>>> WELCOME TO THE THIRD DAY OF PHYSICAL ACTIVITY GUIDELINES PUBLIC MEETING. THIS IS THE THIRD DAY. ALL THE MEETINGS THAT ARE HAPPENING ARE BEING VIDEOCAST AND ALSO WILL BE ARCHIVED ON OUR WEBSITE. SO YOU CAN WATCH THEM AFTER THE FACT AND THEN IN THE NEXT WEEK OR TWO, THEY WILL ADD CHAPTER MARKS. TODAY THERE WILL BE THREE PRESENTATIONS AND COMMITTEE DISCUSSION BY THE THREE WORKING GROUPS. WE WILL START WITH THE PREGNANCY WORKING GROUP. THE FITNESS WORKING GROUP AND THE YOUNG ADULT TRANSITION WORKING GROUP. AND I WILL START THINGS OFF WITH PREGNANCY AND HAND THINGS OFF. >> THANK YOU. KATRINA, THIS IS A WORKING GROUP AT THE DREAM TEAM OF KEN POWELL AND MYSELF, AIDED ESPECIALLY BY THE REAL EXPERT AND THAT WOULD BE, KELLY EVERSON FROM CHAPEL HILL IS OUR OUTSIDE CONSULTANT, AND ONCE AGAIN, A GREAT DEAL OF THANKS TO BONNIE AND RICK, OUR LIAISON HERE, AND KATRINA. MOST OF THIS WORK, IS NOT POSSIBLE WITHOUT YOUR ASSISTANCE HERE ARE OUR WORK GROUP QUESTIONS. WHAT IS THE RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND THE HEALTH OF THE MOTHER DURING PREGNANCY? THE SECOND, WHAT IS THE RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND THE HEALTH OF THE MOTHER DURING POSTPARTUM? WE DEFINED POSTPARTUM AS UP TO ONE YEAR. AND THEN, WHAT IS THE RELATIONSHIP BETWEEN PHYSICAL ACTIVITY DURING PREGNANCY AND THE HEALTH OF THE CHILD AT BIRTH? NOW, IT'S NO SECRET THAT EXERCISE AND PHYSICAL ACTIVITY ARE BENEFICIAL DURING PREGNANCY, BUT THE LITERATURE DEMONSTRATES THAT MOST PREGNANT WOMEN DO NOT ACHIEVE GUIDELINES STILL, DESPITE THEIR BEING IN PLACE FOR MANY YEARS. AND MANY WOMEN WHO MIGHT BE ACTIVE BEFORE PREGNANCY, STOP BEING ACTIVE WHEN THEY GET PREGNANT. OUR RATIONAL FOR EXPLORING QUESTIONS IS TO EXPAND THE 2008 GUIDELINES AND BETTER QUANTIFY THE BENEFITS OF PHYSICAL ACTIVITY ON SELECTED HEALTH OUTCOMES. NOW WE WISH TO PROVIDE RELATIVE RISK, STANDARDIZED MEANING DIFFERENCES SECONDLY, WE WISH TO EXPAND THE GUIDELINES AND PROVIDE BETTER INFORMATION ON DOSE RESPONSE AS WELL AS THE OPTIMAL DOSE OF PHYSICAL ACTIVITY OVER THE COURSE OF GESTATION THIS DOSE RESPONSE INFORMATION CAN BETTER INFORM POLICYMAKERS AND THE PUBLIC. OUR ANALYTIC FRAMEWORK IS VERY, VERY SIMILAR TO EVERYONE ELSE'S. THESE ARE -- I DON'T THINK THIS WORKS ANYMORE. TAKE NOTE OF OUR HEALTH ENDPOINTS, OUR HEALTH OUTCOMES HERE. THERE IS SEVERAL OF THEM -- IT WORKS? [ OFF MICROPHONE ] [ LAUGHS ] THESE ARE OUR ENDPOINTS HERE. OBVIOUSLY WE ARE NOT CONSIDERING MEN IN THIS. WE ARE TARGETING PREGNANT WOMEN, POSTPARTUM MOTHERS AND CHILDREN AT BIRTH. THESE ARE INCLUSION, EXCLUSION CRITERIA. WE STARTED CONSIDERING LITERATURE STARTING FROM 2011 UP UNTIL PRESENT TIME. NOW, WHAT WE DID DO IS TAKE ADVANTAGE OF EXISTING SEARCHES THAT WERE OCCURRING IN OTHER SUBCOMMITTEES. SO FOR EXAMPLE, FOR A QUESTION ON WEIGHT GAIN, GESTATIONAL WEIGHT GAIN, WE ARE ABLE TO MAKE USE OF THE SEARCH GOING ON IN THE CARDIOMETABOLLIC SUBGROUP CONSIDERING WEIGHT MANAGEMENT OR WEIGHT GAIN. THIS IS IT OUR TREE HERE AND AS YOU CAN SEE, WE ARE STILL DECIDING ON A NUMBER OF PAPERS. SO WE ARE NOT HERE IN OUR ABILITY TO TELL YOU HOW MANY PAPERS WE HAVE BEEN CONSIDERING. BUT HERE IS QUESTION 1. AND FOR QUESTION 1, I'M GOING TO PRESENT JUST THE EVIDENCE FOR EXCESSIVE WEIGHT GAIN OVER PREGNANCY. AGAIN, JUST LIKE THE OTHERS, WE WANT TO KNOW IF THERE IS A RELATIONSHIP. WHAT DOSE IS ASSOCIATED WITH THE REPORTED BENEFITS, IF THERE IS A DOSE RESPONSE, WHAT IS THE SHAPE AND THE EFFECT MODIFICATION BY AGE. I GUESS NOT BY SEX BECAUSE WE ARE REALLY ONLY CONSIDERING WOMEN, BUT RACE, ETHNICITY, WEIGHT STATUS, ET CETERA. SO OUR SOURCE FOR THIS, WE ARE RELYING MOSTLY ON OR EXCLUSIVELY ON SYSTEMATIC REVIEWS AND METANALYSIS AS WELL AS ONE EXISTING REPORT, THE ACOG GUIDELINES THAT WERE RECENTLY PUBLISHED WE ARE DEALING WITH 11 REVIEWS AND METANALYSIS THAT ADDRESSED THIS RELATIONSHIP BETWEEN MATERNAL PHYSICAL ACTIVITY AND GESTATIONAL WEIGHT GAIN. AND THE EVIDENCE WE REVIEWED PROVIDES STRONG EVIDENCE OF A SIGNIFICANT, THOUGH MODEST INVERSE RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND GESTATIONAL WEIGHT GAIN. WE ARE A BIT SURPRISED AT THE EFFECT SIZE. AND SO FOR EXAMPLE THE MOST RECENT METANALYSIS OF 18 RANDOMIZED CONTROL TRIALS INVOLVING MANY WOMEN, REPORTED A STANDARDIZED MEAN DIFFERENCE IN GESTATIONAL WEIGHT GAIN OF ABOUT 1 KILO HERE WITH WOMEN IN THE EXERCISE GROUP GAINING LESS WEIGHT THAN WOMEN RECEIVING STANDARD CARE IN OTHER METANALYSIS REPORTED REMARKABLY SIMILAR EFFECT SIZES AS THIS. AND SO, WE HAVE A RANGE OF A THIRD OF A KILO UP TO 1 1/2 KILO DIFFERENCE BETWEEN WOMEN WHO EXERCISE OVER PREGNANCY AND THOSE THAT DID NOT. ANOTHER WAY THAT THE SYSTEMATIC REVIEWS CONSIDERED WEIGHT GAIN WAS BY DEFINING IT AS EXCESSIVE WEIGHT GAIN. AND THAT IS DEFINED ACCORDING TO IOM GUIDELINES FOR NORMAL WEIGHT, OVERWEIGHT AND OBESE WOMEN. SO IF YOU GAIN MORE THAN THE UPPER-LEVEL, THAT IS CONSIDERED EXCESS OR EXCESSIVE. AND SO, IN GENERAL, THESE REPORTS REPORT THAT WOMEN WHO REPORTED PHYSICAL ACTIVITY DURING PREGNANCY EXPERIENCED THE SIGNIFICANTLY LOWER RISK OF EXCESS WEIGHT GAIN COMPARED WITH WOMEN WHO DID NOT. SO THESE POOLED EFFECT SIZES ACROSS THE SYSTEMATIC REVIEWS RANGED FROM 18% TO 23% LOWER RISK AMONG WOMEN WHO EXERCISED DRING PREGNANCY THE DOSE OF PHYSICAL ACTIVITY PRESCRIBED ACROSS THE TRIALS VARIED AMONG STUDIES AND IN THE SAME WAY, THE ASSESSMENT AND CATEGORIZATION OF REPORTED LEISURE TIME, PHYSICAL ACTIVITY, WAS NOT CONSISTENT AMONG THE COHORT STUDIES. HOWEVER, MOST OF THE INTERVENTIONS USED IN EXERCISE REGIMEN INVOLVING PRIMARILY AEROBIC ACTIVITY OF MODERATE INTENSITY, OCCURRING AT LEAST THREE TIMES A WEEK FOR A DURATION OF 30-60 MINUTES. AND SO, WE CONCLUDED THAT THIS DOSE IS CONSISTENT WITH BOTH ACOG GUIDELINES AND THE 2008 PHYSICAL ACTIVITY RECOMMENDATIONS KEN SLIPPED THIS SLIDE INTO THE SLIDE DECK AND SO, WE HAVE THIS ALL CAUSE MORTALITY CURVE. THIS IS WHERE THE RISK OF EXCESS GESTATIONAL WEIGHT GAIN WOULD FALL WITH RELATIVE LOWER RISK ABOUT 18-23% LOWER RISK. AND THAT IS FALLING AT A PROXIMATE DOSE OF WHAT THE GUIDELINES ARE. SO THAT IS OUR LITTLE POINT ON THE CURVE. WITH REGARD TO DOSE RESPONSE, MOST OF THE REVIEWS DID NOT ASSESS WHETHER THERE WAS A DOSE RESPONSE RELATIONSHIP. THE ONE REVIEW THAT ATTEMPTED TO ANSWER THE QUESTION REPORTED THAT PRESCRIBED DOSES OF EXERCISE IN THE TRIALS DID NOT DIFFER BETWEEN THOSE INTERVENTIONS THAT THEY DEEMED SIGNIFICANT MEANING THEY FOUND SIGNIFICANT DIFFERENCES BETWEEN THE EXERCISING AND NON EXERCISING MOTHERS. AND THOSE THAT DID NOT. HOWEVER, ADHERENCE TO THE PRESCRIBED EXERCISE PROGRAM WAS SIGNIFICANTLY HIGHER IN THOSE INTERVENTIONS THAT WERE SO THE MORE PEOPLE PARTICIPATED IN THERE, THE GREATER THE CHANCES WERE THAT THE INTERVENTION WAS GOING TO WORK. ONE REVIEW REPORTED THAT AMONG ALL ELIGIBLE TRIALS, THE MEAN STANDARD MEAN DIFFERENCE IN WEIGHT GAIN BETWEEN THE EXERCISE AND CONTROL GROUPS WAS MODERATELY AND INVERSELY CORRELATED WITH BOTH THE DURATION OF THE INTERVENTION AS WELL AS VOLUME OF EXERCISE PRESCRIBED. THE MORE YOU DO, THE GREATER THE BENEFIT. JUST DIFFICULT TO QUANTIFY. VIRTUALLY NONE OF THE SYSTEMATIC REVIEWS OR METANALYSIS ASSESSED WHETHER THE PURPORTED RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND GESTATIONAL WEIGHT GAIN VARIED BY THESE FACTORS, AGE, RACE, OR SOCIOECONOMIC STATUS. WITH REGARD TO WEIGHT STATUS, WE OBSERVED MOST OF THE FINDINGS WERE REPORTED AMONG WOMEN OF NORMAL WEIGHT. BUT CELERY VIEWS STRATIFIED THEIR DATA BY WEIGHT STATUS -- BUT SEVERAL REVIEWS -- AND THESE STUDIES TENDED TO OBSERVE A LARGER EFFECT SIZE AMONG WOMEN OF NORMAL WEIGHT COMPARED WITH THROWS WHO WERE OVERWEIGHT AND OBESE. THAT SURPRISED ME A LITTLE BIT BASED ON THE LAW OF THE MORE IMPAIRED YOU ARE, THE GREATER OR THE MORE WEIGHT YOU WOULD LOSE. BUT ON THE OTHER HAND IT COULD BE THAT THE OVER WEIGHT AND OBESE PEOPLE COULDN'T ACHIEVE THE LEVEL OF EXERCISE NECESSARY. WE DON'T KNOW. AND THEN IN CONTRAST, ONE REVIEW THAT ONLY CONSIDERED OVERWEIGHT OR OBESE WOMEN REPORTED A GREATER EFFECT SIZE IN OBESE WOMEN COMPARED WITH OVERWEIGHT WOMEN. SO, AGAIN, INCONCLUSIVE. SO HERE ARE OUR CONCLUSION STATEMENTS, STRONG EVIDENCE DEMONSTRATES A SIGNIFICANT BUT MODEST INVERSE RELATION BETWEEN PHYSICAL ACTIVITY AND GESTATIONAL PHYSICAL ACTIVITY. THAT IS STRONG. LIMITED EVIDENCE SUGGESTS THAT THE DOSE OF PHYSICAL ACTIVITY IS CONSISTENT WITH THE ACOG AND PHYSICAL ACTIVITY GUIDELINES. SOMEWHERE IN THE 150 TO 180 MINUTES A WEEK OF MODERATE INTENSITY ACTIVITY. EVIDENCE IS LIMITED. THAT WAS OUR GRADE. AND THEN THERE WAS -- WE FELTED THERE WERE INSUFFICIENT DATA TO DETERMINE WHETHER THERE IS A DOSE RESPONSE RELATIONSHIP AND ALSO INSUFFICIENT DATA TO DETERMINE WHETHER THIS RELATIONSHIP VARIES BY A NUMBER OF SOCIODEMOGRAPHIC FACTORS. SO IN THE LATTER TWO, WE COULD NOT ASSIGN A GRADE. AND SO THEN, OBVIOUSLY, OUR RESEARCH RECOMMENDATIONS ARE NOW TO FOLLOW ALONG THESE LINES AND PROMOTE THESE LONGITUDINAL STUDIES THAT CONSIDER VARIOUS EXPOSURE LEVELS ALSO PERHAPS OCCURRING DIFFERENT TIMES OVER THE GESTATIONAL PERIOD IS ONE. IF YOU'RE NOT GOING TO EXERCISE THROUGH NINE MONTHS, IS THERE ONE PARTICULAR TRIMESTER THAT MIGHT BE MORE IMPORTANT THAN THE OTHER? AND THEN SIMILAR TO OTHER GROUPS. THESE TRIALS NEED TO BE LARGE ENOUGH TO ALLOW FOR SPECIFIC ANALYSIS BY RACE, BY INITIAL WEIGHT STATUS, AND BY OTHER VERY IMPORTANT SOCIAL DETERMINANTS OF HEALTH. WAYNE? >> THANK YOU. THAT IS