13
Physical Inactivity

The problem of physical inactivity, especially among the elderly, needs greater attention from the service and research communities. Recognition of the importance of addressing this issue is apparent in the work of several government agencies. For example, the Public Health Service's (PHS) health objectives for the nation for 1990 called for 60 percent of adults to participate in regular, vigorous exercise;12 the health objectives for the year 2000 identify the need to understand the determinants of physical activity and exercise. A workshop conducted by the Centers for Disease Control in 1984 on the epidemiology and public health aspects of physical activity and exercise underscored the importance of physical activity and pointed out the difficulties involved in its measurement.28

The term physical activity, defined as ''any bodily movement produced by skeletal muscles that results in energy expenditure," has been used interchangeably with exercise and physical fitness.9 However, exercise is a subcategory of physical activity in that exercise is planned, structured, repetitive, and purposive (i.e., designed to move individuals toward physical fitness). Physical fitness on the other hand, is "a set of attributes that people have or achieve."9 The three terms can be conceived as a hierarchy with fitness dependent on exercise and exercise requiring physical activity or the ability to move. The quantitative requirements of motion and exercise necessary to promote health and prevent disability as people age are the focus of this chapter.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability 13 Physical Inactivity The problem of physical inactivity, especially among the elderly, needs greater attention from the service and research communities. Recognition of the importance of addressing this issue is apparent in the work of several government agencies. For example, the Public Health Service's (PHS) health objectives for the nation for 1990 called for 60 percent of adults to participate in regular, vigorous exercise;12 the health objectives for the year 2000 identify the need to understand the determinants of physical activity and exercise. A workshop conducted by the Centers for Disease Control in 1984 on the epidemiology and public health aspects of physical activity and exercise underscored the importance of physical activity and pointed out the difficulties involved in its measurement.28 The term physical activity, defined as ''any bodily movement produced by skeletal muscles that results in energy expenditure," has been used interchangeably with exercise and physical fitness.9 However, exercise is a subcategory of physical activity in that exercise is planned, structured, repetitive, and purposive (i.e., designed to move individuals toward physical fitness). Physical fitness on the other hand, is "a set of attributes that people have or achieve."9 The three terms can be conceived as a hierarchy with fitness dependent on exercise and exercise requiring physical activity or the ability to move. The quantitative requirements of motion and exercise necessary to promote health and prevent disability as people age are the focus of this chapter.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability Physical inactivity, which has generally been studied as a precursor or an outcome of disease and disability, is the central focus of this review. The general perspective of this chapter is informed by two fundamental assumptions. First, for most persons 50 years of age and older, increasing age is not a cause of physical inactivity.13 As noted by Berger,1 current research, especially by Smith,40 suggests that 50 percent of the decline frequently attributed to physiological aging is, in reality, disuse atrophy resulting from inactivity in an industrialized world. Second, the ability to remain physically active underpins the ability to perform the activities of daily living. This chapter considers physical activity separately from disease and disability. Research on the activities of daily living has been most closely associated with measuring detriments to the performance of specific, essential physical activities, caused by disease and disability; consequently, a discussion of such research falls outside the focus of this chapter. Therapeutic exercise prescribed for a specific disability or injury also will not be addressed in this chapter. Rather, what is known of the benefits of physical activity in general and how such activity can be encouraged and maintained during the "second 50" will guide the discussion that follows. BURDEN Prevalence One measure of physical inactivity is sedentariness, which is defined as either no physical activity or physical activity less than three times per week and/or physical activity of less than 20 minutes per occasion.27 The Centers for Disease Control reported the prevalence of a sedentary lifestyle in selected states using data from its Behavioral Risk Factor Surveillance System. The results of a 1985 telephone survey of 25,221 respondents were analyzed, and approximately 55 percent of the respondents were classified as sedentary. Being sedentary was more common among women than men and increased with age (Figure 13-1). To estimate the percentage of individuals in the United States who maintained appropriate levels of physical activity as specified by the 1990 PHS objectives, Caspersen and colleagues analyzed data from the National Health Interview Survey conducted in 1985. They developed detailed scoring procedures using intensity codes for each activity and determined that almost one-third of the population between the ages of 45 and 64 and close to half of the over-65 age group, were sedentary. Table 13-1 shows their data for leisure-time

