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Carol West Suitor and Vivica I. Kraak, Rapporteurs Food and Nutrition Board Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the planning com- mittee responsible for the workshop were chosen for their special competences and with regard for appropriate balance. The study was supported by Contract No. HHSP23320042509XI, Task Order No. 07 between the National Academy of Sciences and the United States De- partment of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13 978-0-309-10402-9 International Standard Book Number-10 0-309-10402-5 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (800) 624- 6242 or (202) 334-3313 (in the Washington metropolitan area), Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: Institute of Medicine (IOM). 2007. Adequacy of evidence for physical activity guidelines development: Workshop summary. Washington, DC: The National Academies Press. The serpent has been a symbol of long life, healing, and knowledge among al- most all cultures and religions since the beginning of recorded history. The ser- pent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the re- sponsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the Na- tional Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE ON THE ADEQUACY OF EVIDENCE FOR PHYSICAL ACTIVITY GUIDELINES DEVELOPMENT WILLIAM L. HASKELL (Chair), Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA RODNEY K. DISHMAN, Kinesiology Department, University of Georgia, Athens JOSEPH E. DONNELLY, Energy Balance Laboratory and The Center for Physical Activity and Weight Management, The Schiefelbusch Institute for Lifespan Studies, The University of Kansas, Lawrence BRUCE H. JONES, Epidemiology and Disease Surveillance, U.S. Army Center for Health Promotion and Preventive Medicine, Aberdeen, MD MIRIAM E. NELSON, John Hancock Center for Physical Activity and Nutrition, The Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA Consultant and Rapporteur CAROL WEST SUITOR, Northfield, VT Staff VIVICA I. KRAAK, Study Director LINDA D. MEYERS, Director, Food and Nutrition Board ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice GERALDINE KENNEDO, Administrative Assistant v

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FOOD AND NUTRITION BOARD DENNIS M. BIER (Chair), Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX MICHAEL P. DOYLE (Vice Chair), Center for Food Safety, University of Georgia, Griffin DIANE BIRT, Center for Research on Dietary Botanical Supplements, Iowa State University, Ames YVONNE BRONNER, School of Public Health and Policy, Morgan State University, Baltimore, MD SUSAN FERENC, Chemical Producers and Distributors Association, Alexandria, VA NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver REYNALDO MARTORELL, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA J. GLENN MORRIS, JR., Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA JIM E. RIVIERE, College of Veterinary Medicine, North Carolina State University, Raleigh NICHOLAS J. SCHORK, Department of Psychiatry, Polymorphism Research Laboratory, University of California, San Diego REBECCA J. STOLTZFUS, Division of Nutritional Sciences, Cornell University, Ithaca, NY JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Boston, MA Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ANTON L. BANDY, Financial Associate vi

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BOARD ON POPULATION HEALTH AND PUBLIC HEALTH PRACTICE JAMES W. CURRAN (Chair), The Rollins School of Public Health, Emory University, Atlanta, GA SUSAN M. ALLAN, Oregon Department of Human Services, Portland RONALD BAYER, Joseph L. Mailman School of Public Health, Columbia University, New York, NY GEORGES C. BENJAMIN, American Public Health Association, Washington, DC DAN G. BLAZER, Duke University Medical Center, Durham, NC R. ALTA CHARO, School of Law, University of California, Berkeley HELEN B. DARLING, National Business Group on Health, Washington, DC STEPHEN B. FAWCETT, Human Development & Family Life, University of Kansas, Lawrence JONATHAN E. FIELDING, Department of Health Services, Los Angeles County, CA MARK SCOTT KAMLET, H. John Heinz III School of Public Policy and Management, Carnegie Mellon University, Pittsburgh, PA ROXANNE PARROTT, Department of Communication Arts and Sciences, The Pennsylvania State University, University Park THOMAS A. PEARSON, Department of Community and Preventive Medicine, University of Rochester, NY SAMUEL SO, Stanford University School of Medicine, CA DAVID J. TOLLERUD, Institute of Public Health Research, University of Louisville, School of Public Health, KY WILLIAM A. VEGA, University Behavioral HealthCare, Robert Wood Johnson Medical School, Piscataway, NJ PATRICIA WAHL, School of Public Health and Community Medicine, University of Washington, Seattle PAUL J. WALLACE, Kaiser Permanente Care Management Institute, Oakland, CA LAUREN ZEISE, Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, Oakland, CA ELENA O. NIGHTINGALE, Member Emerita, Scholar-in-Residence, Institute of Medicine, The National Academies, Washington, DC vii