GOOD AND IMPORTANT INFORMATION. I HAVE 2 QUESTIONS. WAS THERE ANY ASSESSMENT OR ANY MENTION OF UPPER LIMITS FOR EXERCISE OR EXCESSIVE EXERCISE AND INFLUENCES ON YOUR OUTCOMES? >> I DIDN'T SEE THAT THERE SEEMS TO BE A J-SHAPED CURVE WITH CERTAIN OUTCOMES AND WHERE THERE IS A HIGHER RISK OF SOME ADVERSE OUTCOME AT VERY LOW LEVELS BUT ALSO AT VERY HIGH LEVELS. MOST OF THE TRIALS CONSIDERED THE GUIDELINES AS THE EXPOSURE. THEY DELIBERATELY ASSIGNED. >> SO IS THERE A PLACE OR FOR THESE COMMENTS REGARDING RISKS -- >> I WOULD IMAGINE THAT WITH REGARD TO ADVERSE EVENTS WE CAN TOUCH ON. HAVE HIGH AND DEMANDING LEVELS OF OCCUPATIONAL ACTIVITY TEND TO HAVE DELL TEARUOUS EFFECT ON SEVERAL. >> IF YOU COULD GO BACK TO YOUR CONCLUDING STATEMENTS. THE SECOND ONE, JUST CURIOUS ABOUT THE STATEMENT THAT YOU MAKE IN THE SECOND BULLET DOWN THAT THE DOSE OF PHYSICAL ACTIVITY IS ASSOCIATED OR 150-180 -- MINIMIZED WEIGHT GAIN. DID YOU HAVE A DOSE RESPONSE CURVE THAT SHOWED THAT WAS THE NADIR OF WEIGHT GAIN? THE MORE MINIMIZED, SUGGESTS IT'S THE LOWEST POSSIBLE. >> SORRY. I COULD WORD THAT BETTER. WEIGHT GAIN WAS MINIMIZED COMPARED WITH THE PEOPLE THAT DID NOT EXERCISE. >> SO JUST MAYBE A LITTLE WORD TWEAKING THERE. >> LOWER OR REDUCED OR SOMETHING LIKES THAT. SO THANK YOU. >> NICE JOB. SO, THERE ARE DATA BEING ACCUMULATED ABOUT -- AND I KNOW THIS WASN'T YOUR QUESTION BUT WONDERING IF YOU FOUND INFORMATION IN THE PROCESS OF YOUR INVESTIGATIONS DATA BEING ACCUMULATED THAT EXERCISE OF THE MOTHER DURING PREGNANCY HAS TRANSFERENCE EFFECTS ON THE OFFSPRING. IN PARTICULAR WITH RESPECT TO WEIGHT GAIN. DO WE KNOW ANYTHING ABOUT THAT ISSUE? >> WE DO. BUT THOSE ARE RECENT PAPERS COMING OUT AND SO, IT'S NOT JUST WEIGHT GAIN, IT'S DIABETES, CANCER IN ANIMAL MODELS. SO, THEY WOULD NOT HAVE BEEN CAPTURED IN THE SEARCH BUT I THINK WE CAN TRY AND SET THE STAGE FOR THE NEXT GUIDELINES IF I COULD BE SO BOLD AS TO SAY THAT BECAUSE THAT IS LIKE REALLY IMPORTANT. HEART RATE VARIABILITY, RISK FOR CARDIOVASCULAR DISEASE, OBESITY, DIABETES ET CETERA. THOSE ARE THE EPIGENETICS. >> IT APPEARS NOW THAT EVEN EXERCISE BEHAVIOR IN MALE PRIOR TO GESTATION ACTUALLY HAS AN EFFECT ON THE OFFSPRING. SO YOU WANT TO FIND A FIT MEAT. UE MATE. >> WE ALL DO. ISN'T THAT HOW WE ARE DESIGNED? >> SO THE QUESTION IS WHETHER YOU CALL FOR SOME OF THAT RESEARCH IN THE RESEARCH QUESTIONS. >> YES. >> CAN YOU GO TO YOUR LAST SLIDE? BECAUSE IT'S THE THIRD QUESTION ON YOUR LIST, RIGHT? IT'S ABOUT THE CHILD. I ONLY KNOW THIS BECAUSE I HAVE A PH.D. STUDENT WHO IS STUDYING WHO FINISHED THIS ISSUE. I THINK THERE IS LITERATURE ON MATERNAL ACTIVITY AS RELATED TO INFANT BIRTH WEIGHT. I DON'T KNOW ABOUT THE EPIGENETIC ELEMENTS. >> THAT COMINGS IN QUESTION 3 LIKE WE HAVEN'T GOTTEN THERE YET SO -- >> THIS IS AN ISSUE WE NEED ADVICE FROM THE WHOLE COMMITTEE ABOUT. BECAUSE THE WAY WE HAVE DONE OUR SEARCHES IS THAT WE PIGGYBACK ON TO OTHER SEARCHES THAT WERE BEING DONE. WE HAVE RESOURCES THAT ARE LIMITED AND WE COULD NOT DO ANY RESEARCH ON OUR OWN. AND WE FEEL LIKE FOR SOME OUTCOMES, WEIGHT GAIN, ECLAMPSIA RELATED TO HYPERTENSION. GESTATIONAL DIABETES, PROBABLY SLEEP PROBLEMS, HOPEFULLY DEPRESSION, MOOD ANXIETIES, WE ARE PRETTY WELL COVERED BY THE SEARCHES WE HAVE DONE. BUT NONE OF THOSE SEARCHES SPECIFIED ANYTHING ABOUT NEWBORNS. NOW MANY OF THE PAPERS WE GET, THEY ARE VERY GOOD PAPERS AMONG EXCELLENT -- AND THEY TREAT FLOTONLY THE -- THEY LOOK AT NOT ONLY THE CONDITION THAT MAY HAVE BEEN IN THE TITLE BUT PROVIDE INFORMATION ABOUT THESE OTHER FINDINGS. SO IN OUR WEIGHT GAIN GROUP OF PAPERS, WE HAVE QUITE A NUMBER THAT ALSO GIVE INFORMATION ABOUT ECLAMPSIA AND GESTATIONAL DIABETES AND PRETERM BIRTH AND SO ON. BUT THOSE FINDINGS RELATED TO THE CHILD COME INTO US NOT EXACTLY ACCIDENTLY, BUT NOT DIRECTLY BECAUSE WE SET OUT IN THE SEARCH TERMS TO FIND THEM. SO THE QUESTION THAT WE HAVE BEEN ASKING OURSELVES, WE VERY MUCH WANT TO PROVIDE INFORMATION ABOUT THE OUTCOMES YOU JUST MENTIONED BECAUSE WE HAVE SOME OF IT FROM VERY GOOD PAPERS. BUT WE CAN'T CLAIM THAT WE DID A FULL, COMPLETE SEARCH TO FIND EVERYTHING THAT IS OUT THERE ABOUT PRETERM DELIVERY OR INFANT WEIGHT AT DELIVERY. >> SO MY RESPONSE TO THAT IS, NUMBER 1, THIS IS A WORKING GROUP. NUMBER 2, YOU CAN ACTUALL SAY THAT IN THE NARRATIVE. THIS ISN'T -- THIS WASN'T A DETERMINED SEARCH BUT IN THE PROCESS OF OUR RESEARCH, WE FOUND EVIDENCE TO THE FOLLOWING. YOU DON'T CLAIM THAT IS ALL THE ONLY EVIDENCE, BUT WE CAN'T IGNORE IT, RIGHT? SO, WE DIDN'T FIND THE NORTHWEST PASSAGE BUT WE FOUND NORTH AMERICA IN THE PROCESS. I MEAN -- >> OKAY. >> I'M NOT SURE THAT'S THE BESTINALY BUT -- >> SO, IN ANY CASE, RUSS AND BILL, THE HEALTH OF THE INFANT, THE NEWBORN WILL BE CONSIDERED IN QUESTION 3 AND THAT IS WHEN THOSE FACTORS WILL REALLY BE CONSIDERED, ESPECIALLY IN THE RESEARCH. >> WE ARE VERY COMFORTABLE WITH WHAT BILL SUGGESTED AND HOPING THAT SOMEONE WILL SUGGEST IT. SO I'M SEEING MOST PEOPLE ARE IN AGREEMENT. SO THAT IS THE APPROACH. >> TO ME, THE NEWEST STUFF WITH THE EPIGENETICS AND THE WORKING -- AND THAT IS -- NOT JUST IN ONE OUTCOME BUT IN SEVERAL CARDIOVASCULAR DISEASE AS I SAID, CANCER IT'S REMARKABLE. LIND ASORRY? >> IF YOU JUST WANT TO GO TO YOUR EVIDENCE SLIDE, THE PREVIOUS ONE. THAT ONE. YOUR FIRST BULLET, WHEN YOU SAY MODEST. IS IT RANGE OF WEIGHT WHICH YOU SAID WAS THIRD TO ABOUT 1.5KG -- IS IT THE EFFECT SIZE? >> IT'S A MODEST EFFECT SIZE. >> LIKE ON AVERAGE, I MEAN I WOULD SAY, AT MOST, 1 1/2 KILOS. 5 POUNDS. I SUSPECTED IT. IT WAS CONSISTENT ACROSS 11 METANALYSIS THAT RANGE THAT I PRESENTED. I EXPECTED MORE. >> I EXPECTED MORE ALSO. MAYBE WE HAD MISCONCEPTIONS BUSY WHAT IS REALISTIC. IF WE APPLY THAT ONE TO THE IOF GUIDELINES ABOUT HOW MUCH WEIGHT WOMEN SHOULD GAIN, THAT KILOGRAM IS ABOUT 5-7% OF WHAT THE RECOMMENDED WEIGHT GAIN WOULD BE SO, MAYBE LINDA IS RIGHT. THAT'S NOT SO MODEST. IF SOMEONE GAINS 5-10% LESS THAN THEY ARE EXPECTED TO GAIN, WELL, WHAT DID WE EXPECT? DID WE WANT THEM TO GAIN 50% LESS? I MEAN, MAYBE MODEST, MAYBE WE SHOULD JUST TAKE THE WORD OUT AND JUST SAY A SIGNIFICANT INVERSE RELATIONSHIP WITHOUT PUTTING THE VALUE ON IT. >> I AGREE WITH THAT BECAUSE YOU ALSO DON'T KNOW WHAT THE BODY COMPOSITION RESPONSE IS AND MIGHT HAVE BEEN BETWEEN THE GROUP BECAUSE OF THE EFFECTS OF EXERCISE. >> WE HAVEN'T BEEN PRESENTING THE PUBLIC HEALTH IMPACT PART OF THE REPORT. THIS IS EXACTLY WHAT YOU WOULD DISCUSS IS WHAT IS THE PUBLIC HEALTH NEED. AND THAT SORT OF REASONING SHOWS IT MAY BE MORE THAN THE SMALL NUMBERS SUGGEST. >> SO WOULD YOU -- >> I WANT TO ADD A COMMENT ABOUT IMPACT. >> OKAY. YES. >> SHOULDN'T WE SAY, MODEST, THEN? >> SO TAKE OUT THE WORD, MODESTED? >> BECAUSE AND DAVID AND I WERE JUST CHATTING. YOU'RE TALKING ABOUT THE WEIGHT, WHICH ABSOLUTELY APPEARS MODEST. BUT WHEN YOU CONSIDER IT RELATIVELY, AND THEN THE PUBLIC HEALTH IMPACT, IT'S MORE THAN MODEST. >> THE SO WE TAKE THE MODEST OUT OF THIS, AND THEN HAVE A FULL DISCUSSION ON THE IMPACT -- >> WE'LL DO. >> SO THE OTHER COMMENT IS -- THAT'S FINE AT THE GESTATION. BUT THE QUESTION IS WHAT IS THE LONG TERM IMPACT OF THAT? IN OTHER WORDS, YOU'RE STARTING OUT AT A HIGHER POST GESTATIONAL WEIGHT. WE KNOW A GOOD NUMBER OF WOMEN DON'T LOSE BACK TO WHAT THEIR PREVIOUS -- >> THAT'S QUESTION NUMBER 2. >> FAIR ENOUGH. SO THAT MAY IMPACT THAT. SO THAT MOD EAST - I THINK YOU COULD -- >> TAKE IT OUT? THANK YOU. >> OKAY. I'M GOING TO BRING US UP-TO-DATE ON WHERE WE ARE WITH THE PHYSICAL FITNESS WORKING GROUP. WE HAVE BEEN WORKING STEADILY OVER THE COURSE OF THE INTERIM. THE MEMBERS ARE KIRK ERICSSON, CATHY JANES, RUSS, KEN AND MYSELF. RICK IS THE GOVERNMENT REPRESENTATIVE. AND BILL HASKELL HAS BEEN SERVING AS A CONSULTANT. AND WILL HERE ARE THE MEMBERS. OUR TASK HAS BEEN TO CONSIDER THE ROLE OF PHYSICAL FITNESS IN ITS BROADEST DEFINITION. AND HOW IT FITS INTO OUR REPORT. AND WE WANT TO SPECIFICALLY ADDRESS THE FOLLOWING QUESTIONS. WHAT IS -- I SHOULD HAVE PHYSICAL FITNESS. HOW DO WE MEASURE IT? ITS ROLE AS AN EXPOSURE, MEDIATOR OR OUTCOME -- I SHOULD SAY MODERATOR AS WELL OF THE OUTCOME OF THE BENEFITS OF EXERCISE ON HUMAN HEALTH. WE DECIDED THAT OUR ULTIMATE GOAL IS TO DEVELOP A SECTION FOR THE REPORT WITH THE FOLLOWING AND WE'LL HAVE THE FOLLOWING COMPONENTS. AN INTRODUCTION, SOME WILL BE MODELED ON THE -- WHAT THE INFORMATION IS IN THE 2008 REPORT. AND WE WILL REFER SPECIFICALLY TO THE CDC DEFINITION OF PHYSICAL FITNESS. WE WILL EXPLAIN THE CONCEPT OF PHYSICAL FITNESS AND WE WILL CONTRAST THAT WITH PHYSICAL PERFORMANCE AND PERFORMANCE TRAINING. SO WE ARE NOT INTERESTED IN EXTREME FITNESS MEASURES AS WOULD BE DEFINED BY ATHLETIC PERFORMANCE. WE ARE INTERESTED IN ROLE OF PHYSICAL FITNESS IN THE EVERY DAY LIVES OF AMERICANS. WE WILL EXPLAIN A AEROBIC FITNESS AND MUSCULOSKELETAL FITNESS. WE WILL FOCUS ON THOSE BECAUSE THAT'S WHERE MOST OF THE INFORMATION LIES. AND IN THAT PROCESS, WE HAVE DEVELOPED A CONCEPTUAL MODEL OF PHYSICAL FITNESS AS AN EFFECT MODIFIER AND MEDIATOR OF OUTCOMES. SO, FIRST WE HAVE EXCLUDED CONSIDERING PHYSICAL FITNESS AS AN EXPOSURE. THAT SAID STUDIES THAT RELATE TO FITNESS OF AN INDIVIDUAL TO HEALTH OUTCOMES. WE, HOWEVER, ARE INTERESTED IN UNDERSTANDING PHYSICAL FITNESS AS A MODERATOR OF EFFECT, SPECIFICALLY IN THE CONTEXT OF ITEMS A AND B. THAT IS, HOW DOES PHYSICAL FITNESS EFFECT THE ADHERENCE, THE ADOPTION AND THE TRANSLATION OF INTERVENTIONS TO CHANGES