Evaluating the Science to Inform the Physical Activity Guidelines for Americans Midcourse Report

Abstract The Physical Activity Guidelines for Americans (Guidelines) advises older adults to be as active as possible. Yet, despite the well documented benefits of physical activity just 12.8% of those ages 65 and older meet the Guidelines. To address this, the U.S. Department of Health and Human Services (HHS) developed a Midcourse Report focused on effective strategies to improve older adult physical activity behaviors. The first step in this process was a systematic literature review. A literature review team was contracted to examine the evidence on key settings and effective behavioral intervention strategies, as well as effective policy, systems, and environmental (PSE) approaches, to improve physical activity among older adults. The PSE search employed an equity-centered framework adapted to researching PSE approaches for improving physical activity outcomes in older adults. Sixteen thousand eight hundred and eighty-three titles and abstracts were screened, and 734 full articles were reviewed for inclusion. Of those, 64 original research articles were included for the final review to answer two questions, one (plus 5 sub-questions) focused on Settings/Strategies literature (46 studies) and one (plus 2 sub-questions) focused on PSE literature (18 studies). The literature review process identified key settings and evidence-based strategies to support older adults in becoming more physically active, and provides a foundation for the Physical Activity Guidelines for Americans Midcourse Report: Implementation Strategies for Older Adults. More research is needed to address how factors related to equity and psychosocial constructs influence physical activity behaviors among older adults.    Key Words Physical activity, policy, older adults, systematic review, Policy-Systems-Environment, aerobic physical activity, muscle strengthening physical activity     Introduction The Physical Activity Guidelines for Americans (Guidelines) (U.S. Department of Health and Human Services (HHS), 2018) serves as the benchmark and primary, authoritative voice of the federal government for providing science-based guidance on physical activity, fitness, and health for Americans. The most recent edition, released in 2018, provides evidence-based recommendations for Americans ages 3 and older to safely get the physical activity they need to stay healthy (HHS, 2018). In 2013, five years after the release of the first edition of the Guidelines, HHS released a midcourse report (Physical Activity Guidelines for Americans Midcourse Report Subcommittee of the President’s Council on Fitness, Sports & Nutrition (PAG Midcourse Subcommittee), 2013). This report focused on strategies to increase physical activity among youth and focused on five key areas where youth live, learn, and play – preschool and childcare centers, schools, family and home, community (built environment), and primary care medical settings (PAG Midcourse, 2013). The next midcourse report focused on older adults (ages 65 and older). The benefits of regular physical activity occur throughout life and are essential for healthy aging. Research suggests it is never too late to start being physically active. Despite the many benefits of physical activity, only 12.8% of adults over age 65 meet the aerobic and muscle-strengthening Guidelines (HHS Office of Disease Prevention and Health Promotion (ODPHP), 2022). This rate may be influenced by several factors, as barriers to physical activity differ from individual to individual and are influenced by socioeconomic, cultural, built environment, and other community factors. The Guidelines contains quantitative recommendations for older adults but does not include implementation strategies. Therefore, a literature review was conducted to identify successful interventions to promote increased physical activity and adherence to the key guidelines for older adults and summarized in the Physical Activity and Older Adults Systematic Literature Review (ICF Next, 2023). The Physical Activity Guidelines for Americans Midcourse Report: Implementation Strategies for Older Adults (Midcourse Report) (HHS, 2023) serves to further the breadth of the Guidelines to facilitate the implementation of proven programs and other strategies that can increase levels of physical activity among older adults. This paper outlines the literature review methodology to support the Midcourse Report. Methods: Literature Review In 2022, HHS contracted with a Literature Review Team to review the evidence on effective strategies to increase physical activity among older adults. This work was supported by the President’s Council on Sports, Fitness & Nutrition (PCSFN) Science Board (Science Board), made up of 11 experts in physical activity and older adult populations.   The Literature Review Team used a methodology supported by best practices for systematic literature reviews developed by the United States Department of Agriculture’s (USDA) Nutrition Evidence Systematic Review (NESR) (USDA NESR Branch, 2023), the Agency for Healthcare Research and Quality (AHRQ) (AHRQ, 2014), the Cochrane Collaboration (Higgins et al., 2022), and the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine standards to review, evaluate, and synthesize published, peer-reviewed physical activity research (Institute of Medicine (US) Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, 2011). This review process was largely guided by the approach taken to review the literature for the 2018 Physical Activity Guidelines Advisory Committee Scientific Report (2018 Physical Activity Guidelines Advisory Committee, 2018; Torres et al., 2018). Paralleling the 2018 process, this protocol-driven review approach was undertaken to maximize transparency, minimize bias, and ensure the review conducted was timely, relevant, and high quality. There are two major distinctions between this review and that conducted by the 2018 Physical Activity Guidelines Advisory Committee: 1) the decision to review original articles instead of using a “review of reviews” approach; and 2) to focus on research with physical activity outcomes as opposed to health outcomes. All work completed by the Literature Review Team was under the direction and review of ODPHP, on behalf of the National Institutes of Health (NIH), the Centers for Disease Control and Prevention, and the PCSFN. The Literature Review Team coordinated the literature review process, developed an abstraction tool and accompanying abstraction and triage guides, and implemented training and quality control protocols. Several groups supported the literature review work: Librarians reviewed search strategies and provided guidance as needed. The Triage Team conducted title and abstract triage of articles identified through the literature searches. The Abstraction Team engaged in rigorous training before abstracting data from included articles. A portion of this group also assessed risk of bias on a subset of the included articles. The Science Board identified, aggregated, organized, and analyzed the scientific literature. A six-step process was used to examine the literature: Step 1: Develop systematic review questions Step 2: Develop systematic review strategy Step 3: Search, screen, and select evidence to review for each question Step 4: Abstract data and assess the risk of bias of the research Step 5: Describe the evidence Step 6: Complete evidence portfolios and draft Scientific Report Step 1: Developing Systematic Review Questions Following the cadence of previous editions of the Physical Activity Guidelines for Americans with an interim Midcourse Report, HHS initiated the process to review the scientific literature focused on effective approaches to promote physical activity among older adults. ODPHP outlined a need to examine intervention strategies and key settings that are effective in promoting movement and achievement of the key guidelines for physical activity for older adults. Additional factors of interest for the literature review included how engagement in physical activity interventions may influence mental health, well-being, social connection, and other related social and emotional factors; as well as how interventions implemented as policy, systems, and environmental approaches to change the context influence physical activity in older adult populations. Solidifying Systematic Review Questions. The Literature Review Team developed research questions focused on the previously specified topics. The research questions and corresponding sub-questions are as follows: Question 1: What are effective intervention strategies to increase physical activity among older adults? Does the mode of delivery (e.g., virtual, in person, phone) impact the effectiveness of interventions? Does the setting impact the effectiveness of the interventions? What barriers exist to engaging or participating in the intervention? What are the retention, attrition, and/or attendance rates? Do personal characteristics (e.g., ability, age, sex, race/ethnicity, socioeconomic status) or chronic health conditions influence participation? Do interventions assess changes in participant mental health, quality of life, well-being, resilience, or social connection and isolation? Question 2: What are effective policy, systems, and environmental (PSE) strategies to increase physical activity among older adults? Is there a dose-response relation between the scope and reach of the PSE strategy and “success”? Does the “success” of the PSE strategy vary by geographical location or by sociodemographic subgroup? Step 2: Develop Systematic Review Strategy Develop Analytical Frameworks. Analytical frameworks were developed for each research question. Analytical frameworks are graphic representations used to lay the groundwork and initial parameters for each search. The frame