Michigan Governor's Council on Physical Fitness, Health and Sports

Position Statement:

Importance Of Physical Activity

For The Elderly

Contents:

 


Position

Although there is clear scientific evidence that regular physical activity has powerful positive effects on both psychological and physical well-being, 57% of Michigan senior citizens are classified as sedentary. The cost to our state of this physical inactivity is exorbitant. It results in approximately 8,750 premature Michigan deaths from chronic disease per year. It contributes to the escalating cost of health care expenditures for the elderly, which exceeded $9.76 billion in 1993. Worst of all, lack of physical activity most certainly results in needless infirmity and loss of independence for significant segments of our aging population. The Governor's Council on Physical Fitness, Health and Sports believes that programs to facilitate increased physical activity among the aging population are crucial both to the quality of life of senior citizens and to the economic health of the state. We call on senior citizens, health care professionals, and policy-makers at the local and state levels to work together to remove barriers to healthful exercise for our seniors. Delaying initiation of intervention will only add to the existing burdens of needless infirmity, premature death, and uncontrolled health care costs.

Exercise Recommendations

Policy Recommendation for Health Professions

Policy Recommendations for Communities


Introduction

The so-called aging of America is a well-known phenomenon. Throughout the 20th century, both the average age and the life expectancy of Americans have steadily increased. It is estimated that, by the year 2000, 13% of the American population will be over the age of 65.1 As the Baby Boom generation reaches retirement age in the next century, our nation's aging trend will accelerate. By 2050, the proportion of Americans over age 65 will approach 22% - nearly one in four.2

Michigan is currently one of nine states with more than one million residents age 65 and over,1 comprising approximately 12% of our state's total population. As our ranks of elderly residents swell in the years to come, we will see unprecedented challenges in maintaining their health status and in funding their health care costs. The cost of health care for the elderly in Michigan is estimated to be a minimum of $9.76 billion per year as of 1993.*,3,4 The percentage of total personal health care financed by Medicare, the largest purchaser of health care for the elderly, rose in Michigan by 11% between 1980 and 1993,3 which is consistent with a similar trend nationally.5 The heated national debates regarding ways to assure adequate funding for medical care for the elderly have virtually ignored potential savings in health care costs that could be realized through improvements in the personal lifestyle habits related to physical activity.

Regular physical activity can play a major role in ameliorating many age-related declines in the musculoskeletal and cardiovascular systems.6 Furthermore, physical activity often can prevent the need for medical treatment, or it can serve as an important adjuvant to medical treatment. Regular physical activity exerts beneficial effects on the functioning of the cardio-respiratory, vascular, metabolic, endocrine and immune systems. In so doing, it greatly reduces risk factors for coronary artery disease, the nation's leading cause of death, and may also prevent the development of, or effectively treat, diseases such as non-insulin dependent diabetes mellitus, osteoarthritis, osteoporosis, obesity, colon cancer, peripheral vascular occlusive arterial disease, arthritis and hypertension. Regular exercise reduces body fat stores, increases muscle strength and endurance, strengthens bones, and, importantly, improves mental health.7

Although the biochemical and physiological processes associated with aging are poorly understood, both research findings and extensive clinical experience strongly suggest that regular exercise may attenuate the aging process. For example, two common features of aging are decreased muscular strength and reduced functional capacity.6 The resulting weakness and frailty are associated with accidental falls, a major cause of morbidity in the aged, often leading to institutionalization and even death.8,9 However, the deterioration of muscle strength and functional capacity is not entirely a result of aging. Instead, in many cases, it stems largely from disuse.10 Clearly, regular exercise and other forms of physical training can help extend the time that older individuals can continue living independently.

Lack of physical activity is a health issue in all segments of the American population. The most recently available national survey of the leisure-time physical activity of individuals in the United States shows that only 20% of all adults engage in regular, sustained physical activity (at least 5 times/week, at least 30 minutes per session); and only about 14% engage in vigorous physical activity that is regular and sustained (at least 3 times/week, at least 20 minutes per session).7 For individuals aged 65 to 74 years, 27% of males and 19% of females reported engaging in regular activity; 21% of males and 17% of females reported vigorous physical activity. More recent statistics for the State of Michigan11 are equally distressing: overall, only about 22% of state adults participate in regular, sustained activity; and only 15% participate in regular, vigorous activity. In what may be the most striking survey finding, 54% of Michigan adults and more than 57% of Michigan senior citizens have sedentary lifestyles.