IN PHYSICAL ACTIVITY? IE, DO MORE FIT INDIVIDUALS ADOPT INTERVENTIONS MORE EFFECTIVELY AND AT GREATER RATES? AND LIKEWISE, CAN PHYSICAL FITNESS MODERATE THE TRANSLATION OF PHYSICAL ACTIVITY INTO HEALTH OUTCOMES? THAT IS, DO THOSE INDIVIDUALS THAT HAVE GREATER PHYSICAL FITNESS TRANSLATE OUR EXPOSURE INTO BETTER OUTCOMES? WE ARE ALSO INTERESTED IN THE ROLE OF PHYSICAL FITNESS AS A MEDIATOR. SO, DO SOME INDIVIDUALS ATTAIN GREATER RESPONSES IN PHYSICAL FITNESS TO PHYSICAL ACTIVITY EXPOSURE? WHEN WE KNOW FROM THE LITERATURE THAT IS TRUE? AND ARE THOSE THEN REFLECTED IN BETTER HEALTH OUTCOMES ADDICTION RESILIENCE? AND THEN FINALLY, WE ARE INTERESTED IN PHYSICAL FITNESS AS AN OUTCOME, AS A HEALTH OUTCOME IN AND OF ITSELF. THAT IS, IS PHYSICAL FITNESS AS A RESULT OF PHYSICAL ACTIVITY, AN IMPORTANT MEASURABLE HEALTH -- AS OF ITSELF? IRRESPECTIVE OF WHETHER THAT TRANSLATES INTO OTHER HEALTH BENEFITS, CARDIO, METABOLIC OR OTHERWISE. SO, IN THIS PROCESS, WE ARE ALSO GOING TO INCORPORATE INTO THIS SECTION, AND WE THINK IT IS HELPFUL, SPECIFIC EXAMPLES FROM THE LITERATURE. AND SO WE ARE GOING TO BE CALLING ON, IF WE HAVEN'T ALREADY, THE SPECIFIC SUBCOMMITTEE LEADS TO PROVIDE US WITH EXAMPLES THAT CAN BE IDENTIFIED IN THE TEXT OF THE DOCUMENT. WE ALREADY HAVE SOME BUT WE WOULD WELCOME ANY OTHER CONTRIBUTIONS THAT CAN BE VOLUNTEERED OR PARTICULARLY INTERESTED IN THE BRING HEALTH ARENA. AND SOME OF THESE NEW -- BRAIN HEALTH -- AND NEW AREAS THAT HAVE NOT BEEN EXTENSIVELY EXPLORED IN THE LITERATURE OR GUIDELINES IN PRIOR MANIFESTATIONS. OUR NEXT STEPS ARE RUSS AND I ARE GOING TO DRAFT AN INTRODUCTION TO THIS SECTION. WE ARE GOING TO IDENTIFY THE COMPONENTS OF THE PREVIOUS TEXT FROM 2008 TO BRING FORWARD INTO THIS DOCUMENT THAT WAS FOCUSED ONLY ON AEROBIC FITNESS. WE ARE GOING TO INCORPORATE A MUSCULOSKELETAL FITNESS PIECE THAT CATHY IS WORKING ON. AND I JUST ALREADY SLITTERRED CAPACITIES FOR BOTH AEROBIC AND MUSCULOSKELETAL FITNESS. THOSE ARE THE AREAS WE ARE PARTICULARLY INTERESTED IN. AND I CAN SAY THAT ANY EXAMPLES OF TRANSLATING MUSCULOSKELETAL FITNESS IN ANY DOMAIN INTO ANY OUTCOME -- ANYWHERE THAT ANYONE IDENTIFIES ANYTHING IN MUFFIN LOW SKELETAL FITNESS ON A, B, C OR D, WE ARE INTERESTED IN. NOW, OF COURSE, I MUST TELL YOU, THIS D, IS NOT -- WE DON'T WANT THE WHOLE LITERATURE ON STRENGTH OR RESISTANCE TRAINING AND EFFECT -- CHANGE EFFECTS IN STRENGTH. THAT LITERATURE IS BROAD. THE IMPORTANT THING IS, WHAT DO WE KNOW ABOUT THAT ON ITS EFFECT ON IMPORTANT HEALTH OUTCOMES? SO, IT'S A LITTLE HARD TO ENUMERATE WHAT WE ARE LOOKING FOR HERE. LET ME JUST SAY WE CAN FIND PLENTY OF EXAMPLES FOR D. WE DON'T NEED HELP ON THAT. RUSS, DO YOU HAVE A COMMENTED? >> I ALREADY PUT DAVID ON THE SPOT WITH D. SO I'LL GIVE HIM A SECOND TO THINK ABOUT IT. TO YOUR POINT, I THINK WE WERE LOOKING FOR AN EXAMPLE FROM THE LITERATURE WHERE IT WOULD BE CLEAR THAT THE OUTCOME WAS A MANIFESTATION OF FITNESS OR FUNCTION THAT VERY DIRECTLY LINKS TO DAY-TO-DAY LIFE AND DAVID YOU MIGHT WANT TO COMMENT ON THE EXAMPLE YOU GAVE ME, WHICH I THOUGHT WAS PERFECT? >> SURE. I THOUGHT THAT WAS FOR C NOT FOR D. I MEAN, WE CERTAINLY -- I'LL MAKE ONE COMMENT WHICH IS, EXACTY CAN CHIME IN. COMMONLY IN OLDER ADULTS, WHEN YOU DO STRENGTH TRAINING INTERVENTION AND MEASURING EFFECTS ON FUNCTION, IT'S REALLY NOT DIST TO DO BEFORE AND AFTER. AND EVEN RELATIVELY FOR OLDER ADULTS. BUT THAT'S NOT TRUE FOR AEROBIC FITNESS TO DO A MAX FITNESS TEST OR ESTIMATE -- IT WOULD NOT BE AS COMMONLY DONE. SO, THE STUDIES THAT HAVE THAT FULL SET OF AEROBIC AND MUSCLE STRENGTHENING FITNESS MEASURES AND OUTCOMES THAT WOULD BE MEASURED OR WELL MEASURED BY A STANDARDIZED QUESTIONNAIRE, IS NOT THAT LARGE AND TEND TO BE IN THE HEALTHIER OLDER ADULTS WHERE MAX TESTING OF AEROBIC FITNESS IS DONE. BUT THERE ARE EXCEPTIONS AND SOY, WE DID FIND ONE OF THE LARGER STUDIES EARLY ON WAS THE FITNESS ARTHRITIS TRIAL CALLED FAST. AND 450 OLDER ADULTS IN IT WITH KNEE OSTEOARTHRITIS. AND IT FIT THIS PARADIGM WITH C FAIRLY WELL SHOWING CHANGES IN AEROBIC FITNESS AND STRENGTH AND CHANGES IN OVER ALL PHYSICAL FUNCTIONING MEASUREMENT. >> THAT'S EXCELLENT. >> SO I THOUGHT IT WAS A PERFECT EXAMPLE THAT THE POINT IS, WE REALLY ARE TRYING TO FIND EXAMPLES THAT WILL APPLY WELL TO DAY-TO-DAY LIFE, THE APPLICABILITY OF FITNESS OR FUNCTION IN DAILY LIFE AND TYPICAL PEOPLE. I THOUGHT THAT WAS IN THAT CATEGORY. >> TO THE EXTENT YOU CAN FIND COMPARATIVE STUDIES, THEY ARE VERY INTERESTING. FAST HAPPENS TO BE A COMPARATIVE STUDY OF STRENGTH TRAINING ONLY -- AEROBIC TRAINING VERSUS CONTROL. SO WELL SUITED TO THIS TASK. >> AND -- >> DAVID, LIFE, THE LIFE TRIAL, I MEAN, WOULDN'T THAT ALSO SPEAK TO SOME OF THIS? >> ABI, WHAT WERE THE FITNESS MEASURES IN LIFE THAT WOULD -- >> THERE WAS THE 400 METER WALK AS THE FINAL OUTCOME. LIFE WAS A LARGE MULTI-SITE TRIAL TO TRY TO REDUCE PROBABILITY OF DISABILITY. MOBILITY AND DISABILITY. SO THAT WAS THE ENDPOINT AND USING 400 METER WALK THROUGHOUT 2 1/2-3 YEAR INTERVENTION PERIOD TO FRAIL ADULTS AGES 70-89 YEARS DOING A COMBINATION OF WALKING. SO ENDURANCE, AEROBIC, EXERCISE, PLUS STRENGTH TRAINING IN COMMUNITY SETTINGS. SO ALL MEANT TO BE SOMETHING THAT COULD BE TAKEN UP BY COMMUNITY SETTINGS IN THE FUTURE. >> I WOULD ADD THE LEAD TRIAL. THE LIFE AND THE LEAD TRIAL WERE THE TWO THAT MARY WROTE UP IN HER ARTICLE ON THE EFFECTS IT HAD ON THE SET 36 PHYSICAL FUNCTION AND OF COURSE THEY MEASURED PHYSICAL FUNCTION OUTCOME COMES AND THE OTHER THING THEY ADDED WAS SHORT PHYSICAL PERFORMANCE. THEY FOUND OUT THE TIMED WALKS -- I DID HAVE ANOTHER POINT AND I'M NOT EXACTLY SURE HOW TO EXCESS IT. BUT IF YOU LOOK BACK AT SEATTLE FIX IT, MOVE IT STUDY AND MANY OTHER RESEARCH STUDIES, INDIVIDUALS WITH MOBILITY DISABILITY WITH DISABILITY CONDITIONS AND WITH AGING, HAVE GREATLY REDUCED FITNESS LEVELS AND POORER ECONOMIES OF MOVEMENT AND THERE IS A DIFFERENT SLOPE FOR THE IMPACT THAT IMPROVING FITNESS HAS ON THEIR FUNCTIONALITY IN ORDER TO BE ABLE TO REACH THE MESS THAT IS REQUIRED FOR ACTIVITIES OF DAILY LIVING SUCH THAT SMALLER GAINS IN FITNESS CAN MOVE THEM OUT OF THE LEVEL IN WHICH THEY ARE BASICALLY IN A LACTATE THRESHOLD TO A POINT WHERE THERE A CAN DO AT LEAST SLOWLY, FUNCTIONS OF BASIC ACTIVITIES OF DAILY LIVING. THERE IS SOMETHING THAT IS SORT OF NOT REALLY SPOKEN ABOUT IN THAT POPULATION AND I THINK WE CAN SAY SOMETHING ABOUT IT NOW. RICH WOULD YOU POINT US IN THAT LITERATURE? >> MAYBE IF I COULD SOLICIT A PARAGRAPH FROM YOU ON THAT TOPIC. THAT WOULD BE MUCH APPRECIATED. >> AT LEAST A PARAGRAPH. [ LAUGHS ] RUSS? >> I'LL MAKE A SOLICITATION THAT ABI AND HER SUBCOMMITTEE WOULD NEED YOUR HELP FINDING A GOOD EXAMPLE OR EXAMPLES FOR A WHERE MAYBE THERE WAS SOME STRATIFICATION ON BASELINE FITNESS AND THEN OBSERVATION THAT -- AND INTERVENTION APPROACH WORKED DIFFERENTIALLY ACROSS THE FITNESS STRATA. >> LOOKING AT FACTORS THAT IS PREDICTED TWO-YEAR PHYSICAL ACTIVITY PARTICIPATION AND MIDDLE-AGED ADULTS AND FITNESS WAS A MAJOR PART OF THAT MIX. MORE FIT PEOPLE HAD BETTER PA PARTICIPATION ACROSS A TWO-YEAR PERIOD. >> YES? KURT? >> WE HAVE A MESS HERE. I THINK -- >> WHAT DOES PHYSICAL ACTIVITY DO FOR COGNITIVE FUNCTION? >> I THINK C IS VERY IMPORTANT AND IT CERTAINLY IS RELEVANT FOR BOTH CHUCK AND I WOULD AGREE THAT IT'S PROBABLY GOING TO BE VERY RELEVANT FOR BRAIN HEALTH. REGARDING C, I'M WONDERING WHAT THRESHOLD WE WANT TO PLACE ON WHAT IS CONSIDERED TO BE A MEDIATOR. OR MEDIATION. THERE IS DIFFERENT THRESHOLDS THAT PEOPLE HAVE. THERE IS THE MOST CONSERVATIVE, TRUE STATISTICAL MEDIATION, BUT QUITE OFTEN I SEE IN PAPERS PEOPLE TALKING ABOUT FITNESS OR OTHER VARIABLES ACTING AS POTENTIAL MEDIATORS WHEN IT'S NOT REALLY FORMERLY STATISTICALLY TESTED. AND SO I'M WONDERING IF WE ARE GOING TO THINK ABOUT PHYSICAL FITNESS MORE LIBERALLY AS A POTENTIAL MEDIATOR AND PULL UP SOME EXAMPLES FOR HOW IT MIGHT BE, OR DO WE WANT TO TAKE MORE CONSERVATIVE APPROACH AND WANT ARTICLES THAT ARE REALLY TRULY SHOWING THE STATISTICAL MEDIATION. >> I THINK I'M SPEAKING FOR THE WORKING GROUP. WE ARE INTERESTED IN THE LATTER. LET ME GIVE YOU AN EXAMPLE THAT I KNOW OF THAT WE WERE GOING TO QUOTE. THIS WAS THE AGE OF ACTION TRIAL IN 2000, 331 INDIVIDUALS RANDOMIZED TO USUAL CARE OF PHYSICAL ACTIVITY INTERVENTION FOR MEAN FOLLOW-UP OF FOUR YEARS. THOSE THAT HAD THE GREATEST FITNESS RESPONSE, SO CHANGE IN FITNESS, OBJECTIVELY MEASURED, WAS THE GREATEST PREDICTER IN MORTALITY IN THAT TRIAL. SO CONSIDERING MEDICATION CHANGES, ANYTHING ELSE CLINICALLY THAT YOU COULD MEASURE AS RESPONSE TO THE EXERCISE INTERVENTION, DIFFERENTIALLY EFFECTED BY THE INTERVENTION GROUP WAS THE GREATEST PREDICTER OF RESPONSE. SO CLEARLY IT'S A STATISTICAL MEDIATOR OF THAT RESPONSE. >> I'M WONDERING IF YOU COULD CONSIDER PUTTING A COUPLE OF CLINICAL BAROMETERS THAT ARE SHOWN JUST LIKE THE ONE YOU SAID IN STEP ACTIVITY AS IT RELATES TO FITNESS AND THE O2 IS A PREDICTER OF OUTCOMES. TIMED WALKS. AND EVEN CHAIR RISES AND WE HAVE A NUMBER OF STUDIES IN AGING THAT SHOW THAT THESE ARE CLEARLY IMPROVED IN THE PHYSICAL FUNCTION AND I THINK THE NEXT QUESTION TOO, WILL PROBABLY SHOW IS THAT. BUT TO BE ABLE TO INDEX THAT TO WHAT IT MEANS TO PEOPLE MIGHT BE IN ADDITION. >> THOSE ARE EXACTLY THE EXAMPLES WE WANT SO THOSE ARE ALL FITNESS MEASURES. EVERYONENESS 40 METER -- 400 METER WALK, CHAIR RISES. THOSE ARE ALL FITNESS MEASURES. THEY ARE DIFFERENT COMPONENTS OF