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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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2

Children

INTRODUCTION

The health benefits of physical activity in children are strongly supported by evidence. To illustrate, the 2018 Physical Activity Guidelines Advisory Committee conducted an extensive review of the evidence on the relationship between physical activity and health outcomes in school-age children (ages 6 to 17 years). The committee concluded that higher levels of physical activity are associated with better cardiorespiratory and muscular fitness, lower risk of excessive weight gain, more favorable cardiometabolic risk profiles, and bone health. Furthermore, for preschool-age children (ages 3 to 5 years) the Advisory Committee concluded that higher levels of physical activity are associated with bone health and lower risk of excessive weight gain (PAGAC, 2018). Accordingly, the Physical Activity Guidelines for Americans, 2nd Edition, recommends that preschool-age children should be active throughout the day and accumulate at least 3 hours of total physical activity (light, moderate, or vigorous intensity) per day. Furthermore, the guidelines recommend that school-age children should accumulate at least 60 minutes per day of moderate-to-vigorous physical activity and should regularly engage in vigorous intensity, bone-loading, and muscle strengthening activities (HHS, 2018).

Ecological models of behavior suggest that behaviors such as physical activity are influenced by a variety of factors spanning contextual levels of analysis ranging from the individual level to the organizational/environmental level (Sallis et al., 2015). Accordingly, youth physical activity surveillance strategies may assess status, availability, and accessibility of physical activity

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

behaviors, programs, and environments at the (1) individual level such as the volume of physical activity (i.e., intensity duration, frequency), specific forms of physical activity (e.g., walking to and from school, team sports), and objectively measured levels of physical activity (e.g., accelerometer); and (2) organizational level such as physical activity policies, programs, and environments in school and non-school contexts, including child care settings and community-based organizations. The strategies and actions for implementing physical activities surveillance in youth outlined below map onto one or both of these levels of analysis.

The needs for high-quality nationally representative physical activity surveillance data on youth are many-fold. One important application of ongoing and current surveillance data is to compare children’s activity levels with the levels recommended in the guidelines. A second application is to uncover sociodemographic disparities (e.g., pinpointing subgroups that fall short of physical activity recommendations). A third application is to identify critical areas of policy or programmatic need by highlighting behaviors or environments (e.g., lack of standardized physical activity programming in preschools) that require input from government and organizational bodies. Finally, surveillance data on children’s physical activity can be used to as a tool to assess and evaluate the impact of interventions and policies to promote physical activity.

STRATEGIES AND ACTIONS FOR IMPLEMENTATION OF PHYSICAL ACTIVITY SURVEILLANCE IN CHILDREN

Strategy 1

Background

Ensuring that children of preschool age (3 to 5 years of age) attain adequate levels of physical activity is critical for the prevention of chronic diseases (e.g., hypertension, type 2 diabetes) during the child and young adult years (Strong et al., 2005; Timmons et al., 2012; Tammelin et al., 2014). Millions of young American children spend several hours per day in structured child care settings. Their physical activity levels in these settings are influenced by certain physical activity policies and practices (Dowda et al., 2009). Accordingly, multiple entities have recommended that early child care and education programs adopt policies and instructional practices that

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

are known to promote higher levels of physical activity among children in these settings (American Academy of Pediatrics et al., 2012). For example, it has been recommended that child care providers adopt physically active teaching–learning strategies, provide children with substantial amounts of outdoor play time, and include teacher-led physical activities as standard practice (McWilliams et al., 2009; Larson et al., 2011; Pate et al., 2016). In addition, the Institute of Medicine (IOM) recommended that “Child care regulatory agencies should require child care providers and early childhood educators to provide infants, toddlers, and preschool children with opportunities to be physically active throughout the day” (IOM, 2011).

