TARGET POPULATION

These guidelines are relevant to all children aged 5–17 years unless specific medical conditions indicate to the contrary. Children and youth should be encouraged to participate in a variety of physical activities that support the natural development and are enjoyable and safe.

Whenever possible, children and youth with disabilities should meet these recommendations. However they should work with their health care provider to understand the types and amounts of physical activity appropriate for them considering their disability.

These recommendations are applicable for all children and youth irrespective of gender, race, ethnicity, or income level. However the communication strategies, dissemination and messaging of the recommendations may differ so as to be most effective in various population subgroups.

The recommended levels of physical activity for children and youth included in this section, should be achieved above and beyond the physical activity accumulated in the course of normal daily non-recreational activities.

All children and youth should be physically active daily as part of play, games, sports, transportation, recreation, physical education, or planned exercise, in the context of family, school, and community activities.

For inactive children and youth, a progressive increase in activity to eventually achieve the target shown below is recommended. It is appropriate to start with smaller amounts of physical activity and gradually increase duration, frequency and intensity over time. It should also be noted that if children are currently doing no physical activity, doing amounts below the recommended levels will bring more benefits than doing none at all.

NARRATIVE SUMMARY OF SCIENTIFIC EVIDENCE (9–11)

The scientific evidence available for the age group 5–17 years supports the overall conclusion that physical activity provides fundamental health benefits for children and youth. This conclusion is based on findings of observational studies in which higher levels of physical activity were found to be associated with more favourable health parameters as well as experimental studies in which physical activity interventions were associated with improvements in health indicators. The documented health benefits include increased physical fitness (both cardiorespiratory fitness and muscular strength), reduced body fatness, favourable cardiovascular and metabolic disease risk profiles, enhanced bone health and reduced symptoms of depression. (9-11)

Physical activity is positively related to cardiorespiratory and metabolic health in children and youth. To examine the relation between physical activity and cardiovascular and metabolic health, the guideline group reviewed literature from the CDC Literature review (2008) and the evidence reviews from Janssen (2007) and Janssen, Leblanc (2009). (9-11)

A dose-response relationship appears to exist, in that greater doses of physical activity are associated with improved indicators of cardiorespiratory and metabolic health. Taken together, the observational and experimental evidence supports the hypothesis that maintaining high amounts and intensities of physical activity starting in childhood and continuing into adult years will enable people to maintain a favourable risk profile and lower rates of morbidity and mortality from cardiovascular disease and diabetes later in life. Collectively, the research suggests that moderate- to vigorous-intensity physical activity for at least 60 minutes per day would help children and youth maintain a healthy cardiorespiratory and metabolic risk profile. In general it appears that higher volumes or intensities of physical activity are likely to have greater benefit, but research in this area is still limited. (9-11)

Physical activity is positively related to cardiorespiratory fitness in children and youth, and both preadolescents and adolescents can achieve improvements in cardiorespiratory fitness with exercise training. In addition, physical activity is positively related to muscular strength. In both children and youth, participation in muscle-strengthening activities 2 or 3 times per week significantly improves muscular strength. For this age group, muscle-strengthening activities can be unstructured and part of play, such as playing on playground equipment, climbing trees or pushing and pulling activities. (9-11)

Normal-weight youth who have relatively high levels of physical activity tend to have less adiposity than youth with low levels. Among overweight and obese youth, interventions that increase the levels of physical activity tend to show beneficial effects on health.

Bone-loading physical activity increases bone mineral content and bone density. Targeted weight-loading activities that simultaneously influence muscular strength, performed 3 or more days per week are effective. For this age group, bone-loading activities can be performed as part of playing games, running, turning or jumping. The literature used for the rationale and dose-response pattern related to bone health was obtained from the CDC literature review (2008), and the evidence reviews from Janssen (2007) and Janssen, Leblanc (2009). (9-11)

The review of the literature relating muscular strength to the relation and dose-response pattern included literature from the CDC literature review (2008), and the evidence reviews from Janssen (2007) and Janssen, Leblanc (2009).

An overall evaluation of the evidence suggests that important health benefits can be expected to accrue in most children and youth who accumulate 60 or more minutes of moderate to vigorous physical activity daily. (9-11)

The concept of accumulation refers to meeting the goal of 60 minutes per day by performing activities in multiple shorter bouts spread throughout the day (e.g. 2 bouts of 30 minutes), then adding together the time spent during each of these bouts. Furthermore, certain specific types of physical activity must be included in an overall physical activity pattern in order for children and youth to gain comprehensive health benefits (9-11).