PHYSICAL FITNESS BUT THEY ARE PHYSICAL FITNESS MEASURES. >> THERE ARE BEHAVIORAL BUILDING MEASURE THAT IS CORRELATE WITH FITNESS. OBVIOUSLY HOW FAST YOU WALK ARE RELATED TO AEROBIC CAPACITY. IT'S IMPORTANT TO MAINTAIN THAT DISTINCTION. BECAUSE MOBILITY AND DISABILITY MEASURE PRIMARILY NOT AS FITNESS MEASURE AND TO GET THE FITNESS MEASURE TO WORK ON THE WALK, YOU NEED TO WALK FAST. AND IT IS EASIER TO PREDICT. >> YOU NEED TO MAKE A CLEARER DISTINCTION BETWEEN FITNESS AND FUNCTION. >> RUSS? >> I DON'T THINK SO. I THINK THEY ARE THE SAME, KEN. AND I DON'T WANT TO DISTINGUISH BETWEEN THEM. I DO WANT TO MAKE THE CASE CLEARLY THAT THEY ARE DIFFERENT LABELS FOR THE SAME THING. >> DAVID, I DIDN'T HEAR DAVID SEAY THAT WHEN HE -- >> MAYBE NOT EQUIVALENT BUT -- >> PHYSIOLOGIC MEASURES. WALKING SPEED IS THE ABILITY TO DO ANYTHING. AND THEY ARE CORRELATED. AND FOR GERIATRICS AND GERONTOLOGIST IT'S A BASIC DISTINCTION OF MODELS. >> THAT'S NO DIFFERENT, IN MY MIND THAN WHAT ARE THE DETERMINANTS OF MILD RUN PERFORMANCE? IS DO2 MAX HIGHLY WEIGHT RELEVANT HIGHLY RELATED TO MILD RUN PERFORMANCE? YES. ARE THEY THE SAME THING? NO. THERE ARE OTHER FACTORS THAT COME INTO THE EQUATION. SO WHETHER 400 METER WALK IN OLDER PEOPLE OR THE MILD RUN IN HIGH SCHOOL KIDS -- YOU CAN THINK OF THIS AS SOME SORT OF UNDERLYING PHYSIOLOGIC CONSTRUCT, WHICH WE OFTEN DO, OR YOU CAN THINK OF IT AS A BEHAVIORAL OUTCOME, WHICH I WOULD SAY MILD RUN PERFORMANCE IN TENTH GRADERS IS -- IS IT INFLUENCED BY UNDERLYING PHYSIOLOGIC FITNESS? YES. BUT OTHER THINGS COME INTO IT LIKE, DO THEY EVEN WANT TO DO THE TEST? >> I THINK YOU CAN IMAGINE A VERY SIMPLE DIAGRAM WHERE FITNESS AND FUNCTION, THE TWO EGGINGS OVERLAP AND THERE IS DIFFERENT DOMAINS OF FITNESS AND FUNCTION AND THEY INFLUENCE EACH OTHER. AND I THINK THAT THEY ARE NOT EXACTLY THE SAME BUT THEY DEFINITELY INTERACT AND I THINK WE CAN PULT SOME SIMPLE DIAGRAM THERE TO SHOW WHAT THAT EXEMPLARS ARE. >> LET ME HELP YOU OUT WHY GERONTOLOGY TAKES A DIFFERENT VIEWPOINT. SO LOOK AT WALKING FROM THE STANDPOINT OF EXERCISE PHYSIOLOGY, STRENGTH AND AEROBIC FITNESS. KNEE OSTEOARTHRITIS IS IMPORTANT IN THIS SORT OF JOINT PROBLEMS ARE EFFECTING THEIR ABILITY TO WALK. AND PEOPLE, KIRK, HELP ME OUT, BUT PEOPLE WITH DEPRESSIVE SYMPTOMS WALK SLOWER. SO THERE ARE OTHER FACTORS. WALKING IS KIND OF A ACCUMULATING INFORMATION ABOUT NUMEROUS PHYSIOLOGICAL -- BECAUSE IT'S SUCH A DIFFICULT THINGS TO DO. SO IT'S NOT REALLY AS MUCH, ESPECIALLY ONCE YOU START HAVING IMPAIRMENTS AS MUCH AS DIRECT FITNESS MEASURE AS YOU MIGHT LIKE. >> AND LET'S MODIFY THAT TO CLARIFY THE RELATIONSHIP BETWEEN THE TWO, WHICH I UNDERSTAND TO BE SOMEWHAT OVERLAPPING. BUT FOR ME IT'S NOT HELPFUL TO THINK OF THEM AS A TOTALLY SEPARATE CONSTRUCT. I DON'T THINK THEY ARE. >> I WOULD AGREE WITH DAVID AND STROKE PATIENTS WHEN YOUR BALANCE IS DETERMINANT OF YOUR WALK PERFORMANCE. WHEN YOUR LESS IMPAIRED IT'S FITNESS. AND WE KNOW THAT. THAT'S BEEN DONE BEFORE. BOTH OF THOSE CAN BE CHANGED BY EXERCISE, OF COURSE, BUT FITNESS , AND FUNCTION SEPARATE THEMSELVES OUT, ESPECIALLY IN COMPLEX MULTISEGMENTAL MOBILITY TASKS. >> RICH, SINCE YOU'RE SITTING PHYSICALLY BETWEEN THESE TWO ENDPOINTS AND ALSO SEEM TO BE MEDIATING, OUR LINE HERE, AND YOU SAID SOMETHING ABOUT EVENT DIAGRAM TO DRAW, COULD YOU MAYBE COME UP WITH SOMETHING LIKE THAT FOR US? >> AT LEAST -- YES. >> AND PERHAPS YOU'D LIKE TO JOIN OUR FITNESS WORKING GROUP. >> SO, I'M GOING TO STARTS A NEW ARGUMENT. WOULD YOU CONSIDER OR HAVE YOU CONSIDERED FITNESS? AND I TEND TO THINK OF FITNESS IN THE BIOLOGICAL DARWINIAN SENSE, AS A CONFOUNDER IN THIS RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND THESE HEALTH OUTCOMES MEANING IT IS DIRECTLY RELATED TO BOTH. AND THE REASON I'M ASKING IS BECAUSE I THINK IT HAS RELEVANCE TO THE GUIDELINES. SOME PEOPLE BIOLOGICALLY ARE NATURALLY FITTER. SO THEY ARE CAPABLE OF PERFORMING MORE PHYSICAL ACTIVITY AND GREATER AMOUNTS OF IT OR WHATEVER. AND ALSO THEIR BIOLOGICAL FITNESS REDUCES THEIR SUSCEPTIBILITY TO DISEASE. AND WE SEE THIS ESPECIALLY IN OLDER ADULTS. THEY ARE SURVIVORS TO BEGIN WITH SO, I'M THINKING ABOUT THE CONSUMER WHO SAYS, WELL, THESE ARE THE GUIDELINES AND I DO THESE GUIDELINES BUT NOTHING CHANGES OR SOMEONE ELSE SAYS THE GUIDELINES ARE PERFECTLY SUFFICIENT BUT PLAY NOT BE BECAUSE OF A BIOLOGICAL SUSCEPTIBILITY. >> TWO POINTS. WE HAVE AVOIDED LITERATURE ABOUT FITNESS IN THE DARWINIAN SENSE. THERE IS A WHOLE LITERATURE THAT I READ -- I'LL SEE A TITLE IN NATURE, THAT TALKS ABOUT FITNESS AND I'M LIKE, THERE IS A FITNESS ARTICLE IN NATURE. AND IT'S NOT A FITNESS -- IT'S THE ECK LONG CALL FITNESS ISSUE DEALING WITH SALAMANDERS OR SOMETHING. >> THE MAJOR THING CONFOUNDING THAT IS FITNESS. AND THIS GENETIC -- >> YES. SO WHAT WE TRIED TO DO IN THIS -- AND THIS IS A NOVEL CONE INSTRUCT. THIS IS WHAT WE ARE SEEING HERE. -- CONSTRUCT. WE ARE HOPING THIS INCORPORATES OR SHALL WE SAY, DECONSTRUCTS A CERTAIN FOUR ELEMENTS THAT OVERALL FITNESS CONFOUNDER. IT WON'T INCORPORATE ALL OF IT. WE THINK IT INCORPORATES MOST OF IT SO WE CAN BREAK IT DOWN INTO PIECES AND TRY TO IDENTIFY HOW IT FITS IN A PATHWAY OF INCREASED PHYSICAL ACTIVITY ALL THE WAY BACK TO INTERVENTIONS TO OUR OUTCOMES. CATHY? >> I'M WONDER FIGURE HOW IMPORTANT D IS GIVEN. C ALREADY SERVES AS AN OUTCOME, AND EVEN IF YOU WERE PHYSICALLY ACTIVE JUST THO GET PHYSICALLY FIT, VERY COOL IN AND OF ITSELF, YOU'RE GOING TO GET THE GOOD STUFF THAT HAPPENS AFTER TO THE RIGHT OF C, REGARDLESS. IS THAT A LITTLE MORE COMPLICATED THAN NECESSARY BY INCLUDINGS D? >> I DON'T THINK SO. SO THE REAL PROPONENT OF D IS RUSS. WHAT IS THE POINTED OF ALL OF THIS WE ARE ABOUT ANYWAY? IT'S BEING ABLE TO FUNCTION IN OUR LIVES IN A BETTER STATE. AND THAT IS REPRESENTED IN THE -- WHETHER WE CALL IT PHYSICAL FITNESS OR FUNCTION OR THE THEN DIAGRAM THAT INCLUDES THE UNION OF THOSE TWO. IT'S REALLY WHAT WE ARE TRYING TO GET ABOUT HERE AND WE HAVEN'T EXPLAINED IT WELL ENOUGH AND THIS IS WHERE THE TEXT WILL HAVE TO BE MASSAGED. BUT THERE IS SAY STRONG FEELING AND A STRONG FEELING IN 2008. WE PUNTED A LITTLE BIT ON IT BY JUST FOCUSING ON AEROBIC FITNESS. WE ARE TRYING TO EXTEND THAT I A LITTLE MORE THIS ROUND WITH INCORPORATING MUSCULOSKELETAL FITNESS. BUT HOW PHYSICAL ACTIVITY EFFECTS OUR DAILY SLICE REALLY WHAT D IS ABOUT. AS OPPOSED TO THESE A LITTLE MORE OBSCURE OUTCOMES ABOUT ALL CAUSE MORTALITY AND THINGS THAT PEOPLE HAVE A HARD TIME GETTING A HANDLE AROUND. IT'S D THAT PEOPLE WON'T HAVE A HARD TIME GETTING A HANDLE AROUND. >> ONCE YOU'RE AT C, HOW IT INFLUENCES YOUR DAILY LIFE, ISN'T THAT FUNCTIONING AND RESILIENCY? >> YES. >> ANOTHER APPROACH MIGHT BE TO MOVE ONE APPROACH TO MOVE FUNCTION AND RESILIENCE DOWN TO WHERE D IS. AND I'M NOT EVEN TRYING TO CHANGE -- >> I ALMOST SAID THE SAME THING. I AGREE WITH THAT. >> CATHY IS COOL WITH IT. >> OKAY. >> AND WHETHER IT IS TWO SEPARATE DIAGRAMS, I DON'T CARE. BUT TO ME, THAT WOULD BE A MORE COHERENT WAY TO PRESENT THE MODEL. I'M STRUGGLING WITH HAVING YOUR B BEING CALLED A MODERATOR YET FLOATING OUT THERE LIKE A MEDIATOR. MODERATORS ARE BASELINE. IT ALMOST SEEMS TO ME THAT YOUR ARROW UNDER A, A SECOND ARROW SHOULD BE COMING FROM AROUND THAT SAME POINT. IF YOU ARE SAYING IN FACT, THAT YOUR BASELINE FITNESS LEVEL DETERMINES INDEPENDENTLY WHAT IS GOING TO WITH HEALTH OUTCOMES. >> SHOULD A POINT TO INTERVENTIONS AND B POINT TO PHYSICAL ACTIVITY? >> CAN WE MAY BE WORK ON SOMETHING. >> THE GREAT. WE WOULD LOVE TO HAVE INPUT FROM THE KRAMER SCHOOL ON THIS. WE NEED TO RECONVENE THE FITNESS WORKING GROUP AND SOLICIT INPUT FROM SPECIFICALLY METABOLIC SEDENTARY AND CHRONIC DISEASES ALSO FOR THAT DISCUSSION AT SOME POINT IN THE NEAR FUTURE. OKAYS. I THINK THAT WAS THE DISCUSSION THAT WE WANTED TO HAVE ABOUT THIS. THANK YOU EVERYBODY FOR YOUR INPUT. VERY HELPFUL. >> WE ARE GOING TO KEEP GOING BECAUSE IT IS GOING TO BE RELATIVELY SHORT. I LED THE ADULT GUIDELINES AND WAS WELL SUPPORTED BY RICK, KATRINA AND SANDRA AND WORKED WELL AND LEARNED TONSE FROM THE OTHERS, WAYNE, DAVID, PETER, RUSS AND KEN. THE OVER ARCHING QUESTION WAS THE FOLLOWING. N YOUNG ADULTS, ARE THE NEEDS FOR PHYSICAL ACTIVITY AS DESCRIBED IN VOLUME, TYPE AND PATTERN, DIFFERENT? OR WHAT ARE THEY? I'LL DO MORE IN TERMS OF THE VAGUENESS OF THE WORD NEEDS, IN JUST A SECOND. WE STARTED THIS WITH A CONVERSATION WITH TWO EXPERTS FROM CAMBRIDGE. THEY ARE ALSO WORKING ON THE SAME ISSUE. THEY ULTIMATELY TOLD US IT'S A NEW AREA FOR THEM ALO. THEY BELIEVE IT IS IMPORTANT IN TERMS OF HEALTH OF THE U.K. AND WISHED US GOOD LUCK AND WE ARE STILL CORRESPONDING VIA E-MAIL. THIS CAME UP AT OUR FIRST MEETING IN TERMS OF, IF YOU LOOK AT THE TOP GRAPH, THAT'S YRBSS DATA FOR MEETING THE PHYSICAL ACTIVITY GUIDELINE FOR YOUTH, WHICH IS 60 MINUTES PER DAY. AND IF YOU'RE A 12 GRADER, THE GRAY BAR, THE CHANCES ARE GOOD OF YOU NOT MEETING THAT GUIDELINE. SO 23.5% OF THOSE THAT MEET THAT GUIDELINE, BUT THEN YOU HAVE THIS WILD NIGHT. IT'S YOUR BIRTHDAY NIGHT, YOU BECOME A TEEN, AND ALL OF A SUDDEN CHANCES ARE PRETTY GOOD YOU'RE MEETING THE GUIDELINE BECAUSE WE HAVE 53% OF YOUNG ADULTS MEET THE AEROBIC PHYSICAL ACTIVITY GUIDELINE. IT'S 150 MINUTES PER WEEK. THERE IS ALSO A GUIDELINE IN YOUTH FOR MUSCLE STRENGTHENING AND MOST 12 GRADERS ARE A FLIP OF THE COIN, 50% AND THAT GUIDE SIDELINE ALSO DIFFERENT. 