The sedentary lifestyles practiced by such a large proportion of Michigan seniors have clearly been shown to be associated with more medical problems, (e.g., coronary artery disease) and, in general, more maladies than are seen in more physically active individuals.6,7,12 Scientific studies of preventive health programs which include regular light-intensity aerobic and resistance exercise demonstrate that risk factors for illness can be reduced and that the elderly can modify their health behaviors.6,7 There is no question that good health habits and regular exercise would markedly reduce health care costs in this large and rapidly growing segment of our population.

Public health efforts to effect behavior change often face unreceptive target audiences. For example, adolescents and young adults may be unresponsive to preventive health messages focusing on long-term benefits, such as longevity, and they may reject appeals that conflict with peer pressure or the actions of celebrity role models. Likewise, middle-aged adults may be unresponsive to messages promising future health benefits in return for a current investment of significant time and attention. In the elderly, barriers to behavior change persist; however, the growing interest in health and longevity that accompanies aging makes it more likely that barriers can be overcome. Seniors generally possess significant time to act on behalf of their health. Furthermore, senior citizens' commitment to improving exercise patterns is likely to be reinforced because benefits such as enhanced functional independence and self-esteem can be realized almost immediately. Finally, promotion of active lifestyle has the psychological advantage of recommending a behavior rather than proscribing one.


*Estimate based on Health Care Administration report of personal health care expenditures for Michigan ($27,136,000,000)3, applying the most recent projection available of per cent of personal health care expenditures for individuals age 65 and over (36%).4


History of the Issue

Recommendations to the general public for appropriate and safe exercise training for improving physical fitness have come from many sources. The American College of Sports Medicine (ACSM) first published a position statement in 1978 entitled "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Fitness in Healthy Adults".13 This document provided recommendations for developing and maintaining cardio-respiratory fitness and a healthy body composition. Other national organizations published physical fitness recommendations through 1995 using the same scientific information as was used for ACSM, including the President's Council on Physical Fitness,14 the YMCA,15 the American Heart Association,16 and the American Association of Cardiovascular and Pulmonary Rehabilitation.17 The importance of these contributions is that the recommendations were largely based on valid scientific data.

Although the fitness benefits of exercise have long been recognized, the health benefits have only recently been widely acknowledged. In 1990, the U.S. Public Health Service published the document "Healthy People 2000," which listed health objectives for the nation18 (Appendix A), with 1995 revisions to add objectives for physical activity and fitness.19 A combined effort by the Centers for Disease Control and the American College of Sports Medicine in 1995 resulted in guidelines for health enhancement through regular exercise training.20

In contrast to previous advice regarding exercise to improve cardio-respiratory fitness, these recent guidelines to improve both fitness and health recommend more frequent exercise -- preferably daily -- performed at a lower intensity at least 30 minutes per day; or accumulating an equivalent total duration through multiple shorter bouts of exercise. An important document promoting the health benefits of regular physical activity was published in 1996 by the NIH Consensus Development Conference Statement on Physical Activity and Cardiovascular Health21 (Appendix B). This group of scientists and health experts stressed that a sedentary lifestyle was a major public health problem in the United States and recommended that all children and adults exercise daily at a moderate intensity for at least 30 minutes. Most noteworthy is the very recent (1996) report of the U.S. Department of Health and Human Services, "Physical Activity and Health: A Report of the Surgeon General"7 (Appendix C). This is by far the most comprehensive document ever published using scientific evidence to demonstrate the cardio-respiratory fitness and health benefits of regular exercise training. This report strongly supports the promotion of physical activity as an important public health measure.

These and other physical activity recommendations to the public have primarily addressed physical activity for adolescents and middle-aged adults (Consensus Conference on Physical Activity Guidelines for Adolescents, American Academy of Pediatrics;22 the 1988 Surgeon General's Report on Nutrition and Health;23 the 1995 USDA/USDHHS report, "Dietary Guidelines for Americans;"24 the U.S. Preventive Services Task Force recommendations;25 and the American Medical Association's "Guide for Adolescent Preventive Services"26). However, little attention has been focused specifically on the special needs of the aged. It is now time to develop public health measures, including appropriate physical activity programs, to improve and maintain healthy lifestyles in the elderly. This effort is important and should be strongly supported at the local, state and national levels.