Findings

Researchers have summarized state regulations pertaining to physical activity policies and practices in child care centers (Duffy et al., 2014; Benjamin-Neelon et al., 2018) and the Centers for Disease Control and Prevention (CDC), in collaboration with the National Resource Center, has summarized these regulations (CDC, 2016). However, these reviews have been conducted irregularly and not as part of an ongoing surveillance process. Furthermore, practices to promote children’s physical activity in child care settings have not been monitored in the context of a national surveillance system. However, such a monitoring system is in development at CDC. The agency has produced an instrument for soliciting information from directors of child care settings, and has made preparations for pilot-testing that instrument with representative samples of directors of child care settings in a small number of states. CDC is developing instruments and procedures that may be pilot-tested, refined, and incorporated into a comprehensive national surveillance system for monitoring state regulations and center-level practices in all states.

Supporting Actions for Implementation

The committee proposes the following actions to improve national physical activity surveillance:

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Strategy 2

Background

School is a critical context for physical activity promotion as children spend a substantial amount of time in this setting, and it offers the opportunity to deliver comprehensive programming that reaches large numbers of children (Story et al., 2009). The Institute of Medicine’s Educating the Student Body: Taking Physical Activity and Physical Education to School recommends that school-based policies and practices be implemented to ensure that all K–12 students have the opportunity to participate in at least 60 minutes of physical activity during each school day (IOM, 2013). CDC’s School Health Guidelines to Promote Healthy Eating and Physical Activity provides empirically supported strategies to achieve physical activity during the school day, such as requiring daily physical education and recess, providing other physical activity breaks, offering students the opportunity to participate in after-school sports, and implementing walk-/bike-to-school programs (CDC, 2011). Implementation of these types of physical activity policies and practices varies drastically across states, districts, schools, and classrooms. Regular surveillance of school-based policies and practices that support physical activity is necessary for policy makers and educators to make informed decisions about where to target efforts.

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Findings

Federally supported school-based assessment efforts currently provide a comprehensive assessment of school health policies and practices. The School Health Policies and Practices Study (SHPPS) is a national survey periodically conducted by CDC to assess school health policies and practices at the state, district, school, and classroom levels (CDC, 2012). The Classification of Laws Associated with School Students (CLASS) includes codified data on state-level laws related to physical activity from 2003 to 2015 (NIH, 2018), but it was not designed to be a surveillance system. Furthermore, it was a limited-time project funded by the National Cancer Institute (NCI), and data have not been updated since 2015. Plans for NCI to continue funding CLASS are uncertain.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

SHPPS has many survey questions that assess nuanced aspects of school-based physical activity policies and programs. Many of these data are never analyzed nor reported by schools. CDC can streamline the SHPPS survey by prioritizing questions that collect the most critical information, based on what was included in previous CDC reports on SHPPS data. By limiting the length and scope of the SHPPS survey, CDC may be able to refocus resources on administering SHPPS more frequently over the next 5 to 10 years.

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Strategy 3

Background

Physical fitness refers to the body’s ability to function efficiently and effectively in physically demanding activities. Components of physical fitness include agility, balance, body composition, cardiovascular endurance, coordination, flexibility, muscular endurance, and muscular strength. Higher levels of physical fitness in children are linked to numerous health and developmental benefits, including lower cholesterol, lower blood pressure, lower risk of overweight/obesity, and greater academic achievement (Castelli et al., 2007; Janssen and LeBlanc, 2010). To improve and maintain key components of physical fitness, the Physical Activity Guidelines for

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Americans, 2nd Edition, recommends that children engage in vigorous-intensity aerobic activity at least 3 days per week, muscle-strengthening activities at least 3 days per week, and bone-strengthening activities at least 3 days per week (HHS, 2018). Monitoring physical fitness data in youth is useful as an assessment tool of individual health, for program evaluation and improvement of school-based physical education and sports, and understanding military preparedness.

Findings

Between the 1950s and 1980s, components of physical fitness were regularly assessed in nationally representative samples of children through programs such as Presidential Physical Fitness Testing and Awards (Pate, 1983). However, since the 1980s, national surveillance of children’s physical fitness has been limited. In 2012, the National Health and Nutrition Examination Survey (NHANES) National Youth Fitness Survey (NNYFS) conducted assessments of muscle strength and fitness in a nationally representative sample of children ages 3 to 15 years. However, the NNYFS was a onetime assessment. There is not currently a national surveillance system that routinely assesses physical fitness in children. A coordinated surveillance approach that uses a common set of assessments across a range of populations would enhance the link between research and practice.