3 TIMES A WEEK. YOU HAVE YOUR BIRTHDAY AND NOW CHANCES ARE YOU'RE NOT MEETING IT, BUT IT'S A LOWER GUIDELINE SO THERE IS A LITTLE DISCONNECT THERE WHERE FOR ADULTS IT'S TWO TIMES A WEEK AND AS A SIDE, YOUTH HAVE A SPECIFIC GUIDELINE FOR BONE STRENGTHENING. THERE IS NO SPECIFIC GUIDELINE FOR BONE STRENGTHENING, PHYSICAL ACTIVITY FOR ADULTS. THESE ARE RECENT DATA WITH ED HANES. THEY REPRESENT 12,000 PEOPLE MEASURED WITH ASELL ROM TREE AND THE UNIQUENESS OF THIS PAPER WAS ABILITY TO USE CHILD GROWTH CHARTS FROM AGE 6-84 USING OBJECTIVE DATA SO YOU'RE LOOKING AT QUINTILES AND THESE FIRST TWO GRAPHS SHOW TOTAL PHYSICAL ACTIVITY. SO A SUMMING OF ASELL ROM TREE COUNTS. AND WHAT YOU SHOULD SEE IS THAT THE SLOPE OR THE MOST OR GREATEST DECLINE IN PHYSICAL ACTIVITY HAPPENS BETWEEN 6-19 AND IT'S THE PURPLE LINE THAT IS THE MEDIAN DATA. AND THEN THERE IS A SLIGHT TICK UP DURING YOUNG ADULTHOOD. SO THERE IS A SLIGHT INCREASE IN PHYSICAL ACTIVITY DURING THE YOUNG ADULT PERIOD WHEN WE TALK ABOUT PHYSICAL ACTIVITY AS TOTAL PHYSICAL ACTIVITY, WHICH WE DON'T REAL DOE AT THIS POINT WITH THE GUIDELINES. AND THEN LEVELING OUT YOUNG ADULTHOOD, MEDIAN IS PURPLE LINE. EITHER WAY YOU THINK ABOUT IT IN TERMS OF TOTAL PHYSICAL ACTIVITY, THERE IS A TRANSITION PERIOD GOING THERE SO WE THOUGHT THESE DATA JUSTIFIED OUR INITIAL QUESTION IN TERMS OF WHAT IS HAPPENING. IS IT A PARTICULAR IMPORTANT TIME, A SENSITIVE TIME, A WINDOW OF OPPORTUNITY? DIFFERENT WAYS OF THINKING ABOUT THIS. ONE OF THE REASONS THAT WE HAVE THIS DISCONNECT HAS TO DO WITH HOW PHYSICAL ACTIVITY GUIDELINES ARE CONCEPTUALIZED WHEN YOU THINK OF YOUTH. SO CHILDREN AND ADD LESSENS, YOU'RE THINKING ABOUT IDENTIFYING THE PHYSICAL ACTIVITY THAT IS APPROPRIATE FOR HEALTHY GROWTH AND DEVELOPMENT. YOU WANT THOSE KIDS TO BE THE BEST THEY CAN BE YOU ARE NOT WORRIED SO MUCH ABOUT DISEASE PREVENTION BUT YOU MOVE ON AND YOU THINK ABOUT ADULTS, AND NOW YOUR GOAL FOR PHYSICAL ACTIVITY IS PRIMARILY ABOUT DISEASE PREVENTION AND QUALITY OF LIFE. THOSE ARE TWO DIFFERENT PARADIGMS. IT MAKES SENSE YOU MIGHT HAVE DIFFERENT PHYSICAL ACTIVITY GUIDELINES GIVEN THE GROUNDING THAT YOU'RE USING IN TERMS OF WORKING THROUGH THE LITERATURE. THE CATCH THERE, YOUNG ADULTS SHARE BOTH HEALTHY AND GROWTH DEVELOPMENT GOALS AS WELL AS DISEASE PREVENTION AND QUALITY OF LIFE GOALS. THE THREE EXAMPLES THAT WE THOUGHT AS A GROUP THAT WOULD BE WORTHY OF US TAKING ON WOULD BE BONE HEALTH. CLEARLY BONE IS STILL ACCUMULATING AND STILL RESPONSIVE TO PHYSICAL ACTIVITY THROUGH THEIR 20s. PROBABLY STOPS AT SOME OF THE KEY AREAS IN THE EARLY 30s. WEIGHT GAIN AND OBESITY SEEM TO BE AN EXAMPLE OF WHERE YOUNG ADULTS ARE LOOKING LIKE THE REST OF THE ADULTS IN TERMS OF DISEASE PREVENTION. AND THEN BRAIN HEALTH IS A VERY UNIQUE AREA WHERE LIGHT LIKE BONE, BRAIN IS STILL MATURING BUT AT THE SAME TIME, A HIGH PREVALENCE OF VERY IMPORTANT MOOD DISORDERS SUCH AS DEPRESSION AND ANXIETY. SO WE HAVE THAT THING GOING ON WHERE YOUNG ADULTS HAVE UNIQUE THINGS WITH HEALTHY GROWTH AND DEVELOPMENT AS WELL AS DISEASE PREVENTION. THIS IS MY STATUS REPORT. WE STARTED WITH A PHONE CONVERSATION IN JANUARY. WE HAD A VERY GOOD MEETING WITH OUR COMMITTEE. OUR WORKING GROUP IN FEBRUARY. WE MET, AS YOU KNOW, IN MARCH WITH OUR BREAKOUT MEETING AND OUR DECISION IN TERMS OF THINKING ABOUT A TASK AHEAD OF US AND THE LACK OF RESOURCES AND LACK OF TIME TO GET GOING WITH RESOURCES WAS THAT YOUNG ADULT TRANSITION WOULD BE INCLUDED IN THE REPORT BUT THERE WOULDN'T BE A NEW SYSTEMATIC REVIEW QUESTION. SO I DON'T HAVE THE TREE TO SHOW YOU IN TERMS OF WHERE WE WERE. THAT THE POINT WE STARTED WORKING WITH SANDRA SO I SEE UPDATED EXTRACTION FOR 18-35 YEARS OLD WHEN THE SUBGROUPS CHECKED A BOX FOR US SAYING THAT HERE SAY PAPER THAT I READ, FOR EXAMPLE, IN WEIGHT GAIN AND IT INCLUDED A STRATIFICATION FOR YOUNG ADULTS. IN THE END, WAYNE REVIEWED THE WEIGHT GAIN OBESITY PAPERS FOR THE YOUNG ADULT TRANSITION GROUP AND LOOKED AT 18 PRIMARY RESEARCH PAPERS. HIS CONCLUSION WAS, THERE WAS SOMETHING THERE BUT IT WAS NOST A PARTICULAR SYSTEMATIC PROCESS IN TERMS OF WHAT WE WERE LOOKING AT. I'LL GIVE HIM A SECOND. IS THERE ANYTHING YOU'D LIKE TO ADD TO THAT? >> NO, I AGREE WITH EXACTLY WHAT YOU SAID. THE LITERATURE IS INTRIGUING. WE ARE JUST CONCERNED THE WAY WE VETTED OR IDENTIFIED AND VETTED RESEARCH, MAYBE DANGEROUSLY INCOMPLETE WE WOULD PREFER BECAUSE OF THE POTENTIAL IMPORTANCE OF THIS AND NOVELTY OF THIS QUESTION, THAT WE DON'T JUMP OFF WITHOUT REALLY KNOWING WHERE WE ARE GOING. >> I LOOKED AT THE BONE LITERATURE AND I REALLY RELIED ON WORK THAT THE NATIONAL OSTEOPOROSIS FOUNDATION HAD DONE A YEAR AND A HALF AGO AND LOOKED AT TWO REVIEWS AND 8 PRIMARY PAPERS AND THEN ICF SENT US 5 BRAIN HEALTH REVIEWS. I LOOKED AT THOSE ALSO. VERY INTERESTING PAPERS. PRIMARILY FOCUSED ACUTE EFFECTS, WHICH IS NOT EXACTLY THE QUESTION WE HAD IN MIND. WE HAD A PHONE MEETING JUST RECENTLY IN JULY AND SORT OF AS WAYNE SUGGESTED, THAT ALTHOUGH WE HAD EVIDENCE THAT WAS STRATIFIED BY AGE, IT WASN'T ORGANIZED TO LOOK AT A SPECIFIC DOSE OR TYPE OF PATTERN OF PHYSICAL ACTIVITY FOR THIS AGE GROUP. SO OUR DECISION WAS NOT TO PURSUE FOR THE 2018 GUIDELINES. BUT, IT'S NOT ALL LOST. WE ARE HOPING THAT AS A GROUP, THAT WE WILL BE WRITING A PAPER ADDRESSING THE NEED FOR MORE RESEARCH, PARTICULARLY RCTs AND WE WILL BE LOOKING FOR AN APPROPRIATE JOURNAL TO SEND THAT TO. AND WE WOULD LIKE TO CALL TO EVERYBODY'S ATTENTION IF IT'S NOT ALREADY KNOWN, THAT THE LITERATURE THAT IS OUTSIDE PHYSICAL ACTIVITY, IS ALMOST ABSOLUTELY IN AGREEMENT IN TERMS OF THINKING ABOUT THIS AS A WONDERFUL OPPORTUNITY FOR HEALTH PROMOTION BECAUSE IT'S A TIMEFUL CHANGE AND PEOPLE ARE ALREADY CHANGING OTHER THINGS. SO THIS MIGHT BE A SENSITIVE TIME, A WINDOW OF OPPORTUNITY, WHATEVER LANGUAGE YOU WANT TO USE. AND THEN I'M GOING TO FINISH BY SAYING WE DO PLAN ON CONTRIBUTING TO THE 2018 GUIDELINES WITH SOME TEXT THAT MIGHT FIT INTO EMERGING ISSUES, MAYBE THE FIT THINKS, OR MAYBE SOMEWHERE ELSE. AND I'M GOING TO LEAVE YOU WITH THIS IDEA THAT IT MAKES SENSE TO US THAT AS WE PROMOTE THE PHYSICAL ACTIVITY GUIDELINES, THAT WE SHOULD THINK ABOUT A GREATER EMPHASIS ON RELATIVE INTENSITY AND THIS GRAPH WHICH COMES ORIGINALLY FROM BILL HASKELL, SHOWS THE PERCENT OF THE MAX YOU'RE WORKING AT WHEN WORKING AT BRISK WALKING, WHICH IS ABOUT 3.8 MINUTES, WHICH IS HOW WE THINK ABOUT MODERATE ACTIVITY. IF YOU LOOK AT THE 10 I HAVE CIRCLED, THAT'S WHEN YOU HAVE A MAX VO2 OF 10 MINUTES. THAT'S THE AVERAGE FOR 40-50-YEAR-OLD ADULTS. IF YOU TAKE THAT 10, TAKE IT UP TO THE BRISK WALKING LINE, BRING IT ACROSS TO THE Y AXIS, YOU HAVE HIT MODERATE IN TERMS OF THINKING ABOUT AT LEAST 40% OF SOMEONE'S MAX. BUT IF YOU SHIFT OVER TO THE 12, THAT'S THE AVERAGE FITNESS LEVEL FOR A YOUNG ADULT. TAKE THAT UP. YOU'RE GOING TO HIT LIGHT WHEN YOU BRING IT ACROSS. SO THAT EVEN THOUGH WE ARE ASKING YOUNG ADULTS TO WORK MODERATELY, THEY AREN'T BECAUSE THEY ARE MORE FIT THAN THE REST OF THE ADULT POPULATION. THANK YOU FOR YOUR ATTENTION. HAPPY TO ANSWER ANY QUESTIONS. >> CAN YOU GO BACK TO THAT LONGITUDINAL SLIDE WITH PHYSICAL ACTIVITY? THE ONE PREVIOUS TO THAT. THIS CONTINUES TO STRIKE ME AS AMAZING. NUMBER 1, GIVEN ON YOUR LATTER COMMENT, THE FACT THAT IN THE 19-30-YEAR-OLD RANGE -- IT'S UP. IT'S UP FROM WHAT IT WAS IN THE 11-19. FIRST OF ALL, THE 11-19 DROPS SO MUCH. NUMBER 2, IT COMES BACK UP. BUT THE INDIVIDUALS IN THAT AGE GROUP AREN'T GETTING IT AS HIGH AS IT COULD BE GIVEN THEIR INCREASED AEROBIC CAPACITY. >> THAT'S A POINT I HOPE I MADE. >> AND THEN THE QUESTION IS, WHAT IS KNOWN ABOUT HOW HIGH IT IS IN THAT LIFESPAN PERIOD AND HOW THAT TRANSLATES TO HOW IT IS AT THE END OF THE LIFE? IN OTHER WORDS, IF YOU GET -- IT'S LIKE BONE. YOU BUILD A BONE WHEN YOU'RE YOUNG AND THEN YOU HAVE THIS DECLINE THAT HAPPENS NO MATTER WHAT YOU DO. AND WHERE YOU END UP AT THE END OF AGE 80, DEPENDS UPON WHERE YOU WERE IN THIS PERIOD. HOW MUCH DO WE KNOW ABOUT THAT WITH RESPECT TO OTHER PHYSICAL ACTIVITY ATTACKS. >> I KNOW VERY LITTLE AND I'LL OPEN IT UP FOR OTHER PEOPLE TO RESPOND. >> IS THE QUESTION TRACKING? >> NO, THE QUESTION IS, IF YOU TAKE AN INDIVIDUAL AT AGE 19 AND YOU INCREASE THEIR PHYSICAL ACTIVITY TO THEIR CAPACITY, LET'S SAY THEY ARE DOING 300 METAHOURS PER WEEK INSTEAD OF 150. HOW DOES THAT TRACK INTO YES -- HOW DOES THAT TRACK INTO THEIR PHYSICAL ACTIVITY AT AGE 60 OR 70? >> WELL, OTHERS CAN RESPOND TO THIS BUT HAVING LOOKED AT THE TRACKING DATA AND CONTRIBUTING TO SOME OF IT. TRACKING COEFFICIENTS TEND TO BE SIGNIFICANT FOR AT MOST A FEW YEARS AND THEN THEY TEND TO BECOME NON SIGNIFICANT, WHICH I ALWAYS HAVE TAKEN AS, YOU CAN SPIN IT EITHER WAY. IDEALLY YOU WOULD LOVE TO BE ABLE TO INOCULATE PEOPLE AT AGE 8 AND HAVE THEM BE ACTIVE THE REST OF THEIR LIFE. THAT'S CLEARLY NOT WHAT HAPPENS. ON THE OTHER HAND, THE OTHER SPIN IS, THAT EFFECT OF TRACKING COEFFICIENTS DON'T REMAIN SIGNIFICANT VERY LONG, SAYS THIS IS A PLASTIC BEHAVIOR. AND IT IS MODIFIABLE AND I THINK IT IS MODIFIABLE IN BOTH DIRECTIONS. GOD KNOWS WE KNOW IT GOES DOWN BUT IT CAN GO UP ALSO. AND BUT I DON'T THINK THE BEHAVIOR IS NECESSARILY LOCKED IN FOR A LONG TIME. I DON'T THINK THE TRACKING DATA SUPPORT THAT IT IS. >> AND I'M GOING TO ADD TO RUSS AND THEN TAKE IT BACK TO WHAT I THINK WAS YOUR ORIGINAL METAPHOR, THAT LOOKING AT THE EUROPEAN DATA FOR TRACKING ACROSS THE LIFE COURSE, WHICH I DID IN TERMS OF PREPARING FOR THIS, THE TRACKING COEFFICIENTS ARE