Scientific Basis

Exercise is not a single entity but a variety of leisure time, occupational, and self-care activities which, if performed routinely, result in biochemical and physiologic adaptations that improve the body's functional capacity, efficiency, muscular endurance, and range of motion. This can occur regardless of the initial fitness level and age of an individual. Aerobic exercise usually involves sustained, dynamic contractions of large muscle groups. Repeated episodes of aerobic exercises improve muscular endurance and strength while simultaneously improving the functioning of the cardiovascular system. In contrast, resistance exercise, such as lifting heavy weights, increases muscular strength and endurance but has little effect on improving cardio-respiratory efficiency.

Aging is associated with profound changes in body composition, muscle strength and muscle mass, often resulting in reduced functional capacity, physical frailty and impaired mobility.27-30 For example, maximum oxygen consumption (VO2max) declines by 0.40 to 0.45 ml/kg/min/yr 31-33 and maximum physical work capacity declines by 25% to 30% between the ages of 30 and 70.34-39 Loss of strength in healthy elderly individuals has been estimated at 1.5% per year, and loss of power at approximately 3.5% per year.40 Many of the pathological and morphological changes attributed to the aging process appear similar to those seen with a sedentary lifestyle.6,10 Because physical training has such a pronounced effect on the cardiovascular, respiratory, endocrine, musculoskeletal and immune systems, such training has the potential to attenuate and even reverse the cardiovascular, metabolic and musculoskeletal deterioration associated with the aging process. For example, moderate endurance-type exercise training generally augments the VO2max by 20 10%. Among previously sedentary men and women, this level of improvement is equivalent to nearly a 20-year functional rejuvenation; in other words, the improved aerobic capacity approximates that of an untrained individual who is 20 years younger.

Older individuals who have remained active throughout their lives maintain much of their physical strength, endurance and stamina. Relative to the sedentary elderly, the individual who is habitually active has greater lean body tissue, a lower percentage of body fat and greater bone density. The elderly individual who is physically active is better able to perform activities of daily living and, in general, has a better quality of life. For older adults with medical problems and physical limitations, exercise programs are particularly important. For such persons, highly individualized physical activity programs should be designed to maximize safety during exercise activities.41

CARDIOVASCULAR BENEFITS

Cardiovascular adaptations to chronic exercise training occur in the elderly and do not appear to differ over a large age range. Not only can the declines in VO2max associated with aging be attenuated but improvements can surpass those found in younger athletes. Stratton and colleagues42 reported increases in cardiac ejection fraction, stroke volume index, and cardiac index at peak exercise, with improvements in physical work capacity in those individuals ranging from 24 to 32 years of age being similar to those aged 60 to 82 years. Sheldahl and colleagues43 reported that the physiologic adaptations to aerobic training in older individuals are similar to those changes seen in middle-aged healthy men. This study also showed that older individuals in training did not experience any orthopedic injuries associated with their exercise program and showed greater interest in long-term participation and supervised aerobic training. Aerobic exercise performed by the aged has resulted in increased maximal voluntary ventilation,31 increased arterial-venous oxygen difference44 and stroke volume,44-47 lowered vascular resistance,44 and improved left ventricular performance.48 Augmented cardiac output with training is primarily due to an increase in stroke volume, the major hemodynamic change observed in the elderly.

HYPERTENSION

Hypertension is a silent killer that is linked to many cardiovascular complications such as left ventricular hypertrophy, hemorrhagic stroke, retinopathy, aortic aneurysm and dissections, and renal failure. Epidemiologic data49 have shown that the risk of developing hypertension is closely related to being sedentary. The sedentary lifestyle common among the elderly may well be predisposing this population segment to hypertension and its sequelae. Those who participated in sports during college years were less likely to develop hypertension,50 and those engaged in vigorous sports during mid-life had a relatively low risk of developing hypertension.51 Other research52 has found that physically active women aged 55 to 69 years had a 30% lower risk of developing hypertension. Those who have developed hypertension can benefit from engaging in physical activity. In a recent meta-analysis of 47 studies assessing the effects of endurance exercise on individuals with essential hypertension, Hagberg 53 found that exercise training reduced systolic and diastolic blood pressure by 10.5 mm Hg and 8.6 mm Hg, respectively. Even low-intensity physical effort has been shown to cause declines in blood pressure,54 making exercise an especially appropriate intervention for elderly individuals.

