Surveillance of Physical Activity: Actions Needed to Support New Federal Guidelines

Physical activity can provide important health benefits for persons in virtually every segment of the population. That is the core premise underlying the Physical Activity Guidelines for Americans, Second Edition (PAG).¹ The 2018 guidelines were informed by an exhaustive review of the scientific evidence linking higher physical activity to a remarkable number of health benefits,¹ ranging from better bone health in preschoolers to enhanced functional status in older persons with multiple chronic conditions. Unfortunately, most Americans do not meet the PAG, and there are profound disparities in physical activity across demographic groups.² Hence, for the bulk of the population, even a modest increase in physical activity would provide demonstrable health benefits. Limited progress has been made in increasing physical activity in the United States,¹ and this points to the need for comprehensive and well-resourced public health initiatives aimed at helping millions of Americans move toward meeting the PAG.

The purpose of this editorial is to inform the broad public health community about a new report on physical activity surveillance, make the case that new investments are needed to implement the recommendations and are justified by the potential to improve physical activity promotion initiatives, encourage leading public health organizations to support the recommendations on a national level, and request practitioners to implement them locally.

ENHANCING SURVEILLANCE OF PHYSICAL ACTIVITY

A core function of public health is surveillance. The information provided by a comprehensive surveillance system is required to effectively target and monitor interventions that can change behavior and enhance population health. Because physical activity has become a focus of public health practice only in recent decades, the field has not yet established the infrastructure needed to mount initiatives that would increase population-level physical activity. A key step will be creation of a robust physical activity surveillance system.

Creation of a comprehensive approach was the focus of a May 2019 consensus report from the National Academies of Sciences, Engineering, and Medicine.³ This report laid out 22 recommended strategies and 59 implementation actions for the enhancement of physical activity surveillance across four topical areas: children, health care, workplaces, and community supports for physical activity. The strategies and associated implementation actions presented in the new report build on two recent expert panel reviews^4,5 and are aimed at addressing gaps in the current systems that monitor physical activity behavior, as well as assessing setting-based factors known to influence physical activity. The box on page 88 provides a summary of the recommended strategies that are included in the report. The full report is available at http://nationalacademies.org/hmd/Reports/2019/Implementing-Strategies-to-Enhance-Public-Health-Surveillance-of-Physical-Activity-in-the-United-States.aspx.

Recommended Strategies to Enhance Physical Activity Surveillance and Estimated Relative Costs for Implementation.

Children
Strategy 1: Develop and implement state- and national-level systems for monitoring physical activity policies and practices in early child care and early childhood education settings. Estimated costs: high.
Strategy 2: Enhance existing surveillance systems for monitoring elementary through high school–based physical activity policies and programs. Estimated costs: medium.
Strategy 3: Develop a protocol that leverages ongoing administration of physical fitness tests, such as FitnessGram, for the purpose of monitoring fitness levels of children and youths. Estimated costs: low.
Strategy 4: Expand objective monitoring of physical activity in children (ages 3–18 y) by incorporating validated wearable technologies into existing surveillance systems. Estimated costs: medium.
Strategy 5: Develop a system for monitoring community-level availability of organized sports and other physical activity programs for children. Estimated costs: medium.
Strategy 6: Identify features of the built environment that are most likely to influence physical activity in children and embed an assessment of the perceived availability and use of these features into existing surveillance systems. Estimated costs: low.
Health Care
Strategy 7: Develop surveillance systems to monitor the prevalence of physical activity assessment in adults through expanded integration of a standard physical activity vital sign in health care delivery. Estimated costs: medium.
Strategy 8: Develop surveillance systems to monitor the prevalence of physical activity assessment and promotion among children through integration of a standard pediatric physical activity vital sign in health care delivery. Estimated costs: medium.
Strategy 9: Expand the use of data from wearable devices for monitoring physical activity in at-risk patients. Estimated costs: medium.
Strategy 10: Conduct surveillance of cardiorespiratory fitness and muscle strength testing among at-risk populations in health care settings. Estimated costs: high.
Strategy 11: Ensure that national health care delivery surveys include questions about physical activity assessment and counseling in health care settings. Estimated costs: low.
Strategy 12: Conduct surveillance of physical activity levels in the health care workforce and related training programs. Estimated costs: high.
Workplaces
Strategy 13: Document existing surveillance efforts that capture physical activity, physical fitness, and sedentary behavior in the workplace and in employees’ commutes to and from work and identify opportunities to expand these efforts. Estimated costs: low.
Strategy 14: Convene public and private stakeholders to prioritize and implement consensus key measures to assess individual-level physical activity, physical fitness, and sedentary behavior surveillance in the workplace. Estimated costs: low.
Strategy 15: Develop consistent measures for physical activity in workplace designs and operations, policies, programs, culture, and climate, and use these measures in comprehensive surveillance of physical activity and physical fitness in the workplace. Estimated costs: high.
Strategy 16: Obtain longitudinal support and funding for the Workplace Health in America Survey. Estimated costs: medium.
Community Supports for Physical Activity
Strategy 17: Prioritize a set of constructs and corresponding survey items to assess perception of community supports for active transportation and active recreation, incorporate the constructs and survey items into national surveillance systems, and promote their use at the local level. Estimated costs: low.
Strategy 18: Identify and compile GIS–based data sources and methods to facilitate national surveillance of community supports for physical activity. Estimated costs: low.
Strategy 19: Explore opportunities for partnering with professional organizations to query their membership about physical activity–supportive policies in the communities where they work and to share policy-tracking data for surveillance purposes. Estimated costs: low.
Strategy 20: Develop and standardize methods for linking policies, self-reported surveillance systems, and environmental geospatial data to identify opportunities to support physical activity. Estimated costs: low.
Strategy 21: Identify a brief set of prioritized constructs and methods that could be assessed using audits (observations) of streets, parks, and other relevant public spaces. Estimated costs: high.
Strategy 22: Identify methods to assess physical activity events, programs, social environments, and promotion resources. Estimated costs: medium.