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability FIGURE 13-1 Box-plot summaries of the age-specific distribution of sedentary lifestyle prevalence from 22 states participating in the 1985 Behavioral Risk Factor Surveillance System. Source: "Leads from the MMWR: Sex-, Age-, and Region-specific Prevalence of Sedentary Lifestyle in Selected States in 1985—The Behavioral Risk Factor Surveillance System," Journal of the American Medical Association, Vol. 257, p. 2271, 1987. TABLE 13-1 Leisure-time Physical Activity (percentage) by Sex and Age as Reported in the 1985 National Health Interview Survey Characteristic Sedentary Irregularly Active Regularly Active But Inappropriate Activity Appropriate Activity Sex Men 24.8 30.9 36.2 8.1 Women 30.2 31.3 31.5 7.0 Age (years) 18–29 18.3 30.1 41.5 10.1 30–44 24.2 34.5 33.7 7.7 45–64 32.7 31.9 30.8 4.7 65 + 42.6 25.0 24.9 7.5   SOURCE: Adapted from C. J. Caspersen, G. M. Christenson, and R. A. Pollard, "Status of the 1990 Physical Fitness and Exercise Objectives — Evidence from NHIS," Public Health Reports, Vol. 101, pp. 587-592, 1986.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability physical activity by sex and age. In his review of physical activity, Blair2 points out that there has been a decline in the prevalence of sedentariness from approximately 40 percent in the early 1970s to 27 percent in 1985 (Figure 13-2); however, unclear definitions of physical activity and a variety of measurement techniques make it difficult to quantify changes in physical activity habits. Yet despite the apparent decrease in sedentariness over the years, the majority of the U.S. adult population are not vigorously active. In fact, less than half of the adult population engage in regular physical activity. Four studies show the decline in physical activity that occurs as people age from 20 or 30 to 80 years of age.2 Activity limitations owing to chronic health problems were reported in the 1982 National Health Interview Survey. The data indicate that the number of reported activity limitations begins to increase markedly some time after age 44. Activity limitations were reported by 23.9 percent of the population aged 45 to 64 years of age and 45.7 percent of the population over age 65.44 In data drawn from two national probability samples of blacks (the National Survey of Black Americans and the Three-Generation Black Family Study), almost 50 percent of those aged 65 to 74 (N = 472) reported limitations in physical functioning. The percentage exceeds 50 percent in the 80 and older group (Table 13-2).18 FIGURE 13-2 Percentage of U.S. adult population who are vigorously active, 1978-1985 (>12.6kJ [(3 kcal)] · kg-1 · day-1 of leisure-time activity). Source: T. Stephans, "Secular Trends in Physical Activity: Fitness Boom or Bust?" Research Quarterly for Exercise Sport, Vol. 58, pp. 94-105, 1987. Reprinted by permission of the American Alliance for Health, Physical Education, Recreation, and Dance, 1990 Association Drive, Reston, Virginia 22091.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability TABLE 13-2 Physical Health and Functioning of the Black Elderly (percentage) Comparing the Young, Middle-aged, and Very Old (N = 734)   Age Groups Physical Functioning 65–74 (N = 472) 75–79 (N = 142) 80 and older (N = 130) Number of problems with activities of daily living (ADL) Nonea 42.2 38.8 23.8 1-2b 36.6 35.0 40.0 3-7c 21.1 26.3 36.3 Extent of physical or functional limitation Not limited at all or limited very little 50.9 53.5 40.8 Limited some 23.2 21.8 24.6 Limited "a great deal" 26.0 24.6 34.6 a Three-generation telephone respondents were excluded from the percentage base. b Sources on the Overall Health Status Index from 1–13 (high scores = worse health). c Cross-section respondents excluded from percentage base. SOURCE: Adapted from R. C. Gibson and J. Jackson, "The Health, Physical Functioning, and Informal Supports of the Black Elderly," Vol. 65, Suppl., p. 2, Milbank Quarterly, 1987. In the Harvard Alumni Study,31 the most active men in the two oldest age groups (60 to 69 and 70 to 84) had about one-half the risk of dying prematurely as that for the least active men. (Figure 13-3 shows the age-specific death rates over a 16-year follow-up period.) Numerous reports from the Alameda County Study24 show all-cause mortality to be significantly and positively associated with smoking, poor sleep habits, physical inactivity, relative overweight, immoderate alcohol intake, not eating breakfast, and regular snacking. The data also show a relative risk of 1.38 for all-cause mortality in sedentary versus physically active individuals in the 60 to 69 age group and a risk of 1.37 in the 70 and older group. Impairment, Disability, and Handicap Most of the literature concerned with the elderly does not use the World Health Organization's (WHO) classification for the consequences of disease46 (see Chapter 2) to describe the various burdens experienced by individuals who are physically inactive. The observations

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability of a number of authors, however, are roughly analogous to the three descriptive categories (i.e., impairments, disabilities, and handicaps) used in that classification system. Therefore, the discussion below is organized around these categories. The ability of skeletal muscle to perform aerobically for sustained periods of time is influenced by two primary factors: the delivery of oxygen by the cardiovascular system and oxygen consumption by mitochondria in the tissue. Reductions in the oxidative capacity of tissue and reduced oxygen delivery, which often accompany the aging process, support the proposal that aging muscle has impaired ability.7 Yet the precise causes of muscle impairment in the elderly are uncertain.7 Muscle power and strength increase until the third decade; they then plateau and begin to decline in the middle years. With advanced age and senescence, further reductions have been observed. Cross-sectional research using muscle biopsies of healthy older adults indicates that impairments can be attributed to reduced muscle mass as a result, primarily, of a loss of muscle fiber. There are, however, other factors that need further study, including muscle fiber area and changes with age in the ratio of Type I and Type II muscle. Longitudinal studies and more comprehensive FIGURE 13-3 Age-specific death rates from all causes in Harvard Alumni Study over 16 years of follow-up, according to physical activity levels in kilocalories per week. Source: Adapted from R. S. Paffenberger, R. T. Hyde, A. L. Wing, and C. C. Hsieh, "Physical Activity, All-Cause Mortality and Longevity of College Alumni," New England Journal of Medicine, Vol. 314, pp. 605-613, 1986.