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Staff ROSE MARIE MARTINEZ, Director HOPE R. HARE, Administrative Assistant These two IOM boards did not review or approve this workshop sum- mary. The responsibility for the content of the summary rests with the rapporteurs and the institution. viii

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Independent Report Reviewers This workshop summary has been reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Coun- cil’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published summary as sound as possible and to ensure that the summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this summary: I-MIN LEE, Harvard Medical School and Harvard School of Public Health, Boston, MA JAMES R. MORROW, JR., Department of Kinesiology, Health Promotion, and Recreation, University of North Texas, Denton MIRIAM E. NELSON, John Hancock Center for Physical Activity and Nutrition, The Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA KENNETH E. POWELL, Public Health Consultant, Atlanta, GA Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the summary before its release. The review of this summary was overseen by HUGH H. TILSON, University of North Carolina, who was appointed by the ix

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x INDEPENDENT REPORT REVIEWERS Institute of Medicine. He was responsible for making certain that an independent examination of this summary was carried out in accordance with institutional procedures and that all review comments were carefully considered.

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Acknowledgments The collective efforts of many individuals made it possible to plan and conduct the Institute of Medicine (IOM) workshop on the Adequacy of Evidence for Physical Activity Guidelines Development and to pre- pare this workshop summary within a very short time frame. We are grateful for the assistance of many individuals. RADM Penelope Slade- Royall from the U.S. Department of Health and Human Services, Office of Public Health and Science, Office of Disease Prevention and Health Promotion (DHHS, OPHS, ODPHP) secured DHHS resources to sponsor this effort. CAPT Richard Troiano and Jennifer Tucker from ODPHP, Melissa Johnson from the President's Council on Physical Fitness and Sports, and Harold W. (Bill) Kohl III from the Centers for Disease Con- trol and Prevention provided useful suggestions in planning the work- shop. Members of the planning committee (Bill Haskell, Rodney Dishman, Joseph Donnelly, Bruce Jones, and Miriam Nelson) provided invaluable input in planning the workshop agenda and speakers and pro- vided feedback on specific issues related to the written summaries of the presentations. The session speakers prepared insightful presentations, and the discussants were instrumental in identifying areas of controversy and providing supplementary information. The moderators kept the pre- senters and discussants on task and synthesized the evidence presented in the closing session. We also appreciate the oversight for the National Academies’ review process provided by Bronwyn Schrecker Jamrock and Clyde Behney, skillful copyediting by Mark Goodin, formatting by Judy Estep, manuscript preparation and reference checks conducted by Shannon Wisham, and the careful review and oversight of the report production process by Lara Andersen, Sally Stanfield, and others at the National xi

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xii ACKNOWLEDGMENTS Academies Press. We also thank Linda Meyers, Director of the Food and Nutrition Board; Rose Marie Martinez, Director of the Board on Population Health and Public Health Practice; Anton Bandy, Financial Associate; and Shannon Wisham, Research Associate, for assistance. Special thanks are extended to Geraldine Kennedo, Administrative Assistant, for her skillful logistical coordination of the workshop. Carol West Suitor and Vivica I. Kraak, Rapporteurs

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Contents OVERVIEW 1 1 INTRODUCTORY SESSION 5 2 PHYSICAL ACTIVITY, HEALTH PROMOTION, AND CHRONIC DISEASE PREVENTION 17 3 PHYSICAL ACTIVITY, OBESITY, AND WEIGHT MANAGEMENT 59 4 PHYSICAL ACTIVITY AND RISK—MAXIMIZING BENEFITS 73 5 PHYSICAL ACTIVITY AND SPECIAL CONSIDERATIONS FOR CHILDREN, ADOLESCENTS, AND PREGNANT AND POSTPARTUM WOMEN 95 6 PHYSICAL ACTIVITY AND SPECIAL CONSIDERATIONS FOR OLDER ADULTS 111 7 PHYSICAL ACTIVITY AND CONSIDERATIONS FOR PERSONS WITH DISABILITIES 125 8 CLOSING SESSION 141 xiii

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xiv CONTENTS APPENDIXES A Workshop Agenda 159 B Presenter Biographical Sketches 165 C Workshop Participants 183 D Acronyms and Abbreviations 193 E Glossary 195