STROKE

While stroke is the third leading cause of death in the United States,55 research is limited regarding the benefits of exercise in preventing stroke. It is reasonable to expect that exercise would reduce risk of stroke because physical activity reduces risk of one of the primary antecedents of stroke -- hypertension (see above). However, the few studies which have examined direct associations between exercise and stroke do not uniformly show the inverse association expected. Some examples of research supporting a preventive role of exercise in stroke incidence follow.

Kannel and Sorlie,56 studying men aged 35 to 64, showed an inverse association between physical activity and a 14-year incidence of cerebrovascular accidents. Paffenbarger and colleagues57 also showed an inverse association between physical activity and death due to stroke. Most studies of exercise and stroke do not distinguish between ischemic stroke and hemorrhagic stroke. A recent report which did make that distinction found a protective effect of exercise: Abbott and colleagues,58 studying men aged 45-68 years with a 22-year follow-up, showed that sedentary men had a higher incidence of hemorrhagic stroke when they were compared to physically active men. Furthermore, a reduced risk of ischemic stroke was found in physically active smokers when compared to inactive smokers.58

RISK FACTORS FOR ATHEROSCLEROSIS

Risk factors for coronary artery disease escalate with aging.59-63 These risk factors include increases in total serum cholesterol, low-density lipoprotein cholesterol and triglycerides; static levels of high-density lipoprotein cholesterol; and reduced glucose tolerance. Endurance training can favorably alter these risk factors in the elderly. A cross-sectional study by Seals and colleagues64 showed that master athletes (age 55 and older) had favorable plasma lipid and lipoprotein profiles, consistent with very low risk for coronary artery disease. Healthy, post-menopausal women received either 11 months of exercise training, hormone replacement therapy or both therapies to determine the effects on serum lipid and lipoprotein fractions.65 Results of this study showed that both interventions produced favorable alterations in certain lipid and lipoprotein fractions, but that the combined therapies were necessary to optimize reduction of overall cardiovascular risk factors. Improvements in insulin sensitivity, triglycerides and high density lipoprotein cholesterol levels, similar to those found in younger individuals, were noted in persons beyond age 60 who participated in an aerobic training program.66 Among healthy elderly males aged 60-75 years who engaged in habitual physical activity, in vivo insulin sensitivity was closely associated with VO2max.67 Among men and women aged 65 years and older, walking more than 4 hours per week was associated with a reduced risk of hospitalization for cardiovascular disease.68

PERIPHERAL VASCULAR DISEASE

Claudication pain secondary to advanced peripheral vascular occlusive arterial disease becomes more disabling as patients age. Regensteiner and Hiatt69 demonstrated that patients with peripheral vascular occlusive arterial disease who were treated with exercise training showed major improvements in their walking ability, their pain-free walking times and their peak oxygen consumption, without exaggerated heart rate and blood pressure responses. Tinetti and colleagues70 showed that a multifactorial intervention program -- proper medications, behavioral changes and exercise -- was extremely beneficial for elderly patients with intermittent claudication.

CARDIAC REHABILITATION

The prevalence of advanced coronary artery disease increases with aging;71 and the major cause of death in the elderly is ischemic heart disease.72,73 Exercise rehabilitation following an uncomplicated myocardial infarction has been shown in the elderly to improve functional capacity, lipid profiles, obesity indexes, behavioral characteristics and quality of life.74,75

Cardiovascular parameters were compared between a non-exercising healthy older group and a similar group of coronary patients undergoing cardiac rehabilitation.76 While the control group showed no changes in these parameters, the cardiac rehabilitation group showed greater increases in physical work capacity. Elderly patients (65 years and older) who have undergone successful coronary artery bypass grafting have been shown to benefit greatly from a cardiac rehabilitation program. Williams and colleagues77 reported that elderly patients undergoing cardiac rehabilitation improved their functional capacity in a manner similar to that of younger patients, reduced their body fatness and had few adverse effects from exercise training.