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability biopsy techniques (with and among muscles) are needed. Decrements in physical performance are also accounted for by structural and metabolic changes in aging muscle, as well as decreased impulse conduction velocity in the aging nervous system. The causal link between physical work capacity and physical activity is much stronger.3 Physical work capacity (PWC) is important for functional capability as it relates to routine household, occupational, and recreational tasks. The best single indicator of physical work capacity is the maximal oxygen uptake (VO2max).40 Determinants of the VO2max are the cardiac output (itself determined by heart rate, which decreases with age, and stroke volume, which may or may not decrease with age), which is a central adjustment of the body to exercise; arteriovenous oxygen difference, which is a peripheral adjustment to exercise; and pulmonary function, which is measured by the maximum ventilation in the lungs. The prevention of disability and handicaps through physical fitness can be crucial in the elderly. For the general population, the loss of functional capacity that accompanies low levels of physical fitness can be disabling: it is at the least an inconvenience and may diminish an individual's quality of life. The consequences for the elderly may be even more serious, however; in addition to the general disabilities experienced by the sedentary, the physically unfit elderly may lose the capacity for independent living.2 Impaired muscle becomes tired sooner than healthy muscle. Therefore, a given work rate will require a greater percentage of maximal aerobic power in sedentary older persons. This, in turn, contributes to a greater rate of fatigue.7 As Blair2 points out, persons with very low maximal aerobic power may have difficulty providing the energy expenditure necessary for required activities; they may be able to meet day-to-day demands but become exhausted if additional exertion is needed. Shephard36 has postulated that the minimal level of aerobic power necessary for independent living is a VO2max of 15 to 16 mL of oxygen per kilogram of body weight per minute, and Blair2 has claimed that individuals who have power levels lower than this threshold cannot care for themselves and may have to be institutionalized. Under the World Health Organization (WHO) classification system, this level of difficulty is considered a handicap.46 Physical inactivity has also been linked to increased risk for several diseases. In a study of 2,950 men with colon cancer listed in a population-based registry is Los Angeles, Garabrant and coworkers16 rated the occupational physical activity of the participants. Men in sedentary jobs (e.g., accountants, social workers, bus drivers) had a colon cancer risk that was 1.6 times higher than those with highly

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability active jobs (e.g., gardeners, mail carriers). A similar finding resulted from a 19-year follow-up study of 1.1 million men in Sweden.17 The Swedish men in sedentary jobs had a colon cancer risk that was 1 to 3 times that of their active peers. Coronary artery disease has also been linked to physical inactivity.33 If inactivity can increase the risk for disease, then intuitively, physical activity should reduce those risks. However, the evidence for such benefits is preliminary. It has been suggested that physical activity lowers the risk for some cancers, although much work remains to be done before this benefit is established.2 There are 5.8 million known diabetics among the civilian noninstitutionalized population of the United States,29 and diabetes is known to cause significant disability. Approximately half of all diabetics report some activity limitation.2 Although the value of exercise in metabolic control in insulin-dependent diabetics is not established, several studies conclude that regular exercise increases peripheral insulin sensitivity.2 In one study a lower prevalence of diabetes was found in female athletes compared with nonathletic classmates.15 The age-adjusted relative risk for diabetes in that study was 2.24 for the nonathletes. PREVENTABILITY OF BURDEN: AVAILABILITY AND EFFECTIVENESS OF INTERVENTIONS If physical inactivity in aging can be termed the "problem" or diagnosis with which this chapter is concerned, then "activation" must become the goal of "treatment." Rather than focusing on the prevention of specific diseases or disabilities, the ''prescription" is aimed at increasing active life expectancy and the maintenance of independence.25 To achieve this goal the means of initiating and maintaining physical activities for the elderly must be explored. There is great potential for increased physical activity among the elderly. Studies indicate that no more than 20 percent, and possibly less than 10 percent, of adult North Americans get optimal amounts of physical activity, and 40 to 50 percent are nearly totally sedentary. Unfortunately, the determinants of exercise in the elderly remain largely unexplored by empirical research,13 despite the myriad studies and articles about the positive effects of physical activity on both physical and mental health. Scientific knowledge of physical activity determinants is almost exclusively restricted to persons aged 18 to 64.13 This information is certainly useful, but research to inform efforts to initiate exercise programs among the elderly is necessary. It is possible, however, to set intelligent general exercise program