These include regular participation in each of the following types of physical activity on 3 or more days per week:

• resistance exercise to enhance muscular strength in the large muscle groups of the trunk and limbs;
• vigorous aerobic exercise to improve cardiorespiratory fitness, cardiovascular risk factors and other metabolic disease risk factors; weight-loading activities to promote bone health.

These specific types of physical activity can be integrated to achieve 60 minutes or more per day of health and fitness promoting activity.

A detailed reference of the literature used by the guidelines group to develop these recommendations can be found in Appendix 2.

RECOMMENDATIONS

For children and young people, physical activity includes play, games, sports, transportation, recreation, physical education, or planned exercise, in the context of family, school and community activities.

The guidelines group reviewed the above cited literature and recommended that in order to improve cardiorespiratory and muscular fitness, bone health, cardiovascular and metabolic health biomarkers and reduce symptoms of anxiety and depression:

INTERPRETATION AND JUSTIFICATION

There is conclusive evidence that the physical fitness and health status of children and youth are substantially enhanced by frequent physical activity. Compared to inactive young people, physically active children and youth have higher levels of cardiorespiratory fitness, muscular endurance and muscular strength, and well-documented health benefits include reduced body fat, more favourable cardiovascular and metabolic disease risk profiles, enhanced bone health, and reduced symptoms of anxiety and depression.

Aerobic-type activities should make up the majority of the daily discretionary physical activity.

These recommendations represent a minimum target for daily physical activity that allows for health enhancement and prevention of NCDs.

The costs of adopting these recommendations are minimal and essentially related to the translation into country settings, communication and dissemination. Implementation of comprehensive policies that facilitate the achievement of the recommended levels of physical activity will require additional resource investment.

The benefits of being physically active and implementing the above recommendations outweigh the harms. Any existing risk can be significantly reduced by a progressive increase in the activity level, especially in children who are inactive.

In order to reduce the risk of injuries, the use of protective equipment, such as helmets, should be encouraged in all types of activity that can potentially pose these risks (12).

It should be noted that in populations that are already active, the national physical activity guidelines should not promote a physical activity target that would encourage a reduction in current levels.

TARGET POPULATION

These guidelines are relevant to all healthy adults aged 18–64 years unless specific medical conditions indicate to the contrary. The guidelines also apply to individuals in this age range with chronic noncommunicable conditions not related to mobility such as hypertension or diabetes. Pregnant, postpartum women and persons with cardiac events may need to take extra precautions and seek medical advice before striving to achieve the recommended levels of physical activity for this age group.

Inactive adults or adults with disease limitations will have added health benefits if moving from the category of “no activity” to “some levels” of activity. Adults who currently do not meet the recommendations for physical activity should aim to increase duration, frequency and finally intensity as a target to achieving the recommended guidelines.

These recommendations are applicable for all adults irrespective of gender, race, ethnicity or income level. However, to be most effective, the type of physical activity, the communication strategies, dissemination and messaging of the recommendations, may differ in various population groups. The retirement age, which varies from country to country, should also be taken into consideration when implementing interventions to promote physical activity.

These recommendations can be applied to adults with disabilities. However they may need to be adjusted for each individual based on their exercise capacity and specific health risks or limitations.

NARRATIVE SUMMARY OF SCIENTIFIC EVIDENCE (11, 13–19)

The review of the literature relating cardiorespiratory fitness, muscular strength, metabolic health and bone health to the rationale for relation and dose response patterns was based on an evaluation from the CDC literature review (2008), the evidence reviews from Warburton et al (2007 and 2009) and the review by Bauman et al (2005). (11, 13–19)

The dose-response pattern related to depression was reviewed from the CDC literature review (2008). (11)

There is a direct relationship between physical activity and cardiorespiratory health (risk reduction of CHD, CVD, stroke, hypertension). Physical activity improves cardiorespiratory fitness. Fitness has direct dose-response relations between intensity, frequency, duration and volume. There is a dose-response relation for CVD and CHD. Risk reductions routinely occur at levels of 150 minutes of at least moderate-intensity activity per week. (11, 13–19)

Literature from Cook (2008) and Steyn (2005) related to The INTERHEART Africa Study and Nocon (2008) and Sofi (2008) related to cardiovascular disease and mortality were also considered during the peer review process and related specifically to the context of Africa and cardiovascular disease. (14-17)

There is a direct relationship between physical activity and metabolic health, including reduction of risk of diabetes and metabolic syndrome (11, 13–19). Data indicate that 150 minutes per week of moderate- to vigorous-intensity physical activity bring significantly lower risks.

