, prophylaxis of
    venous thromboembolism, back pain, and constipation. There is some
    evidence that physical activity prevents or delays cognitive
    impairment and disability, and improves sleep.

#### POTENTIAL HARMS

**Risk of Physical Activity**

-   Vigorous activity has higher risk of injury and lower adherence.

-   Chronic conditions increase risk of activity-related adverse events
    (e.g., heart disease increases risk of sudden death and osteoporosis
    increases risk of activity-related fractures). Activity-related
    musculoskeletal injuries act as a major barrier to regular physical
    activity. While these considerations lead to more emphasis on risk
    management, there is insufficient research on effective strategies
    to prevent injuries.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

In its recommendation for older adults, the panel used terms as they are
defined conventionally. With the exception that only exercise is
recommended to improve balance, the recommendation uses \"physical
activity\" to indicate that exercise programs are not the only way to
meet the recommendation. Additionally, because of its focus on older
adults, the text uses the terms impairments, functional limitations, and
disability. Impairments refer to abnormalities at the level of tissues,
organs, and body systems, whereas functional limitations are deficits in
the ability to perform discrete tasks such as climbing stairs.
Disability on the other hand is a functional limitation expressed in a
social context such as the inability to clean one\'s home or to shop
independently.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera
CA, Castaneda-Sceppa C, American College of Sports Medicine, American
Heart Association. Physical activity and public health in older adults:
recommendation from the American College of Sports Medicine and the
American Heart Association. Circulation 2007 Aug 28;116(9):1094-105.
\[67 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17671236)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 (revised 2007 Aug)

#### GUIDELINE DEVELOPER(S)

American College of Sports Medicine - Medical Specialty Society\
American Heart Association - Professional Association

#### SOURCE(S) OF FUNDING

American Heart Association

#### GUIDELINE COMMITTEE

American College of Sports Medicine

American Heart Association

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Writing Committee Members*: Miriam E. Nelson, PhD, FACSM; W. Jack
Rejeski, PhD; Steven N. Blair, PED, FACSM, FAHA; Pamela W. Duncan, PhD;
James O. Judge, MD; Abby C. King, PhD, FACSM, FAHA; Carol A. Macera,
PhD, FACSM; Carmen Castaneda-Sceppa, MD, PhD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**Writing Group Disclosures**

  -----------------------------------------------------------------------------------------------------------------------------
  **Writing Group    **Employment**   **Research Grant**  **Other     **Speakers\'   **Ownership   **Consultant/   **Other**
  Member**                                                Research    Bureau/        Interest**    Advisory        
                                                          Support**   Honoraria**                  Board**         
  ------------------ ---------------- ------------------- ----------- -------------- ------------- --------------- ------------
  Miriam E. Nelson   Tufts University None                None        None           None          Lluminari,      Strong Women
                                                                                                   Inc\*\*;        Book Series†
                                                                                                   Mission         
                                                                                                   Pharmacal\*\*   

  W. Jack Rejeski    Wake Forest      None                None        None           None          None            None
                     University                                                                                    

  Steven N. Blair    University of    None                None        None           None          Jenny           Royalties
                     South Carolina                                                                Craig\*\*;      for Human
                                                                                                   Matria\*\*      Kinetics\*

  Pamela W. Duncan   Duke University  GlaxoSmithKline\*   None        None           None          None            None

  James O. Judge     University of    None                None        None           None          None            None
                     Connecticut,                                                                                  
                     Evercare                                                                                      

  Abby C. King       Stanford         National Institutes None        National       None          None            None
                     University       of Health†                      Institutes of                                
                                                                      Health                                       
                                                                      research/                                    
                                                                      scientific                                   
                                                                      panels and                                   
                                                                      task forces\*                                

  Carol A. Macera    San Diego State  None                None        None           None          None            None
                     University                                                                                    

  Carmen             Tufts University None                None        None           None          None            None
  Castaneda-Sceppa                                                                                                 
  -----------------------------------------------------------------------------------------------------------------------------

This table represents the relationships of writing group members that
may be perceived as actual or reasonably perceived conflicts of interest
as reported on the Disclosure Questionnaire, which all members of the
writing group members are required to complete and submit. A
relationship is considered to be \"significant\" if (a) the person
receives \$10 000 or more during any 12-month period, or 5% or more of
the person\'s gross income; or (b) the person owns 5% or more of the
voting stock or share of the entity, or owns \$10 000 or more of the
fair market value of the entity. A relationship is considered to be
\"modest\" if it is less than \"significant\" under the preceding
definition.

\*Modest

\*\*Significant

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Pate RR, Pratt M, Blair SN,
Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King
AC, et al. Physical activity and public health. A recommendation from
the Centers for Disease Control and Prevention and the American College
of Sports Medicine. JAMA. 1995 Feb 1;273(5):402-7.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Heart Association Web
site](http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.185650).

Print copies: Available from the American Heart Association, Public
Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone:
800-242-8721

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI Institute on January 9, 2008. The
information was verified by the guideline developer on February 12,
2008.

#### COPYRIGHT STATEMENT

Copyright to the original guideline is owned by the American Heart
Association, Inc. (AHA). Reproduction of the AHA Guideline without
permission is prohibited. Single reprint is available by calling
800-242-8721 (US only) or writing the American Heart Association, Public
Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for
reprint No. 71-0276. To purchase additional reprints: up to 999 copies,
call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies,
call 410-528-4121, fax 410-528-4264, or email kgray@lww.com. To make
photocopies for personal or educational use, call the Copyright
Clearance Center, 978-750-8400.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008