MUSCLE STRENGTH

There is a decrease in type II muscle fibers associated with aging, which probably accounts for the diminution of muscle strength.78,79 Changes in mitochondria structure and distribution are linked to losses of oxidative activity80-82 and may be a major factor in the reduced ability of the aged to perform endurance activities. While severe muscle dysfunction and weakness are commonly associated with aging, much of this muscle atrophy may be a normal response to disuse. Exercise training resulting in active skeletal muscle use may attenuate or even reverse this muscle wasting. High-intensity resistance training has been shown to improve muscle strength, and to reduce fatigue and pain, in elderly, physically frail individuals.83 Moreover, these benefits can be achieved without exacerbating disease activity or joint discomfort associated with rheumatoid arthritis.84 Brill and colleagues85 conducted a successful 11-week strength and flexibility program for elderly nursing home residents with dementia, which greatly improved strength and flexibility in participants. Animal studies have shown that aerobic training can increase oxidative capacity and facilitate related improvements in the health and function of older muscle tissue.86-88

FALLS

The leading cause of injury in individuals age 65 and over is falls, which often result in hospitalization and long-term disabilities, and sometimes lead to a permanent loss of independence.89-92 Skeletal muscle weakness in individuals of advanced age places them at an increased risk for falls. Nevitt and colleagues90 conducted a prospective study to determine factors leading to injurious falls in the elderly. They reported that the faller's ability to protect him- or herself during the fall affected the risk of injury. Upper and lower extremity strength were associated with the risk of falling and injury. Strength training is very useful in preventing falls. Healthy older women undergoing a 16-week resistance exercise program improved their strength, walking velocity and ability to perform daily tasks.93 Isokinetic strength in persons over 75 years of age improved with resistance training using simple equipment.94 In a recent comprehensive review of the role of resistance training for health, the President's Council on Physical Fitness and Sports recommended resistance training as a preventive measure against falls among the elderly. Specifically, it was suggested that senior citizens perform resistance training exercises for 8-10 muscle groups, performed 2-3 days per week, using 8-15 repetitions of each exercise.95

ARTHRITIS

Long-term exercise training does not appear to contribute to excessive degenerative joint disease. In a study by Panush and colleagues,96 radiological examination of the lower extremities of 17 male runners with a mean age of 56 years, and of 18 male non-runners with a mean age of 60 years, showed comparable values for osteophytes, cartilage thickness and grade of degeneration. Runners in this study did not show an increased prevalence of osteoarthritis. Similarly, Lane and colleagues97 found no increase in the prevalence of osteoporosis or osteoarthritis in veteran runners aged 50 to 72 years. They compared 40 senior long-distance runners to 41 non-runners, examining roentgenograms of the hands, the lateral lumbar spine and the knees. The runners displayed a 40% greater bone mineral content of the first lumbar vertebra, with no group differences in joint space narrowing, crepitation, joint stability or symptomatic osteoarthritis. The usual age-related reduction in total body calcium and total body potassium has not been found in older marathon runners.98 Those with physical disabilities due to knee osteoarthritis improved their physical capacity and had decreased pain following an exercise program.99 Thus, elderly patients with arthritis can greatly benefit from exercise rehabilitation, improving their general strength, range of motion and joint function.87

OSTEOPOROSIS

A major problem for the elderly is the age-related involutional demineralization of bone and increased bone porosity.100-102 The resulting osteoporosis increases vulnerability to serious injury from minor falls. Exercise training can be an important factor in preventing bone loss and also a stimulus in increasing bone mineral content. Both aerobic exercise and strength training can positively affect bone mineral density.95 Smith and colleagues103 reported a 2.29% bone mineral increase in the radius of elderly women who exercised. Total body calcium increased in post menopausal women participating in an exercise training program for one year, whereas it declined in a similarly aged sedentary group.104 Following an eight-month exercise program, elderly women showed a bone mineral increase of 3.5% in the lumbar spine.105 In a study of women between 35 and 65 years of age who exercised for 45 minutes/day, 3 days/week, researchers found significant increases in bone mineral mass and in the width of the radius, ulna and humerus bones.106 Because the greatest increases were in the radius and ulna as compared to the humerus, these investigators concluded that bones function in discrete units in response to exercise, with the greatest changes occurring in bones associated with active muscles or weight-bearing structures. Preisinger and colleagues107 also found prescribed exercise effective in preventing bone loss in post-menopausal women.

Resistance training has been shown to increase bone mineral density in older adults. Nelson and colleagues108 reported that high-intensity strength training for post-menopausal women was effective and feasible in reducing risk factors for osteoporotic fractures. Moreover, they showed that the strength training improved muscle mass, strength and balance. Pollock and colleagues109 showed that men and women 60 to 90 years of age who underwent six months of isolated lumbar training improved lumbar bone mineral density compared to controls. Menkes and colleagues110 reported a significant increase in femoral neck bone mineral density in middle-aged to older men following 16 weeks of strength training.