There is a favourable and consistent effect of aerobic physical activity on achieving weight maintenance. Accumulation of energy expenditure due to physical activity is what is important to achieving energy balance. Accumulation of physical activity can be obtained in short multiple bouts of at least 10 minutes, or one long bout to meet physical activity expenditure goals for weight maintenance. The evidence is less consistent for resistance training, in part, because of the compensatory increase in lean mass, and the smaller volumes of exercise employed. There is substantial inter-individual variability with physical activity and weight maintenance; more than 150 minutes of moderate-intensity activity per week may be needed to maintain weight. Data from recent well-designed randomized control trials lasting up to 12 months indicate that aerobic physical activity performed to achieve a volume of at least 150 minutes per week is associated with approximately 1–3% weight loss, which is generally considered to represent weight maintenance. (11)

Physically active adults are likely to have less risk of a hip or vertebral fracture. Increases in exercise training can minimize the decrease in spine and hip bone mineral density. Increases in exercise training enhance skeletal muscle mass, strength, power, and intrinsic neuromuscular activation. (11, 13, 18, 19)

Weight-bearing endurance and resistance types of physical activity (i.e. exercise training) are effective in promoting increases in bone mass density (e.g. moderate- to vigorous-intensity activity performed 3–5 days per week, 30–60 minutes per session).

Regular practice of physical activity is linked to prevention of breast and colon cancer. Data indicate that moderate- to vigorous-intensity physical activity performed at least 30–60 minutes per day is needed to see significantly lower risks of these cancers.

Overall, strong evidence demonstrates that compared to less active adult men and women, individuals who are more active have lower rates of all-cause mortality, coronary heart disease, high blood pressure, stroke, diabetes, metabolic syndrome, colon cancer, breast cancer, and depression. Strong evidence also supports the conclusion that, compared to less active people, physically active adults and older adults exhibit a higher level of cardiorespiratory and muscular fitness, have a healthier body mass and composition, and a biomarker profile that is more favourable for preventing cardiovascular disease and type 2 diabetes and for enhancing bone health.

A detailed reference of the literature used by the guidelines group to develop these recommendations can be found in Appendix 2.

RECOMMENDATIONS

In adults aged 18–64, physical activity includes leisure time physical activity, transportation (e.g. walking or cycling), occupational (i.e. work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities.

The guidelines group reviewed the above cited literature and recommended that in order to improve cardiorespiratory and muscular fitness, bone health, reduce the risk of NCDs and depression:

INTERPRETATION AND JUSTIFICATION

Conclusive scientific evidence, based on a wide range of well-conducted studies, shows that physically active people have higher levels of health-related fitness, a lower risk profile for developing a number of disabling medical conditions, and lower rates of various chronic noncommunicable diseases than do people who are inactive.

There are multiple ways of accumulating the total of 150 minutes per week. The concept of accumulation refers to meeting the goal of 150 minutes per week by performing activities in multiple shorter bouts of at least 10 minutes each, spread throughout the week then adding together the time spent during each of these bouts: e.g. 30 minutes of moderate-intensity activity 5 times per week.

Evidence of acute effects on biomedical markers points to benefits of undertaking regular physical activity throughout the week (such as 5 or more times per week). Moreover this has the potential to encourage integrating physical activity as part of daily lifestyle such as active travel through walking and cycling.

The recommendations listed above are applicable to the following health conditions: cardiorespiratory health (coronary heart disease, cardiovascular disease, stroke and hypertension); metabolic health (diabetes and obesity); bone health and osteoporosis; breast and colon cancer and depression.

The volume of physical activity associated with the prevention of different chronic NCDs varies. However, the evidence is currently insufficiently precise to warrant separate guidelines for each specific disease, but it is strong enough to cover all health outcomes selected.

Higher volumes of activity (i.e. greater than 150 minutes per week) are associated with additional health benefits. However the evidence is not available to identify additional or increased benefits for volumes greater than 300 minutes per week.

The costs of adopting these recommendations are minimal and essentially related to the translation into country settings, communication and dissemination. Implementation of comprehensive policies that will facilitate the achievement of the recommended levels of physical activity will require additional resource investment.

These recommendations are applicable in low- and middle-income countries. However national authorities need to adapt and translate them into culturally appropriate forms for country level, taking into consideration, among other factors, the need to identify and adapt to the physical activity domain which is most prevalent at the population level (e.g. leisure time, occupational or transportation physical activity).