ALWAYS CONSISTENTLY HIGHER WHEN YOU'RE TRACKING SPORT THAN WHEN YOU'RE TRYING TO TRACK PHYSICAL ACTIVITY. THAT COULD BE A MEASUREMENT ISSUE. BUT IT COULD BE SOMETHING ELSE IN TERMS OF WHAT MIGHT BE UNIQUELY CONTRIBUTEED BY SPORT. AND WE COULD SPECULATE ON THAT BUT I WON'T GO FORWARD WITH THAT. BUT THOSE CAN TRAING COEFFICIENTS, EVEN FOR WOMEN, ARE HIGHER WHEN YOU'RE ASKING ABOUT SPORT ACROSS THE LIFE COURSE RATHER THAN JUST PHYSICAL ACTIVITY. AND I TAKE BILL TALKING ABOUT THAT CONCEPT OF PEAK BONE MASS. IT'S DIFFERENT THAN TRACKING. IT'S REAL BETHIS ACCUMULATION AND THEN AS IT DEGRADES ACROSS THE LIFE COURSE, BECAUSE YOU WERE HIGHER WHERE YOU WERE AT IN YOUR PINNACLE, YOU CAN LOSE THE SAME AMOUNT AND STILL END UP LIVING LONGER BEFORE SIGNIFICANT DISABILITY. I SUPPOSE THE CATCH WITH THE METAPHOR BREAKS DOWN S BONE IS AN ATTRIBUTE. WE KNOW IT IS TRUE. WE KNOW PEAK BONE MASS PREDICTS FRACTURE. BUT PHYSICAL ACTIVITY IS A BEHAVIOR. I'D HESITATE TO GO ANY FURTHER. >> I HEARD WAYNE SAY THAT THE LITERATURE IS DANGEROUSLY INCOMPLETE. AND I SEE THAT YOU CAN'T REALLY REPORT ON IT IN 200018? >> THAT'S NOT WHAT I SAID. I APOLOGIZE IF I MISS COMMUNICATED. WHAT I WAS SAYING IS THAT OUR LITERATURE REVIEW -- AND THE WAY WE HAVE OBTAINED INFORMATION IS INCOMPLETE. NOT THAT THE LITERATURE -- THE LITERATURE, WHAT IS DANGEROUS IS THAT WE MAY NOT KNOW WHAT IS OUT THERE. AND WE MAY NOT BE ABLE TO TELL A COMPLETE OR ACCURATE STORY IF WE ONLY RELY ON WHAT WE HAVE NOW. >> I UNDERSTAND. BUT I ALSO SEE THE LITERATURE SEARCHES THAT WERE METICULOUSLY PERFORMING AND WORKING WITH ICF AND THE TEAM, IS CAPABLE OF GENERATING A LOT OF DATA AND CONCLUSIONS IN OTHER AREAS. SO REGARDLESS OF WHETHER WE CAN PUT IT TOGETHER NOW, MAYBE BECAUSE WE DON'T KNOW IT IS OUT THERE. THERE IS A BIG GAP. AND THAT GAP IS NOT GOING TO BE ADDRESSED IN 2018. AND I'M WONDERING WITH KEN AND ABI, IS THERE A WAY OF EXPRESSING THAT, PERHAPS STATING IT IN INTEGRATION CHAPTER? I SEE THE MOST IMPORTANT -- I LIKE THAT DIAGRAM. BUT -- COULD YOU FLIP TO THAT DIAGRAM? >> IT MAY HAVE BEEN THE FIRST DIAGRAM I HAVE EVER -- >> DISEASE PREVENTION AND QUALITY OF LIFE IS -- IT MAY BE NOT THE STORY THAT WE SHOULD BE TELLING. I LISTENED TO RICHARDAL MAN, THE HEAD OF GERIATRICS AND EXTENDED CARE WHO IS INVOLVED WITH POLICY LEVEL DECISIONS AND WE HAD TO CHANGE THE IMAGE OF WHAT PHYSICAL ACTIVITY CAN DO FOR OLDER PEOPLE, PEOPLE WITH DISABILITIES TO, MAKE IT MORE LIKE THE YOUTH. AND THAT SIMPLE THEN DIAGRAM AND SAYING THAT IS THERE SAY GAP IN THIS TRANSITION, BUT RECOGNIZING THAT THAT STUFF DOWN THERE SHOULD BE DOWN THERE TOO, IS KIND OF AN IMPORTANT MESSAGE. >> IF WE DID THAT, MY UNDERSTANDING IN THE LITERATURE AFTER THIS YEAR OF WORK, WOULD BE WE WOULD BE ASKING FOR MORE AND WE WOULD BE FOCUSING A LITTLE BIT MORE ON MUSCULOSKELETAL IF WE WERE TALKING ABOUT OPTIMIZING WHO WE CAN BE AS MACHINES OR AS HUMANS. >> SO ANOTHER COMMENT HERE. ON THIS DIAGRAM, MY SENSE IS AND MAYBE I'M WRONG AND MAYBE THERE IS LITERATURE ON IT AND MAYBE SOMEBODY LIKE ABI WHO IS CONNECTED TO MORE OF A BEHAVIORAL AND GENERAL APPROACH TO BEHAVIOR, MIGHT KNOW. BUT MY IMPRESSION IS YOUNG ADULTS COULDN'T CARE LESS ABOUT WHAT IS ON THE BOTTOM HERE. THEY DON'T WANT TO THINK ABOUT. YOU CAN SAY ALL THE THING ABOUT GAINING BONE MASS WHEN YOU'RE 18 AND THAT'S HOW YOU'RE GOING TO END UP WHEN YOU'RE 60 AND THEY COULDN'T CARE LESS. BECAUSE THEY ARE NOT THINKING ABOUT WHEN THEY ARE 60 AND THEIR BEHAVIOR NOW, THEY CAN'T SEE HOW THAT TRANSLATES INTO THEIR BEHAVIOR THEN. I KNOW WE DRAW IT THIS WAY AND THAT IS INTERESTING TO THINK ABOUT, BUT THIS TRANSITION KEY AND TO ME, THIS QUESTION IS ALL ABOUT MESSAGING. AND HOW YOU GET YOUNG ADULTS TO PAY ATTENTION TO THE PHYSICAL ACTIVITY, AND IF WE ARE THINKING THEY ARE THINKING ABOUT DISEASE AND HIGHWAY THEY WILL END UP AT THE END OF LIFE, I THINK THAT IS A MISTAKE. >> ALSO RELATED TO THE DIAGRAM IN THE DISCUSSIONS WE HAD YESTERDAY AFTERNOON, AREN'T WE CHANGING, FLIPPING IT TO MORE OF A HEALTH PROMOTION MODEL UNTIL ADULTHOOD THAN A DISEASE PREVENTION? LOOKING AT THE CONTINUUM YOU STARTED TO PUT TOGETHER? IS. >> I THINK - THE IDEA THAT SEEMS TO BE EMERGING IS A GOOD ONE, WHICH IS MAYBE IT'S 3 AGE STRATA, BUT KIDS, YOUNGER ADULTHOOD, OLDER ADULTHOOD, AND THEN FOR EACH OF THOSE SHOWING ACROSS THE ACTIVITY LEVEL CONTINUUM, THE ANTICIPATED HEALTH EFFECTS AND WHILE I'M TALKING I'LL SAY I THINK THIS HAS BEEN VERY HELPFUL TO FOCUS ON YOUNGER ADULTS AND THAT AGE RANGE BECAUSE WHAT I THINK IS BECOMING INTO CLEARER FOCUS IS THE FACT THAT ADULT GUIDELINES REALLY HAS BEEN BASED LARGELY ON DATEDDA THAT HAS BEEN GENERATED WITH PEOPLE THAT ARE INITIALLY IN MIDDLE TO UMER ADULTHOOD WITH THE OUTCOMES COMING 10 YEARS DOWN THE ROAD AND SO ON AND THE YOUTH GUIDELINES THAT ARE BASED LARGELY ON PHYSIOLOGIC RISK FACTOR INFORMATION THAT IS AVAILABLE IN THAT AGE GROUP, AND THAT LEAVES THAT AGE GAP IN THE MIDDLE WHERE WE REALLY HAVEN'T DEVELOPED GUIDELINES BASED ON A LITERATURE THAT HAS BEEN DRAWN FROM RESEARCH ON THAT GROUP. TO THE EXTENT WE CAN FILL THAT GAP THIS TIME, I THINK IT WILL BE GOOD. >> GOOD DISCUSSION. AND ONE OF THE THINGS THAT OR THE QUESTION THAT COMES UP IS TALKING ABOUT THESE THINGS IS WHERE TO PUT SOME OF THESE PIECES, WHERE IS THE FITNESS PIECE GO? WHERE WOULD THE TRANSITIONS PIECE GO? AND THAT'S OPEN FOR US TO DISCUSS AND CONSIDER. I THINK ONE OF THE PARTS OF OUR REPORT, WHICH WE HAVEN'T TALKED ABOUT MUCH, A LITTLE BIT BUT NOT MUCH S WHAT IS CURRENTLY CALLED THE BACKGROUND. AND 2008, THE BACKGROUND WAS AT LEAST AS I LOOKED THROUGH IT, A PRETTY GOOD EXERCISE PHYSIOLOGY TEXTBOOK. IT HAD GOOD USEFUL INFORMATION IN IT. I DON'T THINK WE WANT TO REPEAT THAT AS VALUABLE AS IT WAS, I HAVE BEEN ENVISIONING THAT THIS IS A SECTION THAT GIVES US AN OPPORTUNITY I TO PROVIDE THE BACKGROUND FOR THE QUESTION THAT IS WE ASKED. EN AND ABLE US TO TALK ABOUT THINGS THAT WE DON'T ADDRESS OR DIDN'T ADDRESS IN QUESTIONS FOR ONE REASON OR ANOTHER. THAT SECTION INCLUDES A FLOOR DISCUSSION ABOUT SEDENTARY BEHAVIOR AND HOW IT MAY RELATE TO THE MORE MODERATE TO VIGOROUS PHYSICAL ACTIVITY IN THIS SAME AREA, I THINK THE FITNESS DISCUSSION AND THE TRANSITION DISCUSSION WILL FIT VERY NICELY INTO THIS SECTION. I JUST OFFER THAT AS AT LEAST A TEMPORARY HOLDING PLACE FOR THESE WRITE UPS WE ARE PLANNING AND MAYBE THERE ARE OTHER THINGS. LIKE ONE THING WE HAVEN'T TALKED ABOUT MUCH BUT IT IS PRETTY IMPORTANT TO OUR QUESTIONS IS THIS RELATIONSHIP BETWEEN REPORTED DATA AND DEVICE MEASURE AND OBJECTIVE MEASURES. AND SOMEWHERE WE NEED TO TALK ABOUT THAT AND THE BACKGROUND IS A GOOD PLACE TO PUT IT. >> I REALLY LIKE THAT. WHAT IT DOES IS PUTS OUR ARROW WHERE WE ARE T SAYS THIS IS WHERE WE ARE IN 2018 WITH RESPECT TO WHERE WE WOULD LIKE TO BE. AND WILL WITH RESPECT TO WHERE WE WERE BEFORE. SO WE DON'T HAVE TO DISCUSS ALL OF THAT WE DID BEFORE. BECAUSE THAT WAS A DIFFERENT PLACE. HERE IS WHERE WE ARE NOW AND HERE ARE THE PROBLEMS. AND HERE ARE THE THINGS WE DON'T KNOW AND HERE ARE THE THINGS WE ARE PRESENTING WE DO KNOW. THAT'S BASICALLY WHAT IT IS. >> I LIKE THAT IDEA OF A DIAGRAM. I AGREE WITH RUSS. WHAT ABOUT THE RESEARCH RECOMMENDATIONS? HOW DO YOU LAY A BACKGROUND SECTION TO THE RESEARCH RECOMMENDATIONS? >> IN MY THINKING THE BACKGROUND SECTION AND RESEARCH RECOMMENDATIONS ARE DIFFERENT. AND SO IN MY MIND THEY HAVEN'T BEEN LINKED YET. THEY PROBABLY COULD BE, BUT I STILL THINK THAT THERE IS VALUE IN HAVING THIS SECTION OF RESEARCH RECOMMENDATIONS THAT REALLY LIST THEM IN ONE PLACE. WE COULD ALLUDE TO THEM IN THE BACKGROUND SECTION. >> I'M SORRY I WASN'T QUITE CLEAR. ARE YOU COMFORTABLE PUTTING INFORMATION IN THE BACKGROUND SECTION IS THAT IS THEN FOLLOWED UP WITH THE RESEARCH RECOMMENDATION? >> SURE. YES. DEFINITELY. >> LET'S TAKE OUR BREAK NOW. BUT BEFORE WE DO THAT, LET'S SPEND A COUPLE OF MINUTES PLANNING THE REST OF OUR DAY. WE HAVE FINISHED ALL THE FORMAL PRESENTATIONS THAT ARE ON SCHEDULE AND THE TIME THAT IS LEFT FOR GROUP CONVERSATIONS HERE, THEN WE HAVE A LUNCH -- TAKE A BREAK. OKAY. NOW IS THE BEST TIME FOR US TO TAKE A BREAK (BREAK). PLEASE COME BACK AT 9:45. WE MANAGED TO EXTEND OUR MEETING, OUR PUBLIC MEETING TO 11:30 TODAY. IF WE WANTED TO USE IT. SO WE HAVE ABOUT AN HOUR-AND-A-HALF FOR DISCUSSION IF WE WANTED TO TAKE THAT MUCH TIME. THAT'S GREAT. WHAT I'D LIKE TO SAY FIRST IS, I WANT TO THANK ALL OF YOU FOR YESTERDAY'S END OF THE DAY DISCUSSION. IT WAS REALLY VERY GOOD AND IT HELPED ME THINK THROUGH A LOT OF THINGS AGAIN TO OPEN UP MY MIND, TO A NUMBER OF NEW IDEAS AND THOUGHTS ABOUT HOW WE CAN BE MOVING FORWARD. AND THAT WAS REALLY GREAT. AND WE MAY NOT BE ABLE TO CAPTURE THAT SAME MAGIC AGAIN THIS MORNING, BUT I'M HOPING WE CAN AT LEAST GIVE IT A GO AND CONTINUE THAT CONVERSATION ABOUT HOW WE CAN BEST DELIVER, MAKE UNDERSTANDABLE THE MESSAGES IN OUR THEATRE WE WANT TO CONVEY TO PEOPLE. AND I THINK THE MAJOR THOUGHT THAT I TOOK AWAY YESTERDAY IS THAT, WE DON'T HAVE TO -- WE PROBABLY CAN'T, AND DON'T HAVE TO TRY TO SQUEEZE IT INTO ONE IMAGE. WHAT WE ARE DEALING WITH CAN BE LOOKED AT AND SHOULD BE LOOKED AT FROM A NUMBER OF DIFFERENT PERSPECTIVES. AND THAT WILL HELP US MAKE OUR WORK CLEARER TO EVERYBODY AND THAT IS WHAT WE SHOULD BE TRYING TO DO. WHAT WE WOULD LIKE TO DO IS, I WANT TO JUST SHARE SOME OF THE THINGS THAT I'VE THOUGHT ABOUT OVER THE LAST YEAR RELATED TO THIS COMMITTEE AND DISCUSS THEM, AND THEN OPEN