Note. GIS = geographic information system. See the full report at nationalacademies.org/PhysicalActivitySurveillance for the accompanying implementation actions.

Source. National Academies of Sciences, Engineering, and Medicine.³

RESOURCES NEEDED TO ACT ON RECOMMENDATIONS

The recommended surveillance strategies in the National Academies report (see the box on page 88) are aimed at expanding the availability of physical activity information at national, state, tribal, and local levels. Though costs are not directly addressed in the report, the recommendations were crafted with an eye toward optimizing use of existing resources. Thus, various levels of financial resources, from few or no new resources, to substantial new investments, will be needed to implement the recommendations. See the box on page 88 for estimated relative level of financial costs (low, medium, high) to implement each recommendation. For example, strategy 19, under “Community Supports for Physical Activity,” involves partnering with professional organizations in the city planning and transportation fields to query their membership about physical activity–supportive policies in the communities where they work. One of the supporting actions for this strategy leverages ongoing policy tracking by organizations such as the Road to Zero Coalition, which could provide valuable longitudinal data about transportation safety policies that are consistent with physical activity promotion. Other strategies such as developing new national surveillance systems (e.g., strategy 8 under “Health Care”) will require substantial investments to ensure a representative sample that allows examination of differences by subpopulations.

Additional considerations for implementing these recommendations include effective collaboration, engaging multiple stakeholders, and policy supports. Several recommendations will require collaboration across agencies and organizations, especially those that involve data sharing. Establishing data use agreements could facilitate data sharing across organizations to enhance physical activity surveillance by using existing data for new surveillance purposes.

Engaging multiple stakeholders is also important for advancing the recommendations. For example, strategy 1, in the section on “Children,” involves developing and implementing state- and national-level systems for monitoring physical activity policies and practices in early child care and early childhood education settings. Developing new systems cannot occur without strong partnerships with the education and child care sectors.

Policy tools such as legislation, regulation, and private-sector or institutional policies are needed to support implementation of some recommendations.⁶ For example, strategy 16 in the “Workplace” section calls for sustained funding for the Workplace Health in America Survey. Policies that support appropriation of funds for the survey could help ensure its sustainability and utility.

RESOURCES NEEDED TO INCREASE PHYSICAL ACTIVITY

Surveillance is just the beginning of evidence-based public health, but the data are essential because they inform subsequent actions related to planning, implementation, and evaluation. The inadequate state of physical activity surveillance is one consequence of inadequate commitment to physical activity in general. The investment in physical activity appears disproportionately low in comparison with the high prevalence of inactivity, large burden of disease, and substantial health care costs.² It has been recognized for at least 10 years that public health investments in physical activity are low, and there are many evidence-based and promising solutions that are not being implemented to increase physical activity and reduce health disparities.⁷

It appears there has been more success in adopting policies that improve dietary habits and reduce tobacco access and use than those aimed at increasing physical activity, though it is difficult to quantify these differences. A portion of the progress in the diet and tobacco areas could be attributed to specific offices in the US Department of Health and Human Services that are responsible for coordinating nutrition research and tobacco control. The creation of a permanently funded Office of Physical Activity Coordination at the Centers for Disease Control and Prevention that would be responsible for coordinating and advocating physical activity initiatives could address this need.

SUMMARY AND CONCLUSIONS

Surveillance is a fundamental component of public health practice that informs all subsequent activities. Physical activity is a major driver of health, and the National Academies report makes it clear there are many deficiencies in surveillance that need to be addressed. Improved surveillance of physical activity will contribute to a better evidence base to guide design of interventions, better targeting to communities in need that will enhance health equity, and better estimates of the resources needed to increase physical activity. We encourage the Centers for Disease Control and Prevention to lead implementation efforts and prioritize surveillance actions based on a combination of public health significance and cost.

National surveillance is essential, but local surveillance is also needed to guide local decisions. Only local data can identify local inequities and guide locally targeted actions. Leading public health organizations are encouraged to support improved national physical activity surveillance, and local health departments are encouraged to conduct local surveillance using the same measures being used nationally. We urge public health professionals not only to advocate for adequate resources to conduct robust physical activity surveillance but also to take public health actions supported by evidence to increase physical activity in all communities.