Activity-related adverse events such as musculoskeletal injuries are common but are usually minor especially for moderate-intensity activities such as walking. Overall, the benefits of being physically active and implementing the above recommendations outweigh the harms. The inherent risk of adverse events can be significantly reduced by a progressive increase in the activity level, especially in inactive adults. Selecting low-risk activities and adopting prudent behaviour while doing any activity can minimize the frequency and severity of adverse events and maximize the benefits of regular physical activity. In order to reduce the risk of injuries, the use of protective equipment, such as helmets, should be encouraged.

It should be noted that, in populations that are already active the national physical activity guidelines should not promote a physical activity target that would encourage a reduction in current levels.

TARGET POPULATION

These guidelines are relevant to all healthy adults aged 65 years and above. They are also relevant to individuals in this age range with chronic NCDs. Individuals with specific health conditions, such as cardiovascular disease and diabetes, may need to take extra precautions and seek medical advice before striving to achieve the recommended levels of physical activity for older adults.

These recommendations are applicable for all older adults irrespective of gender, race, ethnicity or income level. However, the communication strategies, dissemination and messaging of the recommendations may differ in various population groups in order to be most effective.

The recommendations can be applied to older adults with disabilities however they may need to be adjusted for each individual, based on their exercise capacity and specific health risks or limitations.

NARRATIVE SUMMARY OF SCIENTIFIC EVIDENCE (11, 13, 20, 21)

The review of the literature relating cardio respiratory fitness, muscular strength, metabolic health and bone health to the rationale for relation and dose response patterns was based on an evaluation from the CDC literature review (2008) the evidence reviews from Warburton et al (2007 and 2009), the review by Bauman et al (2005) and the systematic reviews by Paterson et al (2007 and 2009). (11, 13, 20, 21)

There is strong scientific evidence that regular physical activity produces major and extensive health benefits in both adults aged 18–64 and in older adults aged 65 and above. In some cases the evidence of health benefits is strongest in older adults because the outcomes related to inactivity are more common in older adults. This results in an increased ability of observational studies to detect the protective effect of physical activity in this age group. Overall, conclusive evidence shows that both moderate-intensity and vigorous-intensity activity provide similar health benefits in both adult age groups. (11, 13, 20, 21)

The overall evidence for adults aged 65 years and above demonstrates that, compared to less active individuals, men and women who are more active have lower rates of all-cause mortality, coronary heart disease, high blood pressure, stroke, type 2 diabetes, colon cancer, breast cancer, a higher level of cardiorespiratory and muscular fitness, healthier body mass and composition, and a biomarker profile that is more favourable for the prevention of cardiovascular disease, type 2 diabetes and the enhancement of bone health. (11, 13, 20, 21)

These benefits are observed in adults in the older age range, with or without existing NCDs. Hence inactive adults of the 65 years and above age group, including those with NCDs, are likely to gain health benefits by increasing their level of physical activity. If they cannot increase activity to levels required to meet guidelines, they should be active to the level their abilities and health conditions allow. Older adults who currently do not meet the recommendations for physical activity should aim to increase physical activity gradually, starting with increasing duration and frequency of moderate-intensity activity before considering increasing the intensity to vigorous-intensity activity. In addition, strong evidence indicates that being physically active is associated with higher levels of functional health, a lower risk of falling, and better cognitive function. There is observational evidence that mid-life and older adults who participate in regular physical activity have reduced risk of moderate and severe functional limitations and role limitations. In older adults with existing functional limitations, there is fairly consistent evidence that regular physical activity is safe and has a beneficial effect on functional ability. However, there is currently little or no experimental evidence in older adults with functional limitations that physical activity maintains role ability or prevents disability. The CDC literature Review (2008) and the systematic reviews by Paterson (2007) and Patterson and Warburton (2009) were used to develop the recommendation related to limited mobility due to health conditions. The dose-response pattern related to depression and cognitive decline were reviewed from the CDC Literature review (2008). (11, 20, 21)

In older adults with poor mobility, there is consistent evidence that regular physical activity is safe and reduces risk of falls by nearly 30%. For prevention of falls, most evidence supports a physical activity pattern of balance training and moderate-intensity muscle-strengthening activities three times per week. There is no evidence that planned physical activity reduces falls in adults and older adults who are not at risk of falls. Evidence specific for this age group related to the maintenance or improvement of balance for those at risk of falling was reviewed from the systematic reviews by Paterson (2007) and Patterson and Warburton (2009). (20, 21)

A more detailed reference of the literature used by the guidelines group to develop these recommendations can be found in Appendix 2.