IT UP AGAIN AND WE'LL GET ABI WORKING ON A FLIP CHART HERE OR OTHERS WORKING, AND WE CAN SKETCH OUT SOMEOF THE IDEAS THAT WE TALKED ABOUT YESTERDAY. AND THEN TRY TO GET SEVERAL CONCEPTS THAT WE WOULD LIKE TO THINK MORE ABOUT AND MOVE FORWARD. IS THAT A REASONABLE DESCRIPTION? JUST TO TELL YOU, THIS IS A SLIDE THAT I USED AT ACSM TO TRY TO DESCRIBE TO PEOPLE WHAT WE ARE ABOUT. AND THE THREE ANGLES ARE WHAT I WOULD CALL 3 OF THE 4Ps OF PUBLIC HEALTH. IT'S A CONCERN FOR POPULATIONS, A CONCERN FOR PREVENTION AND A CONCERN OF HEALTH PROMOTION. THE P THAT IS MISSING IS POLICY. SO THESE ARE THE THREE THINGS THAT WE ARE DEALING WITH. AND JUST TO LET YOU KNOW, THE TOP ONE, PROMOTION S ONE THAT AT FLEET MY MIND, HAS A COUPLE OF MEANINGS ASSOCIATED WITH IT. ONE IS VERY OBVIOUSLY THE WORK THAT ABI HAS BEEN LOOKING AT. HOW DO WE FORMERLY PROMOTE PHYSICAL ACTIVITY IN THE POPULATION? THE OTHER IS MORE AKIN TO THE PREVENTION CORNER OF THIS. THERE ARE SOME DISEASES THAT WE WANT TO PREVENT, HEART DISEASE, DIABETES AND SO FORTH. THERE ARE OTHER ASPECTS OF HEALTH THAT WE WANT TO PROMOTE, QUALITY OF LIFE, HIGH QUALITY SLEEP. MOSTLY THINGS THAT ARE IN THE BRAIN HEALTH AREA SO THE PROMOTION ANGLE HAS -- THOSE TWO MEANINGS. AND THEN I TRIED TO PUT OUR VARIOUS SUBGROUPS ON TO THE POINTS OF THE TRIANGLE WHERE I THOUGHT THEY BEST FIT. A NUMBER OF THEM OVERLAP AND BRAIN HEALTH, I PUT ALONG THAT LINE THERE BECAUSE THAT'S ONE I FELT REALLY OVERLAPPED A LOT BETWEEN PREVENTION WHEN YOU THINK ABOUT DEMENTIA AND THE PROMOTION OF IMPROVED MOOD AND THAT SORT OF THING. AND WE HAD TWO COMMITTEES THAT FOCUSED QUITE SPECIFICALLY ON PHYSICAL ACTIVITY ITSELF. THE SEDENTARY EXPOSURE. THIS MY BE SOMETHING WE COULD USE OR SOMETHING LIKE IT TO HELP DESCRIBE HOW WE THOUGHT ABOUT AND DID OUR WORK. THIS ONE I WANTED TO PUT UP SO YOU KNOW IT IS HERE AND HAVE A CHANCE TO LOOK AT IT AGAIN. I CHOSE THE 2008 TARGET DOSE DID THE SPOTS WE WERE ABLE TO PUT ON FROM THAT LAST YEAR. THIS IS THE SAME ONE BUT I PUT IN LORETTA'S POINT FOR GESTATIONAL WEIGHT GAIN TO SHOW HOW THAT FITS IN THERE. THIS IS A CURVE THAT SHOWS ALL CAUSE MORTALITY. REDUCTION IN RELATIVE RISK, THAT IS THE CURVE. AND THEN ALONG THE BOTTOM, I PLOTTED THE PREVALENCE OF THE POPULATION BY WHERE THEY FALL ALONG THE DIFFERENT VOLUME OF PHYSICAL ACTIVITY THAT IS REFLECTED IN THE FIGURE. AND THE ARROWS ARE HARD TORE DESCRIBE PERHAPS BUT WHAT THAT MEANS, IS THE ONES THAT SAY, 100%, MEAN THAT AT THOSE POINTS, THE PEOPLE WHO ARE THAT PHYSICALLY ACTIVE HAVE MORE OR LESS ACHIEVED 100% OF THE BENEFIT THAT THEY CAN RECEIVE IN TERMS OF REDUCTION OF ALL CAUSE MORTALITY. AND YOU CAN SEE THAT THAT FIRST A LITTLE BIT THERE, THEY GET HALF OF THE POTENTIAL REDUCTION IF THEY JUST GET HALF OF THE WAY TO THE CURRENT GUIDELINES. I SHOWED YOU THIS SLIDE. THIS IS ESSENTIALLY THE SAME SLIDE BUT THOSE PERCENTAGES ACROSS THE BOTTOM ARE THE PERCENT OF THE POPULATION THAT ARE TO THE LEFT OF THAT POINT. I HAVE USED THIS IN MY THINKING SOMETIMES WHEN I HAVE BEEN TRYING TO FIGURE OW WHAT DOES IT MEAN WHEN A STUDY GIVES US HIGHEST AND LOWEST? MAYBE THEY ARE KIND ENOUGH TO SAY IT IS TERTILES OR QUARTILES. -- [ OFF MICROPHONE ] I'LL GO BACK OVER HERE. MAYBE THIS IS TOO MUCH ESTIMATION. IT HELPS ME TO THINK ABOUT THINGS LIKE THAT. AND HERE IS A FIGURE WHERE I PLOTTED THE CURVE AGAIN FOR ALL CAUSE MORTALITY AND I DID SOME TRANSFORMING OF SOME OF THE CANCER INCIDENTS DATA ADAPTED FROM THE MORE ARTICLE. AND YOU GET A SORT OF SIMILARLY-SHAPED LINE BUT IT DOESN'T EVER GET DOWN TO WHERE THE OTHER IS IN TERMS OF THE AMOUNT OF REDUCTION. AND THEN I THOUGHT, WELL, WE CAN MAKE A TABLE THAT TAKES THAT INFORMATION AND SHOWS GETTING TO HALFWAY TO THE GUIDELINES FROM 2008. YOU GET A UPON 51% REDUCTION. YOU GET 51% OF THE REDUCTION YOU CAN GET FOR ALL CAUSE MORTALITY. AND YOU GET A 60% REDUCTION OF WHAT YOU CAN GET FOR REDUCING INCIDENTS OF COLON CANCER. SO THESE ARE SOME OF THE THINGS I THOUGHT ABOUT AS WAYS WE MIGHT BE ABLE TO PACKAGE AND PRESENT OUR DATA AND I'D LIKE THE REST OF IT TO BE -- YOUR THINKING. HOW DO YOU THINK YOU CAN BEST -- WE CAN BEST TAKE THE INFORMATION WE HAVE, PACKAGE IT, USE DIFFERENT WAYS TO PRESENT IT. AND I THINK IN THE END IF WE CAN COME UP WITH SOME FIGURES, DESCRIBING THE OVERALL FINDINGS AND APPROACH, AND THEN WITHIN EACH OF YOUR CHAPTERS AND QUESTION ANSWERS, I THINK IF YOU CAN THINK, MAYBE THERE IS A REALLY GOOD VISUAL THAT WE COULD ADD TO HELP MAKE THIS POINT, THAT WOULD BE GOOD ALSO. OPEN TO COMMENTS OR TURN IT OVER TO ABI. >> THANK YOU, KEN. ACCOUNTED YOU JUST GO BACK A COUPLE OF SLIDES TO WHERE YOU HAD THE FIRST CURVE? THIS MIGHT GET TO COMMENTS WE HAD YESTERDAY ABOUT THE RECOMMENDATIONS ARE REALLY A RANGE, 150 TO 300. SO WHEN IT SAYS, TIMES RECOMMENDATION, WHAT IS THE RECOMMENDATION? >> THE RECOMMENDATION WAS ESSENTIALLY 2008 RECOMMENDATION. >> 150 OR 300? >> 150? SO THIS GETS TO THE BUOYANT EVEN THE SCIENTISTS, THEY ARE USING 150 AS A RECOMMENDATION. THEY ARE NOT LOOKING AT THE RANGE. [ LAUGHS ] >> THANK YOU, PETER. [ LAUGHS ] WHEN I WAS PUTTING PUTTING THIS TOGETHER LAST NIGHT, I HAD A DEBATE WITH MYSELF WHETHER I WANTED TO LEAVE THESE HALFTIMES -- TWO TIMES, 3 TIMES THE RECOMMENDATIONS OR WHETHER I WANTED TO ACTUALLY PUTS THE NUMBERS IN THERE AND I DECIDED THIS IS SIMPLER. OBVIOUSLY I SHOULD HAVE MADE ANOTHER DECISION. [ LAUGHS ] >> NO, NO, NO. THIS IS FROM THE LITERATURE. THAT'S FROM THE PAPER. >> YES, THAT'S THE WAY -- >> THAT'S THE WAY THEY EXPRESS IT. SO SCIENTISTS USING THE RECOMMENDATIONS IN THE LITERATURE ARE SAYING THE RECOMMENDATION IS 150 AND IT GOES TO WAYNE'S POINT YESTERDAY. EVERYONE IS USING THAT ALTHOUGH IT SAYS 150-300. >> ANNA IS AT GW, I ADJUSTMENTED EVERYBODY TO KNOW THAT. -- I JUST WANTED -- >> KEN, PLEASE GO BACK TO THE EARLIER SLIDE WHERE YOU HAD THE RANGES OF CURRENT RECOMMENDATIONS ON THE RED BAR OF THAT CONTINUUM THERE. KEEP GOING. YOUR THIRD SLIDE THAT YOU PRESENTED. THIS ONE. CAN YOU JUST PLEASE JUST SO WE ARE CLEAR ON WHAT WE ARE LOOKING AT, COULD YOU PLEASE DESCRIBE WHAT ARE EACH OF THE DIFFERENT POINT SYMBOLS REPRESENTING? ARE THEY REPRESENTING MINIMUM RISK OR MAXIMAL EFFECT OF A GIVEN AMOUNT OF PHYSICAL ACTIVITY? OR A RELATIVELY RISK AT A CERTAIN TARGET PHYSICAL I'M NOT SURE -- I UNDERSTAND THE ALL CAUSED MORTALITY BAR OR LINE. BUT HELP ME UNDERSTAND THE CONTEXT OF THE SPECIFIC POINTS. >> EACH SPECIFIC POINT REPRESENTS IN 2008, WAS DETERMINED TO BE THE AMOUNT OF REDUCTION AND RISK THAT MATCHED THAT PARTICULAR VOLUME OF PHYSICAL ACTIVITY SO THAT AS THEY REVIEWED THE LITERATURE AS YOU HAVE BEEN REVIEWING IT, YOU GET PAPERS THAT GIVE YOU EFFECTED SIZES, REDUCTIONS IN RISK, AND THIS WAS THE POINT THAT THEY COULD PUT ON THIS FIGURE BASED ON THAT INFORMATION. >> COULD YOU DESCRIBE YOUR WAY THROUGH ONE OF THE POINTS? SO YOU'RE SAYING THAT IF YOU HAVE, FOR EXAMPLE, 2 1/2 HOURS OR 180 MINUTES OF EXERCISE PER WEEK, THEN YOU'RE SOMEWHERE -- RELATIVE RISK OF DIABETES OR HIP FRACTURE IS.6. IS THAT THE WAY I'M SUPPOSED TO READ THIS? SO IT'S NOT NECESSARILY THE MAXIMUM, LIKE HOW MUCH PHYSICAL ACTIVITY IN ORDER TO GET YOUR MAXIMUM NADIR. THIS IS NOT THAT? >> RIGHT. RUSS? >> ON THE SAME POINT. I'LL HAVE TO SAY, I PREFER THE CURVES TO THE POINT ESTIMATES. I FIND THAT HARD TO INTERPRET AND I SUPPOSE IT'S MESSIER IF YOU'RE GOING TO PUT 10 CURVES ON A GRAPH. BUT TO ME, IT IS SORT OF MORE CONSISTENT WITH WHAT WE KNOW, WHICH IS, THESE ARE CURVES. IT'S NOT JUST ONE THRESHOLD LEVEL THAT PROVIDES BENEFIT. AND YOU'RE NOT THAT THE LEVEL, YOU DON'T GET ANYTHING OUT OF IT. I THINK THESE ARE SMOOTH CURVES AND I JUST THINK THAT APPROACH BETTER COMMUNICATES THE NATURE OF THE RELATIONSHIPS. >> RUSS, I AGREE WITH YOU 100%. YOU ISSUE EXACTLY RIGHT. IF WE HAD THE DATA, THAT'S A MUCH BETTER AND MUCH CLEARER PICTURE AND I WAS HOPING WE MIGHT BE ABLE TO DO MORE OF THAT THIS TIME AROUND. I'M STILL HOPING THAT FOR SMALL OUTCOMES WE WILL BE ABLE TO PUT THE DOSE RESPONSE CURVE THERE. BUT I STILL -- AT LEAST FROM MY THINKING, I FOUND THIS HELPFUL BECAUSE WHAT THIS SUGGESTS IS THAT CURVE FOR THAT PARTICULAR OUTCOME GOES THROUGH THAT POINT. SO COLON CANCER IS SOMEWHERE AROUND THIS RED LINE. IN 2008, WE WEREN'T CONFIDENT ENOUGH TO DRAW THIS LINE OUT IN SOMETHING WE PUT OUT INTO THE PUBLIC DOMAIN. BUT THOSE POINTS WERE JUST TO GIVE AN IDEA OF WHERE OR HOW THOSE OTHER CURVES PROBABLY LOOK WITHOUT ACTUALLY DRAWING THE OTHER CURVES. BUT I AGREE. IF THIS IS CONFUSING TO PEOPLE, LET'S NOT -- RICH AND THEN -- >> I WANTED TO SEE IF I COULD MAKE THINGS EVEN MORE CONFUSING. >> GOOD. >> YESTERDAY, WE BROUGHT UP THE POINTS OF A CONTINUUM, WHICH IS CLEAR THAT THERE IS A CONTINUUM, AND THE SECOND POINT IS THAT THAT CONTINUUM CHANGES IT'S DIFFERENT FOR PEOPLE WITH DIFFERENT LEVELS OF SEDENTARY ACTIVITY. AND SO, MY QUESTION IS HOW UPFRONT IN THE BIG PICTURE -- BECAUSE YOU'RE TALKING ABOUT THE BIG PICTURE HERE. ARE WE GOING TO EXPRESS THIS RATHER NEW INFORMATION ABOUT THE INTERACTION IF YOU WILL, OF SEDENTARY BEHAVIOR AND HOW THAT ACTUALLY INFLUENCES HOW MUCH PHYSICAL ACTIVITY IS RECOMMENDED? >> I'M CERTAINLY HOPING THAT WE CAN PRESENT THAT AND THAT WE WILL BE UPFRONT ABOUT IT. AND THE BEST VISUALS TO DO THAT HAVE YET TO BE DEVELOPED. BUT CERTAINLY, I THINK THAT IS ONE OF THE MOST INTERESTING AND IMPORTANT ASPECTS OF WHAT WE HAVE BEEN FINDING. WE NEED TO TALK ABOUT IT. ABI? >> I'M GOING START TO MAKE A LIST. SO ARE THERE ANYMORE