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability goals based on accumulated experience. The following programs, organized by target, provide basic guidelines from which to determine specific goals in a wide range of settings. Individuals Exercise programs recommended for older individuals have been based on programs designed for the general adult population. Healthy adults have been advised by the American College of Sports Medicine (as reported by Pollock32) to train three to five days a week, with an intensity of 50 to 80 percent VO2max or maximum heart rate (HRmax) reserve. Training should be from 20 to 60 minutes (the lower the intensity, the greater the duration); longer lasting, lower intensity programs are recommended for nonathletic adults. Exercise should use large muscle groups in continuous motion (as in jogging and rhythmic aerobics) and should include resistance training of moderate intensity that is nevertheless sufficient to develop and maintain fat-free weight and bone integrity. The great variations in fitness levels among the elderly, however, make certain precautions necessary before exercise programs are initiated: programs often need to be modified to suit the particular needs and abilities of the participants. Writing for the American College of Sports Medicine, Heath recommends that individuals who participate in supervised exercise programs complete a brief medical history and risk factor questionnaire.22 Diagnostic tolerance testing is recommended for participants with diabetes mellitus or coronary heart disease and for individuals known to be at risk for these diseases. For vigorous programs, the college advises exercise leaders to ensure that program applicants have had a physical examination by a physician within the two years previous to program initiation.22 Adaptations of exercise programs may vary considerably. In the old-old population (usually 75 years of age and older), emphasis often is placed on maintaining flexibility, strength, coordination, and balance rather than on aerobic training. However, moderate aerobic training may be included in programs for the young-old.45 Programs for the elderly are likely to require exercises of lower intensity and impact and to approach their most strenuous moments more gradually than programs designed for the general adult population.32 As a result, the diminished intensity of these exercises may call for increased frequency. The American College of Sports Medicine's recommended adaptations for older persons include exercising between five and seven days a week for periods of 20 to 40 minutes.22 Given the vast differences among elderly individuals and the dearth of

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability research on exercises for the elderly, however, the recommendation to individualize programs remains prudent. Physicians should recommend exercise training for their elderly patients and should provide information regarding the physiologic and psychological benefits of exercise.24 The committee's message to physicians echoes the advice to program designers: individualize the program prescribed. Physicians should make recommendations to their patients with regard to intensity, duration, frequency, and type of exercise. They may also need to emphasize the importance of non-weight-bearing activities, such as cycling, swimming, and chair and floor exercises, for frail individuals. In addition, because intense stretching exercises and calisthenics may present difficulties for patients with knee and hip mobility problems or for those with degenerative joint changes,22 these activities should not be part of an exercise program for patients with such problems. Finally, because women and individuals from lower socioeconomic classes and minorities are less inclined to adopt rigorous exercise programs,2 physicians and policymakers should take steps to encourage their participation. Although interventions to increase physical activity among persons 65 or older have received study,13 supervised exercise has been shown to increase peak VO211,35 and physical activity interventions offer the promise of increasing active life expectancy.6 However, the actual activity is dependent on the individual to carry it out. Variables that affect whether individuals engage in exercise (either supervised or spontaneous) were summarized by Dishman and colleagues14 (Table 13-3). The table summarizes both cross-sectional and correlational, as well as experimental, findings, but the authors warn that there is "little standardization in defining and assessing determinants and physical activity." When planning supervised activities, it is important to consider individual behavioral differences. Unfortunately, those who may benefit the most from an exercise regimen seem most resistant to adopting or maintaining one. Interventions aimed at personal change, therefore, may be more effective if they help improve an individual's self-image than if they focus exclusively on knowledge of the health benefits of physical activity and exercise.14 At present, research needs for studies of the determinants of exercise in the elderly can only be stated as abstract goals. It therefore follows that the ability to perform detailed analytic evaluations of the effectiveness of these interventions cannot compare with other fields in which there is greater confidence in definitions and standards. Nevertheless, the abstract and perhaps subjective goals that are currently available provide an initial direction necessary for development.