CANCER

Cancer is the second leading cause of death in the United States.111 Epidemiologic studies have examined the relationship between cancer risk and sedentary living. At present, the only cancer for which prevention has been linked to habitual physical activity is colon cancer.7 While there are studies suggesting that exercise may help prevent other types of cancer, further research is needed to clarify how regular physical activity may reduce the risks of developing other cancers, such as prostate, testicular, breast, ovarian and endometrial cancers. From a treatment perspective, the positive effects of physical activity on mental health make regular exercise an important component of therapy. Yoshioka112 reported that terminal cancer patients who received exercise in a hospice facility felt it made an important contribution to their overall health care.

OBESITY

Obesity, a common condition among the elderly, is often associated with sedentary habits. Obesity can often be successfully treated with appropriate physical activity programs.113 This is important because obesity has been associated with many debilitating diseases114 and increased health risks.115 A loss of lean body mass of 25 to 30% is associated with aging, with weight being maintained by increased fat accumulation.116-121 A sedentary lifestyle may be a major factor in body composition changes in the elderly. Elderly athletes have been shown to have less than 14% body fat whereas their sedentary counterparts had 30% or more.122 It has been reported that previously active older persons who became sedentary increased their body fatness,123,124 being 12 kg heavier than those continuing to exercise past the age of 55, and 7 kg heavier than those routinely exercising at 65 years. Sidney and colleagues122 found that just a mild level of activity, resulting in a caloric expenditure of 150-200 kcal per day, can increase lean body mass by 10% and decrease skinfold thickness by 17% in elderly subjects. Regular exercise, even without weight loss, can markedly improve cardiac risk factors.125 Physical activity is an important component in weight loss programs126 and for sustaining long-term weight loss.127

URINARY INCONTINENCE

Stress urinary incontinence is a condition where the urethral sphincter is unable to adequately prevent urine loss when a sudden increase in intra-abdominal pressure may occur, as it may with coughing or laughter.128 This condition is fairly common in the elderly, especially in older women.129 While surgery can be a treatment, alternative therapy such as pelvic muscle exercises or Kegel exercises that train the pubococcygeous muscle can help alleviate this condition. The importance of training this muscle group is that it can exert a closing force on the urethra that effectively increases urethral resistance. Wells and colleagues130 compared pelvic muscle exercise to pharmacological treatment, phenylpropanolamine hydrochloride, 50 mg per day, for the treatment of stress urinary incontinence in 82 women aged 55 to 90 years. After 6 months of therapy, pelvic exercises were as beneficial as drug treatment in reducing stress incontinence. Others have also shown that pelvic muscle exercise is effictive in the treatment of stress urinary incontinence in older women.131-133

PSYCHOLOGICAL PARAMETERS

Physical activity has consistently been shown to have positive effects on various measures of mental health. Most well-documented are the effects of aerobic exercise in improving depression, reducing anxiety and improving mood.7 Such improvements have been demonstrated both in epidemiologic134-138 and clinical studies.139-150 Although there have been relatively few studies of the effects of exercise on mental health specifically in the elderly, patterns of improvement in psychological well-being with exercise in the elderly have been shown to be similar to patterns seen in younger persons.151 Several studies of exercise interventions among the elderly support the idea that the aged can greatly benefit psychologically from exercise training. Men aged 60 to 79 were shown to become more self-sufficient following a 14-week program of walking and jogging.152 In another study, following a 5-6-week program of walking on a treadmill, male subjects aged 70 to 81 reported feeling healthier and more relaxed.153 Of particular significance, there are a few studies showing that regular physical activity has a strong positive association with higher levels of cognitive performance on tasks such as math, acuity, and reaction time.154-156 As found in the young, the elderly benefit from exercise training by reporting and showing decreased symptoms of depression, improved sleep, enhanced self-esteem, and feelings of greater energy.157,158


Potential Impact on the Citizens of Michigan

Important to all people in Michigan are public health programs that attenuate, prevent or postpone premature aging and its link to morbidity and mortality. Exercise training programs designed to retard the health deterioration associated with aging159 should be essential components of Michigan's public health planning process. Such measures will improve these citizens' current health status, prevent much of the increased morbidity and mortality associated with aging, and improve quality of life while reducing their needs for health care and human welfare resources in both the public and private sectors.