In many schools across the United States, the Presidential Physical Fitness Testing program has been replaced by FitnessGram, a health-related fitness assessment and reporting program for children developed by The Cooper Institute. FitnessGram tests are conducted by school physical education teachers to assess cardiovascular fitness, muscle strength, muscular endurance, flexibility, and body composition. Using proprietary FitnessGram software, schools can create personalized fitness reports for each student. Schools may also report FitnessGram data to a national database managed by The Cooper Institute. Although FitnessGram offers a comprehensive and well-validated system for assessing key components of physical fitness, it was not designed to be a national surveillance system. Schools opt in, which creates a patchwork of data that is incomplete and often not representative.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Strategy 4

Background

The only regularly administered surveillance system that monitors children’s compliance with physical activity guidelines is the Youth Risk Behavior Surveillance System (YRBSS), which is limited to self-reported physical activity in high school students (Brenner et al., 2003). NHANES has included device-based measures of physical activity in two survey cycles. The waist-worn monitor was used in the 2003–2004 and 2005–2006 cycles, and the data it collected were used to determine compliance with the Physical

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Activity Guidelines for Americans in children ages 6 to 17 years (Troiano et al., 2008). The wrist-worn monitor was used in the 2011–2012 and 2013–2014 cycles, but because of limitations in data-reduction procedures, those data have not been used to determine compliance with the guidelines.

Findings

Algorithms that transform raw accelerometry data from wrist-worn monitors into metrics can be used to indicate compliance with guidelines. In addition to developing these algorithms, it would be helpful to incorporate device-based measurement of physical activity in children into an existing national surveillance system. If collected and reported in appropriate terms, these physical activity data would allow assessment of population-level compliance with guidelines for children at each 1-year age increment between 3 and 18 years of age.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Strategy 5

Background

Youth sports and other organized physical activity programs are important opportunities for children to be physically active. Authoritative organizations endorse the participation in high-quality sports programs (Elster and Kuznets, 1994; Committee on Sports Medicine and Fitness and Committee on School Health, 2001; NPAPA, 2016). While the doses of physical activity associated with sports participation vary considerably across types of activity (e.g., soccer versus baseball/softball) (Leek et al., 2011), it has been shown that, in general, children who participate in sports programs tend to be more physically active than their non-participating peers (Pate et al., 2000; Harrison and Narayan, 2003; Walters et al., 2009).

A majority of U.S. children participate in organized sports programs (CDC, 2017; The Aspen Institute: Project Play, 2017); only 15 percent of children in the 3rd to 12th grades report never having participated in a sports program (Sabo and Veliz, 2008). Prevalence of participation in youth sports programs decreases markedly as children transition from childhood to adolescence (Seefeldt et al., 1992; Harris, 2000; Sabo and Veliz, 2008), and drop-out rates are higher in girls than boys (Sabo and Veliz, 2008). These observations suggest that preventing drop-out from sports programs could be expected to lessen age- and gender-related declines in physical activity.

Findings

Previous surveillance efforts have assessed participation in organized sports and physical activity programs, with varying levels of detail and specificity. The National Federation of State High School Associations has monitored high school students’ participation in inter-scholastic sports programs for many years (NFHS, 2017). Some surveys of participation in sports programs have been conducted within the context of national surveillance systems (CDC, 2017; HRSA, 2017), and others have been undertaken by nongovernmental education and trade groups (Sabo and Veliz, 2014; Physical Activity Council, 2018; Sports and Fitness Industry Association, 2018). These studies have indicated that participation rates in sports programs differ across demographic and geographic groups (Walters et al., 2009). Moreover, the availability of sports programs may vary markedly

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

across neighborhoods, municipalities, counties, states, and regions in the United States. No existing surveillance system monitors the availability of organized sports and other physical activity programs for children at these jurisdictional levels. Ongoing assessment of these community-based physical activity opportunities for youth at the local- and county-levels can identify disparities and fluctuations in program availability to stimulate public and private investment.