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability TABLE 13-3 Summary of Variables that May Determine the Probability of Exercise   Changes in Probability Determinant Supervised program Spontaneous program Personal characteristics Past program participation ++   Past extra-program activity +   School athletics, 1 sport + 0 School athletics, > 1 sport   + Blue-collar occupation — * Smoking —   Overweight —   Type A behavior *   High risk for coronary heart disease ++   Health, exercise knowledge * 0 Attitudes 0 + Enjoyment of activity +   Perceived health ++   Mood disturbance — — Education + ++ Age 00 * Expectation of personal health benefit +   Self-efficacy for exercise   + Intention to adhere 0 0 Perceived physical competence 00   Self-motivation ++ 0 Evaluating costs and benefits +   Behavioral skills ++   Environmental characteristics     Spouse support ++ + Perceived available time ++ + Access to facilities ++ 0 Disruptions in routine —   Social reinforcement (staff, exercise partner) +   Family influences   ++ Peer influence   ++ Physical influences   + Cost   0 Medical screening *   Climate *   Incentives +   Activity characteristics     Activity intensity 00 * Perceived discomfort — * Note: ++ = repeatedly documented increased probability; + = weak or mixed documentation of increased probability; 00 = repeatedly documented that there is no change in probability; 0 = weak or mixed documentation of no change in probability; * = weak or mixed documentation of decreased probability; — = repeatedly documented decreased probability. Blank indicates no data. SOURCE: R. K. Dishman, J. F. Sallis, and D. R. Orenstein, "The Determinants of Physical Activity and Exercise," Public Health Reports, Vol. 100, No. 2, p. 161, 1985.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability Researchers have only begun to probe the factors that contribute to an individual's maintenance of physical activity. Those most likely to engage in regular exercise tend to be well-educated and self-motivated, with "the behavioral skills to plan an exercise program and prepare for relapses."14 Beyond this, little is known, although Dishman and colleagues14 have postulated that successful programs address behavioral and environmental factors affecting exercise maintenance. These programs encourage self-regulation of exercise as well as preparation for relapse, and they include tangible reinforcements of activity. Simply encouraging elderly persons to exercise because the evidence suggests it will be to their benefit is not sufficient in most cases. Programs should prompt, reinforce, and remove the barriers to maintaining physical activity.13 The Community There have been relatively few attempts to promote physical activity at the community level. Early community intervention studies in California and Finland did not give major emphasis to physical activity and did not report improvements in physical activity participation. The second generation of community studies appears to place more emphasis on a reduction in sedentary living habits. One study evaluated the effectiveness of a public health intervention for increasing stair use at a commuter train station (Figure 13-4). The investigators found overall diminution in the targeted behavior following withdrawal of the intervention.6 Those planning community-based programs are advised to strongly encourage senior participants to consult with a physician before starting such a program, and to provide options to accommodate the physical and behavioral difficulties elderly individuals sometimes experience. Worksite The promotion of physical activity at the worksite has become extremely popular. One program that follows the community health model, Johnson and Johnson's Live for Life project, demonstrated striking changes in population physical activity. Blair reports that, by the end of two years, 20 percent of the initially sedentary women and 30 percent of the initially sedentary men were exercising regularly at or above the optimal level.2 Economic analyses of the Live for Life program show reduced hospitalization costs.4 Other benefits of employee participation in a worksite exercise program include decreased absenteeism, turnover, and medical care costs.38

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability FIGURE 13-4 Percentage of subjects using stairs before, during, and after a public health intervention for increasing stair use at a commuter train station in Philadelphia (N = 24,603). Source: K. D. Brownell, A. J. Stunkard, and J. M. Albaum, "Evaluation and Modification of Exercise Patterns in the Natural Environment," American Journal of Psychiatry, Vol. 137, p. 1542, 1980. COST-EFFECTIVENESS OF INTERVENTIONS Questions regarding the effects of exercise on the health of elderly persons have prompted great speculation. Many have wondered if the benefits of physical fitness would have significant implications for the reduction of dependency; others have seen increased physical fitness as a way to reduce health care costs. Shephard has suggested that participation by the elderly in three one-hour exercise classes per week may reduce health care costs from acute and chronic treatment, mental health treatment, and extended residential care by more than $600 for each senior citizen per year.38

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability If true, these findings would indicate that exercise is a great economy. Systematic research to determine how often exercise can make a difference, how much of a difference, and whether it can postpone or reduce dependency of the elderly has yet to be performed.44 Therefore, the potential economic benefits of physical activity in the elderly have yet to be quantified. RECOMMENDATIONS Services The heterogeneity of the over-50 population in terms of physical capability and maintenance of function must be recognized. The research of Harris and coworkers20 indicates that a substantial proportion of persons aged 80 and older have no functional impairment and maintain that status at least over a short-term follow-up period. Continued physical ability at baseline was associated with lack of cardiovascular disease or arthritis and moderate body weight. Interventions to modify physical inactivity should be accompanied by an explanation of the benefits of exercise. Practitioners need to apply