RECOMMENDATIONS

In older adults of the 65 years and above age group, physical activity includes leisure time physical activity, transportation (e.g. walking or cycling), occupational (if the individual is still engaged in work), household chores, play, games, sports or planned exercise, in the context of daily, family and community activities.

The guidelines group reviewed the above cited literature and recommended that in order to improve cardiorespiratory and muscular fitness, bone and functional health, reduce the risk of NCDs, depression and cognitive decline:

JUSTIFICATION AND INTERPRETATION

Despite the similarities between the recommendations for adults aged 18–65 and for adults aged 65 and above, separate recommendations should be adopted and implemented. Promoting and facilitating the regular practice of physical activity in older adults is especially important because this population group is very often the least physically active. Efforts to promote physical activity in older adults will generally place less emphasis on attaining high volumes of activity, or engaging in vigorous-intensity activity. However, the health status and abilities of older adults vary widely, and some older adults are capable of, and regularly perform, high volumes of moderate- and vigorous-intensity activity.

Conclusive scientific evidence based on a wide range of well-conducted studies shows that adults of the 65 years and above age group, who are physically active, have higher levels of cardiorespiratory fitness, a lower risk profile for developing a number of disabling medical conditions, and lower rates of various chronic noncommunicable diseases than do those who are inactive.

If an individual has a low exercise capacity (i.e. low physical fitness), the intensity and amount of activity needed to achieve many health-related and fitness benefits are less than for an individual who has a higher level of activity and fitness. Because the exercise capacity of adults tends to decrease as they age, older adults generally have lower exercise capacities than younger persons. They therefore need a physical activity plan that is of lower absolute intensity and amount (but similar in relative intensity and amount) than is appropriate for people of greater fitness, especially when they have led sedentary lifestyles and are starting out on an activity programme.

As with adults of the 18–65 age group, there are a number of ways older adults can accumulate the total of 150 minutes per week. The concept of accumulation refers to meeting the goal of 150 minutes per week by performing activities in multiple shorter bouts of at least 10 minutes each spread throughout the week then adding together the time spent during each of these bouts: e.g. 30 minutes of moderate-intensity activity 5 times per week.

It is worth noting that the recommended moderate- to vigorous-intensity activity is relative to the capacity of the individual to perform such activities.

Evidence of acute effects on biomedical markers points to benefits of undertaking regular physical activity throughout the week (such as 5 or more times per week). This also has the potential to encourage integrating physical activity as part of daily lifestyle such as active travel through walking and cycling.

The recommendations listed above are applicable to the following health conditions: cardio-respiratory health (coronary heart disease, cardiovascular disease, stroke and hypertension); metabolic health (diabetes and obesity); bone health and osteoporosis; breast and colon cancer and prevention of falls, depression and cognitive decline.

The volume of physical activity associated with the prevention of different chronic NCDs varies. Although the current evidence is insufficiently precise to warrant separate guidelines for each specific disease, it is sufficiently sound to cover all the health outcomes selected.

Higher levels of activity (i.e. greater than 150 minutes per week) are associated with additional health benefits. However the evidence suggests there is decreasing marginal benefit from engaging in physical activity above volumes equivalent to 300 minutes per week of moderate-intensity activity, and an increased risk of injuries.

The costs of endorsing these recommendations are minimal and essentially related to the translation into country settings, communication and dissemination. Implementation of comprehensive policies that will facilitate the achievement of the recommended levels of physical activity will require additional resource investment.

These recommendations are applicable in low- and middle-income countries. However, national authorities need to adapt and translate them into culturally appropriate forms for country level taking into consideration, among other factors, the physical activity domain which is more prevalent at population level (i.e. leisure time, occupational or transportation physical activity).

Overall, the benefits of being physically active and implementing the above recommendations outweigh the harms. Activity-related adverse events such as musculoskeletal injuries are common but are usually mild, especially for moderate-intensity activities such as walking. The inherent risk of adverse events can be significantly reduced by a progressive increase in the activity level, especially in sedentary older adults. A series of small increments in physical activity, each followed by a period of adaptation, is associated with lower rates of musculoskeletal injuries than is an abrupt increase to the same final level. For sudden cardiac adverse events, intensity of activity, rather than frequency or duration appears to have more adverse effect. The selection of low-risk activities, and prudent behaviour while performing any activity, can minimize the frequency and severity of adverse events and maximize the benefits of regular physical activity.

It should be noted that in populations that are already active, the national physical activity guidelines should not promote a physical activity target that would encourage a reduction in their current levels.