Supporting Actions for Implementation

The committee proposes the following actions to improve national physical activity surveillance:

___________________

1 Also see Chapter 5, Supporting Action 22.1.

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

Strategy 6

Background

The built (i.e., physical) environment and its influence on children’s physical activity levels has been the subject of much research in recent years. Several systematic and comprehensive literature reviews have identified key features of built environments that are associated with children’s physical activity, such as recreational infrastructure, transport infrastructure, and safety/crime (Davison and Lawson, 2006; Ding et al., 2011; McGrath et al., 2015). Although much of the research has focused on objective assessments of built environment features (using Geographic Information Systems [GISs] and Global Positioning Systems [GPSs]), a growing emphasis has been placed on how individual perceptions (i.e., subjective evaluations) of the built environment may influence physical activity in children (Duncan et al., 2005). It is common for subjective and objective assessments of physical activity environments to differ (Ball et al., 2008), and evidence suggests that perceived availability of physical environment resources (in the home, neighborhood, and school) are associated with physical activity in children (Fein et al., 2004). National-level surveillance of the quantity and quality of built environment features that support children’s physical activity can inform environmentally related policies and interventions to promote physical activity in children.

Findings

Assessing individual perceptions of environmental supports for children’s physical activity may be a promising approach to nationwide surveillance on this topic. Although research on this topic is limited, one area that has received some attention is parental concerns about neighborhood safety. Such concerns are related to lower physical activity levels in children (Weir et al., 2006; Carver et al., 2010). Currently, national surveil-

___________________

2 Also see Chapter 5, Supporting Action 22.1.

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

lance systems such as the National Survey of Children’s Health (NSCH) assess parental perceptions of neighborhood features that may be related to children’s activity levels, including the perceived availability of parks and playgrounds, sidewalks and walking paths, and recreation centers (NSCH, 2018). The NSCH also assesses parental perceptions of neighborhood disorder (e.g., litter, broken windows, and graffiti). However, there is not a coordinated effort to comprehensively assess perceived environmental features related to children’s physical activity (either within or across various national surveys), making it difficult to generate national estimates.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

___________________

3 Also see Chapter 5, Supporting Action 17.1.

4 Also see Chapter 5, Supporting Action 17.2.

Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×

CONCLUSION

The health benefits of physical activity in children are supported by strong and increasing evidence, which paved the way for the recommendations in the Physical Activity Guidelines for Americans, 2nd Edition, released in 2018. National surveillance enables a comparison of children’s current physical activity levels with recommended levels, and can also reveal sociodemographic disparities and inequities in children’s physical activity opportunities. Surveillance data are also vital for evaluating the availability, accessibility, and impact of programs, policies, and environments that promote physical activity among children. These data also help shape new interventions and policies that seek to improve physical activity prevalence. The 6 strategies and 16 implementation actions presented in this chapter will promote high-quality surveillance of physical activity in children and ultimately improve children’s physical activity levels so they are more closely aligned with the Physical Activity Guidelines for Americans.

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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
×
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Suggested Citation:"2 Children." National Academies of Sciences, Engineering, and Medicine. 2019. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States. Washington, DC: The National Academies Press. doi: 10.17226/25444.
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Physical activity has far-reaching benefits for physical, mental, emotional, and social health and well-being for all segments of the population. 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.

Surveillance in public health 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. Surveillance of physical activity is a core public health function that is necessary for monitoring population engagement in 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. However, 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. The lack of surveillance systems to assess both physical activity behaviors (including walking) and physical activity environments (such as the walkability of communities) is a critical gap.

Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States develops strategies that support the implementation of recommended actions to improve national physical activity surveillance. This report also examines and builds upon existing recommended actions.

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