behavioral research to encourage physical activity in persons over the age of 50. Good examples of such studies include the work of Berger1 and Owen and Lee.30 In fact, the committee has abstracted the following recommendations from selected guidelines developed by Owen and Lee30 and endorses their principles. Exercise programs should accommodate the participants. Programs should be inexpensive and convenient, provide a wide variety of clear, specific, entertaining alternatives, and use existing social networks, although there may be alternatives that can be performed alone that will also encourage maintenance of function. The stages of the behavioral change process must be understood and used. To facilitate the adoption of a new behavior, a person must be made aware of the problem created by the old behavior, motivated to adopt a new one, taught how to change, and encouraged to adopt and then maintain the new behavior. Program planners must determine where an individual is in this process and intervene accordingly. At the community level, this precept requires programs in which all stages are addressed. The program must respect the diversity of participant health statuses. Specifically, realistic targets must be set, and interventions should be available at several levels.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability The above recommendations apply generally to all adults; however, there are several specific recommendations for the elderly developed by Berger.1 New activities such as walking, swimming, and aerobics classes should be adopted to replace working roles. An explicit association should be established with one's age group (e.g., community organizations, sports organization, or senior citizens center). Work responsibilities should be replaced by enjoyable activities that are not dependent on a work environment. Satisfactory physical living arrangements should be developed including easy access to shopping, medical care, friends, and recreational activities. Research Dishman and colleagues have produced a long, detailed list of research priorities from a review of the literature.14 The following areas have been identified by the committee as prime research areas for determining the factors that lead to exercise or the decision to begin exercise. The relevance of an individual's cognitive, behavioral, and physical abilities should be investigated—for example, the kind of interactions necessary for initiation of exercise, the perception of barriers, and the relationship of other health risks to physical inactivity interventions. The relevance of the individual's occupational background, history of physical activity, lifestyle, and age should be explored. Environmental factors are also worthy of investigation. These include, specifically, the kind of activities participants are requested to perform, whether there is supervision, and whether various activities reinforce or negate each other. Longitudinal (three to four years) and other studies that trace the determinants of exercise maintenance at particular stages should be performed. Some studies should isolate particular groups. The use of methodological ground rules could greatly assist research efforts. Researchers should attempt to reach a consensus over study questions, variables, and measurement methods. Moreover, the concerns of current studies suggest a need to bridge applied questions with theory if physical activity, exercise, and fitness are to be examined in relation to other health behaviors and outcomes.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability Education As Berger1 points out, "Organized exercise programs, individualized for the needs of specific subpopulations, are greatly needed to combat the ageism stereotypes that are rampant in American society. Diminished self-expectancies coupled with social expectancies that one should act his or her age greatly reduce the amount of exercise most older individuals pursue. Supervised exercise programs that encourage the elderly to explore, develop, and extend their physical capabilities are urgently needed" (p. 54). Health care professionals need to provide recommended protocols for individualizing exercise programs. This information should include specific assessment criteria, types of exercises and their effects, and how to monitor and evaluate exercise programs. The expertise of other related professions that may not always be consulted in the care of the elderly (e.g., physical educators and specialists in human kinetics, physical and occupational therapists) would enhance any activity program. Physical and occupational therapists in particular possess specialized knowledge of the use of movement and exercise for treatment of injury and disability. Their knowledge can add greatly to the prevention of injury and disability as well. Unsafe environments (e.g., lack of sidewalks, poorly lighted streets, inaccessible or hidden bus stops far from populated areas) should be eliminated. In addition, city planners, architects, council-persons, mayors, and others who make decisions regarding aspects of the physical environment should take into account the effect of these decisions on the elderly person's use of resources. Policymakers General recommendations for policy regarding exercise programs for the overall population have already been developed.30 Although these recommendations are not specifically aimed at exercise for the "second 50," several are applicable. Guidelines should be developed for selecting a particular population group or subgroup for attention, and efforts should be focused specifically on these individuals (thus avoiding a "scattergun" approach). Incentives and facilities for exercise programs should be provided in occupational and institutional settings. Adequate facilities