 


Implications for Public Policy

Important to all people in Michigan are public health programs that attenuate, prevent or postpone premature aging and its link to morbidity and mortality. Exercise training programs designed to retard the health deterioration associated with aging159 should be essential components of Michigan's public health planning process. Such measures will improve these citizens' current health status, prevent much of the increased morbidity and mortality associated with aging, and improve quality of life while reducing their needs for health care and human welfare resources in both the public and private sectors.


Summary

An important public health goal is to achieve more physically active lifestyles among Michigan's elderly residents. Achieving this goal will improve the health status and quality of life for this growing population, increasing the period of time individuals can remain contributing members of society. Additionally, more active senior citizens will have fewer needs for health care and human welfare resources. The policies developed to attain this goal must address both the behavioral and environmental barriers that interfere with or prevent Michigan's elderly residents from adopting more active lifestyles.


APPENDIX A

Healthy People 2000: National Health Promotion and Disease Prevention Objectives17

Selected Fitness-related Objectives

Health Status Objectives

1.1 Reduce coronary heart disease deaths to no more than 100 per 100,000 people.

1.2 Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than 15 percent among adolescents aged 12-19.*

Risk Reduction Objectives

1.3 Increase to at least 30 percent the proportion of people aged 6 and older who engage regularly, preferably daily, in light to moderate physical activity for at least 30 minutes per day.&

1.4 Increase to at least 20 percent the proportion of people aged 18 and older and to at least 75 percent the proportion of children and adolescents aged 6-17 who engage in vigorous physical activity that promotes the development and maintenance of cardio-respiratory fitness 3 or more days per week for 20 or more minutes per occasion.**

1.5 Reduce to no more than 15 percent the proportion of people aged 6 and older who engage in no leisure-time physical activity.

1.5a Reduce to no more than 22% the proportion of people aged 65 and older who engage in no leisure-time physical activity.

1.6 Increase to at least 40 percent the proportion of people aged 6 and older who regularly perform physical activities that enhance and maintain muscular strength, muscular endurance, and flexibility.

1.7 Increase to at least 50 percent the proportion of overweight people aged 12 and older who have adopted sound dietary practices combined with regular physical activity to attain an appropriate body weight.

Physical Activity and Health Objectives

1.11 Increase community availability and accessibility of physical activity and fitness facilities as follows:
    Facility Year 2000 Target
    Hiking, biking, and
    fitness trail miles 1 per 10,000 people
    Public swimming pools 1 per 25,000 people
    Acres of park and recreation open space 4 per 1,000 people

1.12 Increase to at least 50 percent the proportion of primary care providers who routinely assess and counsel their patients regarding the frequency, duration, type, and intensity of each patient's physical activity practices.

Other Health Status Objectives

9.4a Reduce deaths from falls and fall-related injuries to no more than 14.4 per 100,000 people age 65-84.

9.4b Reduce deaths from falls and fall-related injuries to no more than 105 per 100,000 people age 85 and older.

17.3 Reduce to no more than 90 per 1,000 people the proportion of all people aged 65 and older who have difficulty in performing two or more personal care activities,&& thereby preserving independence.

17.3a Reduce to no more than 325 per 1,000 people the proportion of all people aged 85 and older who have difficulty in performing two or more personal care activities,&& thereby preserving independence.


#Overweight For people aged 20 and older, overwight is defined as body mass index (BMI) equal or greater than 27.8 for men and 27.3 for women. For Adolescents, overweight is defined as BMI equal to or greater than 23.0 for males aged 12-14; 24.3 for males aged 15-17; 25.8 for males aged 18-19; 23.4 for females aged 12-14; 24.8 for females aged 15-17; and 25.7 for females aged 18-19. The values for adults are gender specific   85th percentile values of the 1976-1980 National Health and Nutrition Examination Survey (NHANES II), reference population 20-29 years of age. For adolescents, overweight was defined using BMI cutoffs based on modified age- and gender-specific 85th percentile values of the NHEANES II. BMI is calculated by dividing weight in kilograms by the square of height in meters. The cut points used to define overweight approximate the 120 percent of desirable body weight definition used in the 1990 objectives.

&Light to moderate physical activity requires sustained, rythmic muscular movements, is at least equivalent to sustained walking, and is performed at less than 60 percent of maximum heart rate for age. Maximum heart rate equals roughly 220 beats per minute minus age. Examples may include walking, swimming, cycling, dancing, gardening, yard work, various domestic and occupational activities, and games and other childhood pursuits.

