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Introduction

Physical activity provides important health benefits to all segments of the population. These benefits, which are extensively documented in the 2018 Physical Activity Guidelines Advisory Committee Report (PAGAC, 2018), include reduced risk for development of multiple noncommunicable diseases such as heart disease, type 2 diabetes, breast cancer, and colorectal cancer (also see Box 1-1). Furthermore, physical activity provides numerous near-term benefits, and these include reduced risk for development of overweight and obesity, improved cardiorespiratory and muscular fitness in youth, reduced risk of falls in older persons, and improvements in several elements of brain health in children, adults, and older adults. Despite these documented health benefits and previous efforts to promote physical activity in the U.S. population, most Americans do not meet current public health guidelines for physical activity (CDC, 2014). Accordingly, the Centers for Disease Control and Prevention (CDC) has launched a multicomponent effort to increase population levels of physical activity through initiatives that target changes at the personal, institutional, and community levels (CDC, 2019).

Within public health, surveillance is the ongoing systematic collection, analysis, and interpretation of outcome-specific data, which can then be used for planning, implementation, and evaluation of public health practice (Thacker et al., 1988). Therefore, surveillance of physical activity is a core public health function that is necessary for measuring and analyzing population prevalence of physical activity, including participation in physical activity initiatives. Surveillance activities are guided by standard protocols and are used to establish baseline data and to track implementation and

evaluation of interventions, programs, and policies that aim to increase physical activity.

Physical activity is challenging to assess because it is a complex and multidimensional behavior that varies by type, intensity, setting, motives, and environmental and social influences. Accordingly, there is a need to develop and implement surveillance systems that effectively integrate measurement of specific physical activity behaviors (like walking) with assessment of environmental factors that influence physical activity behavior (such as the walkability of communities). This need is addressed in the U.S. National Physical Activity Plan (NPAPA, 2016) and was highlighted in “Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities” (HHS, 2015).

STUDY BACKGROUND AND CONTEXT

To address concerns around the need for physical activity surveillance, in 2014 CDC collaborated with the American College of Sports Medicine (ACSM) to review the state of surveillance related to physical activity behavior, human movement, and community programs and policies that support physical activity initiatives. An outcome of the collaboration was the development of an overarching strategy to establish a national plan for physical activity surveillance, with the goal to enhance coordination and collaboration among sectors. Five strategic priorities to guide future physical activity surveillance in the United States were identified (Fulton et al., 2016) and are included in Box 1-2.

Subsequently, groups involved in the 2014 meeting, including CDC, ACSM, the National Institutes of Health (NIH), the American Heart Asso-

ciation, and the National Physical Activity Plan Alliance, continued discussions about their shared interest in acting on the priorities identified (see Box 1-2). As a result, in April 2017, the Physical Activity and Health Innovation Collaborative, an ad hoc activity affiliated with the Roundtable on Obesity Solutions of the National Academies of Sciences, Engineering, and Medicine, served as the convener for a meeting of more than 40 experts who were brought together to identify specific actions that could improve physical activity surveillance in the United States and to suggest approaches for implementing those actions. The agenda and participant list can be found in Appendix D. The experts who attended the meeting represented four topical areas in which the needs and opportunities were seen as particularly significant: (1) children, (2) health care, (3) workplaces, and (4) community supports for active transportation. Throughout the 2-day convening, attendees identified a total of 23 recommended actions to advance surveillance of physical activity in specific population subgroups and to enhance monitoring of institutional and community supports that influence physical activity behaviors. A discussion paper was developed that provided the recommended actions that resulted from the convening (Pate et al., 2018 [see Appendix B for the full text of the discussion paper]).

STUDY PURPOSE AND APPROACH

As a follow-up to the April 2017 meeting, based on a request from CDC, a 7-member ad hoc committee was convened to develop strategies to support the implementation of the recommended actions to improve national physical activity surveillance that were identified in the discussion paper (Pate et al., 2018 [see Appendix B]). The committee’s statement of task appears in Box 1-3.

As noted in the task, the committee was charged with convening a group of experts to examine and build on the existing recommended actions in the four topical areas (children, health care, workplaces, and community supports for active transportation). On November 1–2, 2018, as a way of helping the committee gather information, the committee held a public meeting for approximately 30 individuals with expertise in the four areas to discuss strategies for implementing actions to improve physical activity surveillance (see Appendix C for the open session agenda and the list of participants organized by the four subgroups). As a way of organizing the discussion based on the time available during the public meeting, the committee prioritized the recommendations in the discussion paper (Pate et al., 2018; Appendix B) in advance based on criteria listed in Box 1-4. As prescribed in the task, information gathered during the meeting of experts was the primary source of input that informed the committee’s recommendations. It should be noted that the committee was not charged with

conducting a formal search of the relevant scientific/professional literature, and such a search was not undertaken.

During the meeting, the four subgroups considered five questions regarding implementation of the recommended actions from the discussion paper (Pate et al., 2018; Appendix B), as seen Box 1-5.

Following the meeting, the committee drew on the participants’ contributions and the meeting discussions, and used several overarching principles and guidance in its selection of strategies and implementing actions.