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability (e.g., showers, changing rooms) as well as flexible exercise times are essential. Management and employee groups need to cooperate to enhance opportunities for exercise in the workplace. Training programs and further education for health practitioners in exercise counseling, instruction, and promotion should be developed. Explicit policy directives should be formulated to encourage liaison among different government units that are currently or potentially will be involved with exercise. Better use should be made of existing community facilities (e.g., the use of churches during the week or schools on weekends). The promotion of mall walking, with inexpensive, convenient transportation provided to and from the mall, might go a long way toward helping elderly people become less sedentary. REFERENCES 1. Berger, B. G. The role of physical activity in the life quality of older adults. In: W. W. Spirduso and H. M. Eckert (eds.), Physical Activity and Aging. American Academy of Physical Education Paper No. 22. Champaign, Ill.: Human Kinetics Books, 1989, pp. 42-58. 2. Blair, S. N. Exercise, health, and longevity. In: D. R. Lamb and R. Murray (eds.), Perspectives in Exercise Science and Sports Medicine. Vol. 1, Prolonged Exercise. Indianapolis: Benchmark Press, 1988, pp. 443-488. 3. Blair, S. N., Brill, P. A., and Kohl, H. W. Physical activity patterns in older individuals. In: W. W. Spirduso and H. M. Eckert (eds.), Physical Activity and Aging. American Academy of Physical Education Paper No. 22. Champaign, Ill.: Human Kinetics Books, 1989, pp. 120-139. 4. Bly, J. L., Jones, R. C., and Richardson, J. E. Impact of worksite health promotion on health care costs and utilization: Evaluation of Johnson & Johnson's Live for Life Program. Journal of the American Medical Association 1986; 256:3235-3240. 5. Brody, J. A. Prospects for an aging population. Nature 1985; 315:463-466. 6. Brownell, K. D., Stunkard, A. J., and Albaum, J. M. Evaluation and modification of exercise patterns in the natural environment. American Journal of Psychiatry 1980; 137:1542. 7. Buskirk, E. R., and Segal, S. S. The aging motor system: Skeletal muscle weakness. In: W. W. Spirduso and H. M. Eckert (eds.), Physical Activity and Aging. American Academy of Physical Education Paper No. 22. Champaign, Ill.: Human Kinetics Books, 1989, pp. 19-36. 8. Caspersen, C. J., Christenson, G. M., and Pollard, R. A. Status of the 1990 physical fitness and exercise objectives—evidence from NHIS 1985. Public Health Reports 1986; 101:587-592. 9. Caspersen, C. J., Powell, K. E., and Christenson, G. M. Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports 1985; 101(2):126-131. 10. Cornoni-Huntley, J., Brock, D. B., Ostfeld, A. M., Taylor, J. O., and Wallace, R. B. (eds.) Established Populations for Epidemiologic Studies of the Elderly:

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability Resource Data Book. NIH Publ. No. 86-2443. Bethesda, Md.: National Institute on Aging, Public Health Service, 1986, p. 428. 11. Cunningham, D. A., Rechnitzer, P. A., Howard, J. H., and Donner, A. P. Exercise training of men at retirement: A clinical trial. Journal of Gerontology 1987; 42(1):17-23. 12. Department of Health and Human Services. Promoting Health/Preventing Disease: Objectives for the Nation. Washington, D.C.: U.S. Government Printing Office, 1980. 13. Dishman, R. K. Determinants of physical activity and exercise for persons 65 years of age or older. In: W. W. Spirduso and H. M. Eckert (eds.), Physical Activity and Aging. American Academy of Physical Education Paper No. 22. Champaign, Ill.: Human Kinetics Books, 1989, pp. 140-162. 14. Dishman, R. K., Sallis, J. F., and Orenstein, D. R. The determinants of physical activity and exercise. Public Health Reports 1985; 100(2):158-171. 15. Frisch, R. E., Wyshak, G., Albright, N. L., et al. Lower prevalence of breast cancer and cancers of the reproductive system among former college athletes compared to non-athletes. British Journal of Cancer 1985; 52:885-891. 16. Garabrant, D. H., Peters, J. M., Mack, T. M., and Bernstein, L. Job activity and colon cancer risk. American Journal of Epidemiology 1984; 119:1005-1014. 17. Gerhardsson, M., Norell, S. E., Kiviranta, H., Pedersen, N. L., and Ahlbom, A. Sedentary jobs and colon cancer. American Journal of Epidemiology 1986; 123:775-780. 18. Gibson, R. C., and Jackson, J. S. The health, physical functioning, and informal supports of the black elderly. Milbank Quarterly 1987; 65(Suppl. 2):421-454. 19. Guralnik, J. M., and Kaplan, G. A. Predictors of healthy aging: Prospective evidence from the Alameda County study. American Journal of Public Health 1989; 79(6):703-708. 20. Harris, T., Kovar, M. G., Suzman, R., Kleniman, J. C., and Feldman, J. J. Longitudinal study of physical ability in the oldest-old. American Journal of Public Health 1989; 79(6):698-702. 21. Haskell, W. L., Montoye, H. J., and Orenstein, D. Physical activity and exercise to achieve health-related physical fitness components. Public Health Reports 1985; 100:206. 22. Heath, G. W. Exercise programming for the older adult. In: S. N. Blair, P. Painter, R. R. Pate, L. K. Smith, and C. B. Taylor (eds.), American College of Sports Medicine Resource Manual for Guidelines for Exercise Testing and Prescription. Philadelphia: Lea and Febiger, 1988. 23. Idiculla, A. A., and Goldberg, G. Physical fitness for the mature woman. Medical Clinics of North America 1987; 71:135-149. 24. Kaplan, G. A., Seeman, T. E., Cohen, R. D., Knudsen, L. D., and Guralnick, J. Mortality among the elderly in the Alameda County Study: Behavioral and demographic risk factors. American Journal of Public Health 1987; 77:309. 25. Lampman, R. M. Evaluating and prescribing exercise for elderly patients. Geriatrics 1987; 42:63-76. 26. Larson, E. B., and Bruce, R. A. Health benefits of exercise in an aging society. Archives of Internal Medicine 1987; 147:353-356. 27. Leads from the MMWR. Sex-, age-, and region-specific prevalence of sedentary lifestyle in selected states in 1985—the behavioral risk factor surveillance system. Journal of the American Medical Association 1987; 257:2270-2272.