##Vigorous physical activities are rythmic, repetitice physical activities that use large muscle groups at 60 percent or more of maximum heart rate for age. An exercise rate of 60 percent of maximum heart rate is about 50 percent of maximal cardio-respiratory capacity and is sufficient for cardio-respiratory conditioning. Maximum heart rate equals roughly 220 beats per minute minus age.

&&Personal care activities are bathing, dressing, using the toilet, getting in and out of bed or chair, and eating.


APPENDIX B

The National Institutes of Health Consensus Development Conference on Physical Activity and Cardiovascular Disease21

December 18-20, 1995

Abstract of Conference Statement

Objective. To provide physicians and the general public with a responsible assessment of the relationship between physical activity and cardiovascular health.

Participants. A non-Federal, non-advocate, 13-member panel representing the fields of cardiology, psychology, exercise physiology, nutrition, pediatrics, public health, and epidemiology. In addition, 27 experts in cardiology, psychology, epidemiology, exercise physiology, geriatrics, nutrition, pediatrics, public health, and sports medicine presented data to the panel and a conference audience of 600.

Evidence. The literature was searched through Medline and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience.

Consensus Process. The panel, answering pre-defined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference.

Conclusions. All Americans should engage in regular physical activity at a level appropriate to their capacity, needs, and interest. Children and adults alike should set a goal of accumulating at least 30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week. Most Americans have little or no physical activity in their daily lives, and accumulating evidence indicates that physical inactivity is a major risk factor for cardiovascular disease. However, moderate levels of physical activity confer significant health benefits. Even those who currently meet these daily standards may derive additional health and fitness benefits by becoming more physically active or including more vigorous activity. For those with known cardiovascular disease, cardiac rehabilitation programs that combine physical activity with reduction in other risk factors should be more widely used.


APPENDIX C

Physical Activity and Health: A Report of the Surgeon General7

Document Description

A New View of Physical Activity

This report brings together, for the first time, what has been learned about physical activity and health from decades of research. Among its major findings:

The Benefits of Regular Physical Activity

Regular physical activity that is performed on most days of the week reduces the risk of developing or dying from some of the leading causes of illness and death in the United States. Regular physical activity improves health in the following ways:

A Major Public Health Concern

Given the numerous health benefits of physical activity, the hazards of being inactive are clear. Physical inactivity is a serious, nationwide problem. Its scope poses a public health challenge for reducing the national burden of unnecessary illness and premature death.


APPENDIX D

Healthy People 2000: National Health Promotion

And Disease Prevention Objectives18

Objective

Objective 1.3 - By the Year 2,000, at least 30% of people aged 6+ years will engage regularly in light to moderate physical activity for at least 30 minutes per day.

Objective 1.4 - By the Year 2,000, at least 20% of people aged 18+ years will engage in vigorous physical activity 3 or more days per week for 20 minutes or more per occasion.

Objective 1.6 - By the Year 2,000, at least 40% of people aged 6+ years will regularly perform muscle strengthening and stretching exercises.

Percentage of Population Needing to Improve if Recommendation is to be Met#

7-10% All Ages, Overall Population
1-3% of Males Aged 65-74 Years
5-8% of Males Aged 75+ Years
9-11% of Females Aged 65-75 Years
14-16% of Females Aged 75+ Years
8-9% of All Ages, Michigan Overall

4-6% All Ages, Overall Population
0% Males Aged 65-74 Years*
0% Males Aged 75+ Years*
2-4% of Females Aged 65-75 Years
7% of Females Aged 75+ Years
4-5% of All Ages, Michigan Overall

Strengthening
35% All Ages, Overall Population
34% of Males Aged 65-74 Years
35% of Males Aged 75+ Years
37% of Females Aged 65-75 Years
39% of Females Aged 75+ Years

Stretching
15% of All Ages, Overall Population
24% of Males Aged 65-74 Years
24% of Males Aged 75+ Years
18% of Females Aged 65-74 Years
22% of Females Aged 75+ Years


#Estimates are calculated as the difference between the Healthy People 200018 objective and the per cent of individuals found to be meeting the objective in national surveys conducted in 1991 and 1992, as reported in "Patterns and Trends in Physical Activity," Chapter 5, Physical Activity and Health: A Report of the Surgeon General.7

*The unexpectedly high number of senior citizens reported as engaging in vigorous activity patterns is due to the fact that simple activities such as walking can be vigorous to the elderly because cardio-respiratory capacity declines with age. Source: Richard Lampman, Ph. D.


References