Overarching Principles

• The committee’s work was intended to enhance the current physical activity surveillance system so that it is equitable and appropriately inclusive. Recognizing that there are wide disparities across demographic groups in both compliance with physical activity guidelines and access to physical activity resources, the committee’s recommendations support a system that is as equitable as possible. Particular consideration was given to establishing surveillance protocols that include samples that are appropriately representative of the diverse U.S. population and its institutions and communities.
• Physical activity is a complex behavior and it is influenced by factors operating in a variety of settings. This concept is well conveyed by ecological models of behavior that, when applied to physical activity behavior, posits that activity is affected by layers of influence ranging from broad societal factors to those operating within and proximal to the individual person (Sallis et al., 2015). The committee’s work, as delineated in the statement of task, was focused on one sub-population (children) and three settings (health care, workplaces, and community support for physical activity). Nonetheless, the committee approached its work recognizing that personal physical activity behavior is performed in the context of a system comprising unique settings that operate interactively. Accordingly, the recommendations for children considered all levels of the social-ecological model, and the recommendations for the

• three specific settings considered influences on each setting from other settings and levels of the overall system.
• The major focus of this study was the creation of a more robust system for surveillance of physical activity to support public health practice by enhancing what is currently measured. Accordingly, the committee strove to consider the needs and interests of a broad array of stakeholders, collaborators, and professionals whose interests, skills, and needs would ultimately determine the extent to which the committee’s recommendations would be acted upon. The committee recognized that, given the complexity of physical

• activity behavior, a comprehensive surveillance system can only be successful only if a diverse set of key partners participate in the design of the system, and then act to implement enhancements.

Guidance

• Surveillance often involves collection of sensitive information. The committee’s recommendations are intended to be implemented in a manner that is legal, ethical, and properly attendant to personal, institutional, and community confidentiality.
• To enhance the utility of surveillance as a component of public health practice, the committee’s recommendations are intended to expand the availability of physical activity information at the state, tribal, and local levels, as well as at the national level.
• Though delimited by the components of physical activity surveillance that were specified by the statement of task, the committee’s work was undertaken with the awareness that there are needs and opportunities to enhance physical activity surveillance in other areas. These include population subgroups other than children and settings including the home, faith-based organizations, and educational institutions.
• The committee’s work took place during a time of dynamic change and technological advances related to methods of data collection. Important innovations include broad application of biometry in the population and advances in methods for analysis of “big data.” The committee’s recommendations are intended to be forward looking and to strategically leverage new technology.
• Current physical activity guidelines call for regular participation in multiple types of physical activity including large muscle, whole-body physical activity of moderate-to-vigorous intensity; resistance exercise to enhance muscular strength; bone-loading activity to promote skeletal health; and, in older persons, movements that enhance balance. The committee’s recommendations are intended to address surveillance of participation in all those types of physical activity.
• The committee’s recommendations are intended to be feasible for implementation in the near term. While financial investments will be required to implement some of the recommendations, the committee’s intent was to minimize the need for new investments and optimize use of existing resources. Multiple stakeholders will be asked to share data, make new investments, and reallocate existing resources.
• Although the focus of this study is on creating a more robust physical activity surveillance system to support public health practice,

• the committee’s recommendations are also intended to support research on the public health implications of physical activity.

Development of the Recommendations

The committee’s recommendations were developed in two phases. First, the committee identified four to six key strategies for each of the four topical areas. In addition to the November 2018 public meeting, two additional sources informed the committee’s selection of these strategies, including the recommendations from the 2014 CDC-ACSM expert panel (Fulton et al., 2016) and the Pate et al. (2018) discussion paper that resulted from the April 2017 expert convening (see also Appendix B). Ultimately, 22 strategies were selected for inclusion in this report: 6 for children, 6 for health care, 4 for workplaces, and 6 for community supports for physical activity.

Second, drawing on their individual expertise as well as the ideas shared during the November 2018 meeting, the committee identified specific actions to support implementation of each strategy in the four topical areas. In the identification process, committee applied several criteria to the implementation actions. First, each supporting action was intended to be attainable within a 2- to 3-year period. Second, an “actor,” typically an organization or agency, was to be specified. Third, each supporting action was intended to make a unique and important contribution to attainment of the strategy. Each supporting action was to be phrased concisely, with additional detail provided for clarification as needed. A total of 59 implementation actions were identified: 16 for children, 16 for health care, 12 for workplaces, and 15 for community supports for physical activity.

The committee’s task also included providing guidance and oversight to a consultant hired to develop tools to facilitate surveillance, specifically within the topical area of community supports for active transportation, including prioritized questionnaires and “how-to” protocols. The reports developed by the consultant are in Appendix E. The reports do not necessarily reflect the opinions of the committee and served as additional pieces of evidence that informed the committee in its development of the strategies and supporting actions for implementation.

ORGANIZATION OF THIS REPORT

This report is organized into chapters that present background information followed by the recommended strategies and actions for implementing national physical activity surveillance in the four topical areas: children (Chapter 2), health care (Chapter 3), workplaces (Chapter 4), and community supports for physical activity (Chapter 5). Appendix A is a glossary of acronyms and terms used in the report. Appendix B contains the

agenda, participant list, and discussion paper for the April 2017 convening. Appendix C contains the open session agenda and participant list for the November 2018 public meeting that informed the committee’s deliberations. Appendix D provides a table of surveillance systems. Appendix E contains the consultant’s reports, and Appendix F includes biographical sketches of the committee members.

REFERENCES