OCR for page 224
The Second Fifty Years: Promoting Health and Preventing Disability 28. Mason, J. O., and Powell, K. E. Physical activity, behavioral epidemiology, and public health (editorial). Public Health Reports 1985; 100(2):113-115. 29. National Center for Health Statistics (Drury, T. F., and Powell, A. L.). Prevalence, impact and demography of known diabetes in the United States. DHHS Publ. No. (PHS) 86-1250. Advance Data from Vital and Health Statistics, No. 114, 1986. 30. Owen, N., and Lee, C. Development of behaviorally-based policy guidelines for the promotion of exercise. Journal of Public Health Policy 1989; 10:(1):43-61. 31. Paffenbarger, R. S., Hyde, R. T., Wing, A. L., and Hsieh, C. C. Physical activity, all-cause mortality and longevity of college alumni . New England Journal of Medicine 1986; 314:605-613. 32. Pollock, M. L. Exercise prescriptions for the elderly. In: W. W. Spirduso and H. M. Eckert (eds.), Physical Activity and Aging. American Academy of Physical Education Paper No. 22. Champaign, Ill.: Human Kinetics Books, 1989, pp. 163-174. 33. Powell, K. E., Thompson, P. D., Caspersen, C. J., and Kendrick, J. S. Physical activity and the incidence of coronary heart disease. Annual Review of Public Health 1987; 8:253-257. 34. Russell, L. B. Is Prevention Better than Cure? Washington, D.C.: The Brookings Institute, 1986. 35. Seals, D. R., Hagberg, J. M., Hurley, B. F., Ehsani, A. A., and Holloszy, J. O. Endurance training in older men and women. I. Cardiovascular responses to exercise. Journal of Applied Physiology 1984; 57:1024-1029. 36. Shephard, R. J. Exercise and aging. In: R. S. Hutton (ed.), Exercise and Sports Sciences Reviews. Philadelphia: Franklin Institute Press, 1979, pp. 1-57. 37. Shephard, R. J. The impact of exercise upon medical costs. Sports Medicine 1985; 2:133-143. 38. Shephard, R. J. Physical Activity and Aging, 2nd ed. London: Croom Helm, 1987. 39. Somers, A. R. Preventive health services for the elderly. In: R. Andres, E. L. Bierman, and W. R. Hazzard (eds.), Principles of Geriatric Medicine. New York: McGraw-Hill, 1985. 40. Smith, E. L. Age: The interaction of nature and nurture. In: E. L. Smith and R. C. Serfass (eds.), Exercise and Aging: The Scientific Basis. Hillside, N.J.: Enslow, 1981, pp. 11-17. 41. Stamford, B. A. Exercise and the elderly. In: K. B. Pandolf (ed.), Sports Sciences Review. New York: Macmillan, 1988, pp. 341-379. 42. Stelmach, G. E., and Goggin, N. L. Psychomotor decline with age. In: W. W. Spirduso and H. M. Eckert (eds.), Physical Activity and Aging. American Academy of Physical Education Paper No. 22. Champaign, Ill.: Human Kinetics Books, 1989, pp. 6-18. 43. Stephens, T. Secular trends in physical activity: Fitness boom or bust? Research Quarterly for Exercise Sport 1987; 58:94-105. 44. U.S. Department of Health and Human Services (Bloom, B.). Current Estimates from the National Health Interview Survey; United States, 1981. National Center for Health Statistics, Public Health Service. DHHS Publ. No. (PHS) 82-1569. Washington, D.C.: U.S. Government Printing Office, 1982. 45. Wheat, M. E. Exercise in the elderly. Western Journal of Medicine 1987; 147:477-480. 46. World Health Organization. International Classification of Impairments, Disabilities, and Handicaps. Geneva: World Health Organization, 1980.