COMMENTS -- [ OFF MICROPHONE ] >> KEN, JUST ON THE LAST SLIDE THAT RUSS COMMENTED ON WITH THE POINT ESTIMATES ON THE CURVE FOR THE VARIOUS THINGS -- >> HERE IS SNAG BILL PUT TOGETHER -- SOMETHING -- THESE ARE HYPOTHETICAL BUT IT'S WHAT WE REALLY LIKE TO GET TO. [ OFF MICROPHONE ] >> BILL COAL PUT THIS TOGETHER AFTER 2008 EXPERIENCE OR MAYBE DURING, I CAN'T REMEMBER. BUT MADE IT AVAILABLE TO PRESENT. THESE ARE HYPOTHETICAL CURVING BUT ROUGHLY REFLECT HIS UNDERSTANDINGS OF WHERE WE WERE WITH KNOWLEDGE. THE QUESTION IS, TO WHAT EXTENT CAN WE START TO BUILD THIS, GIVEN THE DATA WE ACCUMULATED FOR OUR OUTCOMES NOW? >> SO ONE OF THE CONFOUNDERS IS AGE AND SO THAT IS WHERE I THINK IT WOULD HELP TO DO THIS THREE TIMES. ONE FOR KIDS, ONE FOR YOUNGER ADULTS AND ONE FOR OLDER ADULTS. >> WHILE THIS IS HYPOTHETICAL, IT ALSO IS INTERESTING THAT IF YOU LOOK AT WHAT WAS DESCRIBED AS BODY COMPOSITION, OSTEOPOROSIS AND BONE, HARD LEAN TISSUE AND SOFT LEAN TISSUE AND WEIGHT GAIN OR HOWEVER YOU WANT TO SAY IT, VERSUS CARDIOMETABOLLIC ONES, THAT THERE IS DIFFERENT -- AND SO IT AGAIN LEADS TO THE RECOMMENDATION OR RANGE, IT IS JUST NOT ONE-SIZE-FITS-ALL BUT THERE ARE PATTERNS FOR BROAD CATEGORIES OF HEALTH PROMOTION AND WEIGHT CONTROL. >> AND CANCER WOULD BE HERE. > SO SHOW OF HANDS, STARTING WITH YOUTH. HOW MANY CURVES WOULD YOUR SUBCOMMITTEE FEEL THAT YOU COULD PUT ON THIS KIND OF SLIDE? >> WE WILL TALK ABOUT IT THIS AFTERNOON. >> OKAY. >> HOW ABOUT FOR GENERAL ADULT POPULATIONS? JUST TRYING TO CANVASS THE DIFFERENT SUBCOMMITTEES. HOW MANY PEOPLE FEEL THAT THEY COULD DEVELOP THIS KIND OF DOSE RESPONSE CURVE WITH SOME ACCURACY KNOWING THAT THERE MAY BE DOTTED LINEOS PARTS OF THAT CURVE BUT YOU'RE NOT SURE. YOU MAY HAVE SOME EVIDENCE BUT MAYBE IT DOESN'T GO OUT ALL THE WAY? >> CASHEDIO METABOLIC PROBABLY WOULD DO SOMETHING WITH INCIDENTS HYPEESH TENSION. WORKING RIGHT NOW ON A -- HYPERTENSION -- WEIGHT AGAIN POTENTIALLY. SO AT LEAST THOSE TWO ISSUES -- WE HAVEN'T DONE DIABETES ONE YET BUT POTENTIALO THAT ONE. >> THAT'S WHEN WE HOPEFULLY -- I THINK WE CAN DO DIABETES. >> AND THAT WOULD BE IN THE GENERAL ADULT AGE GROUP PROBABLY YOU WOULD SAY? >> I THINK THE CHALLENGE IS HERE WE HAVE IT BY AGE BUT WE DIDN'T FIND A LOT OF EVIDENCE OF CONSISTENT FINDINGS SO WE WOULD BE STRETCHING IT BY PUTTING IT INTO TWO SEPARATE BUCKETS. >> SO PROBABLY IN THE GENERAL ADULT AGE GROUP. AND AGING, DO YOU HAVE -- NOT SURE YET. >> IT'S AN INTERESTING ISSUE BECAUSE RANDOMIZED TRIALS ARE USUALLY NOT DOSE RESPONSE TRIAL -- [ LOW AUDIO ] SOMETIMES THEIR ABILITY TO DOSE TEST, YOU CAN TRY TO GET PART OF THE DOSE RESPONSE -- BUT NEVER GET ALONG THE DOSE RESPONSE CURVE OUT OF THE RANDOMIZED TRIAL. AND QUESTIONS 1 AND 2 FOR AGING PRIMARILY WOULD BE ANSWERED BY RANDOMIZED TRIALS. >> THERE BEEN COHORT DATA AS WELL TO SHOW THAT BUT IT'S NOT CAUSE AND EFFECT. >> IT WAS LIMITED, RIGHT? SO FOR QUESTION 1, OUR DOSE RESPONSE DATA WAS LIMITED. THERE MAY BE COHORT DATA WE WILL PUT OUT ON QUESTION TWO. >> OKAY. >> VERY GOOD. AND I HOPE WE CONTINUE IT. WHEN WE DO THIS, THINK ABOUT DOING IT AND LOOK AT THE LITERATURE THAT DOES SHOW SOME OF THIS INFORMATION, MOST OF THE TIME THEY WON'T PROVIDE -- THEY WILL NOT PROVIDE A P-VALUE ORB THE CONFIDENCE INTERVALS THEY GIVE YOU OVERLAP NOT ONLY WITH OTHER POINTS ALONG THE CURVE, BUT WITH ONE ITSELF SO THERE WILL BE PLACES WHERE WE COULD DRAW THESE CURVES BUT THEY WOULD NOT BE NEEDING THE TRADITIONAL STATISTICAL REQUIREMENTS OF P LESS THAN .05. >> SO WE ARE TRYING TO FIGURE OUT HOW TO CAPTURE THE CONTINUUM. SO OUR CHARGE WE DISCUSSED YESTERDAY IS TO BUILD ON THE FOUNDATIONAL WORK THAT HAS BEEN DONE IN 2008 BUT CAPTURE THE 10 YEARS OF ADDITIONAL WORK THAT I THINK A LOT OF US FEEL LIKE WE HAVE TO THINK IN DIFFERENT WAYS TO CONVEY THIS INFORMATION. SO THIS IS JUST ONE WAY TO DO IT AND IT SOUNDS TO ME WE WOULD COMBINE ADULTS AND OLDER ADULTS BECAUSE THERE MAY NOT BE SUFFICIENT STUFF GOING ON IN OLDER ADULTS TO LAY OUT THESE CURVES BUT IT SOUNDS LIKE WE DO HAVE SOME NEWER KINDS OF CURVES THAT COULD BE LAID OUT, YOUTH FOR SURE. THAT WOULD BE NEW HAVING A SEPARATE YOUTH GRAPH. I DON'T KNOW IF THAT IS EVER -- I HAVEN'T SEEN THAT. >> WE ARE GOING TO HAVE TO TALK ABOUT IT. THE DOSE RESPONSE LITERATURE IS LIMITED AND THAT'S THE CHALLENGE WE WILL HAVE. WE NEED TO LOOK AT IT FROM THAT PERSPECTIVE BEFORE WE DECIDE. >> SO THIS IS ONE WAY OF THINKING ABOUT IT AND OBVIOUSLY WE DON'T HAVE TO DECIDE ANYTHING NOW, BUT THIS IS ONE, I THINK, SORT OF TRADITIONAL WAY OF SHOWING DATA THAT I THINK WE ARE PROBABLY GOING TO WANT TO HAVE THIS KIND OF FIGURE IN HERE. NOW ARE WE DONE WITH THIS? ARE WE DONE WITH THIS SLIDE SO WE CAN GET RID -- SO WE ARE GOING TO CHANGE THINGS OUT AND WHILE WE ARE DOING THAT, DID SOMEONE -- SO NOW FOR SOMETHING COMPLETELY DIFFERENT -- I'M GOING TO SING AND -- [ LAUGHS ] NO! WE'LL SPARE YOU FROM THAT. WHAT WE WANT TO DO IS JUST CONTINUE THE BRAINSTORMING THAT WE STARTED YESTERDAY. AND SOME OF US HAVE BEEN DRAWING THINGS. BECAUSE WHAT WE NEED TO DO IS COMMUNICATE IN AN EFFECTIVE WAY, NOT JUST TO SCIENTISTS BUT ALL OF OUR CONSTITUENTS, WHICH INCLUDE PHYSICIANS, POLICYMAKERS , THE PUBLIC, EVERYBODY, FROM TERMS OF THIS IDEA OF THIS CONTINUUM OF BENEFIT. AND I THINK A LOT OF US WERE RESONATING TO THIS IDEA OF NOT JUST WHAT YOU CAN DO TO AVOID BAD THINGS BUT WHAT CAN YOU DO TO ACHIEVE GOOD THINGS. SO CURVES THEY GO UP. THESE THINGS STICK TO THE WALL AND SO I THINK OVER THE NEXT HOUR, MY BEAUTIFUL ASSISTANT, KEN, WE CAN JUST TEAR THIS OFF. SO THIS IS JUST A LIST OF THE KINDS OF FIGURES WE ARE THINKING THAT WOULD BE GOOD SO RICH'S IDEA OF A FIGURE THAT SOMEHOW SHOWS RELATIONSHIPS BETWEEN SEDENTARIY AND PHYSICAL ACTIVITY, I THINK THAT WOULD BE A REALLY UNIQUE AND WORTHWHILE FIGURE. AND THESE OTHER FIGURES TO TRY TO CATCH YOUR DOSE RESPONSE AND DIFFERENT AGE RANGES I THINK WOULD BE GOOD. A THIRD FIGURE THAT PEOPLE ARE THEN KICKING AROUND, NOW I'M GOING SWITCH TO -- WE GOT THREE DIFFERENT KINDS OF MICS GOING ON HERE. SO AS WE RUN AROUND THE ROOM, HOPEFULLY WE CAN CAPTURE WHAT EVERYBODY IS SAYING. SO WE HAVE TO CONTINUE TO TALK INTO THE MIC. ANY MIC. AND WE HAVE A HANDHELD MIC HERE AS WELL. SO I'M GOING TO TRY TO START TO DRAW SOMETHING AND THEN ASK PROBABLY JOHN OR RUSS OR SOMEONE TO COME UP AND HELP US WITH THIS AND I KNOW RICH HAD HIS OWN THINKING ABOUT SOMETHING THAT YOU MENTIONED. THERE IS NO SUCH THING AS ONE GOOD IDEA. I THINK THERE IS LOTS OF WAYS WE CAN GO AND WE CAN WORK ON IT. THE GOAL IS TO GET TO A PLACE WHERE WE CAN BUILD SOME CONSENSUS AROUND TYPES OF FIGURES THAT WE THINK ARE GOING TO CAPTURE SOME OF THESE CONCEPTS OF THE CONTINUING EFFECTS OF PHYSICAL ACTIVITY THROUGHOUT THE RANGE AND SEDENTARY BEHAVIOR. AND THEN WE CAN WORK ON THOSE AFTER THIS MEETING. WE DON'T HAVE TO DECIDE ANYTHING TODAY BUT WE WANT TO GET SOME INNOVATIVE OUT-OF-THE-BOX IDEAS GOING. SO, ONE THING THAT WE ARE -- COULD BE THINKING ABOUT, HAS TO DO WITH SORT OF BLOCKS OF PHYSICAL ACTIVITY STARTING FROM SEDENTARY BEHAVIOR WHERE YOU'RE DOING HARDLY ANYTHING, AND THEN MOVING INTO LOWER LEVELS OF ACTIVITY, WHICH MAY BE 20 MINUTES. AND WE DON'T EVEN NEED TO PUT POINT ESTIMATES. I KNOW PEOPLE ARE A LITTLE SQUEAMISH ABOUT SAYING THAT'S EXACTLY AT THIS POINT. IT'S USUALLY A RANGE WE ARE TALKING ABOUT TO GETTING INTO A LOWER RANGE OF DURATION AND TALKING WITH OUR BRAIN HEALTH COLLEAGUES FOR INSTANCE. SAYING FOR ACUTE EFFECTS OF MODERATE WALKING AND MODERATE ACTIVITY ON EXECUTIVE FUNCTION. YOU CAN DO AS LITTLE AS 20 MINUTES AND GET THAT ACUTE EFFECT GOING. AND IF YOU DO MORE, IF YOU CAN BUILD ON THAT, THAT'S SORT OF WHAT WE ARE LOOKING FOR, I THINK. SO AT THE LOWER RANGE, WHAT KINDS OF BENEFITS START TO KICK IN? AND FOR OLDER ADULTS, I WOULD ARGUE PHYSICAL FUNCTION CHANGES START TO KICK IN AT THIS LOWER RANGE THAN IF YOU MOVE UP A BIT AND YOU'RE HEADING TOWARDS THE 150. THERE ARE PROBABLY SOME OTHER INTERMEDIATE KINDS OF BENEFITS THAT -- >> JUST A SECOND. SO IT'S 20 MINUTES A WEEK TO 150 MINUTES A WEEK? >> WELL, WHAT WAS THE. >> SO THE X AXIS WILL BE HARD TO FOLLOW IF THE NEXT PLOT IS 150. >> ITS LET'S NOT WORRY SO MUCH ABOUT STICKING NUMBERS UP HERE BECAUSE THAT IS WHERE -- THAT'S THE HARD PART. WHAT WE WANT TO LOOK FOR ARE THE BIGGER CONCEPTS OF HOW TO TRY TO SHOW THESE THINGS. AND WHETHER WE CAN AT LEAST ONE FIGURE SHOW THIS IDEA THAT YOU DON'T -- IT'S NOT A THRESHOLD. AS YOU MOVE UP AND BECOME MORE ACTIVE, MORE KINDS OF BENEFITS CAN START TO EMERGE AND NOT TO SAY IT'S OPTIMAL BUT THEY CAN START TO EMERGE. >> I APPRECIATE THAT. IT'S THE X IF WE COULD BE CONSISTENT. IS IT PER WEEK IN TERMS OF MINUTES OR PER DAY? >> FOR THIS CASE WESTERN TALKING 20 MINUTES A DAY, MAYBE WOULD YOU SAY? IF SOMEONE DOES 20 MINUTES OF EXERCISE ON A MONDAY, THEY WILL GET THESE BENEFITS. >> I THINK WE SHOULD REFRAIN FROM USING 20 MINUTES. THAT'S THE MAJORITY OF WORK USES IN OUR FIELD RIGHT NOW AND WORKING THROUGH ANALYSIS AND WE ARE TALKING -- PEOPLE HAVE USED SHORTER AND LONGER DOSES. IT'S ALSO CONFOUNDED BY INTENSITY OF EXERCISES AND AS WELL AS THE TYPE OF EXERCISE. >> WHATEVER THAT NUMBER IS, I GUESS I'M TRYING TO SEE IF WE CAN PLOT EMERGENT BENEFITS THAT GET US AWAY FROM THIS IDEA THAT IT IS AN ALL OR NOTHING. THAT YOU HAVE TO HIT THE 150 MINUTES. AND IN IS WHERE THE MESH PUBLIC IS AT. -- AMERICAN PUBLIC. IF YOU DON'T DO YOUR 150 MINUTES, THEN IT'S A WASTE. AND I CAN'T TELL YOU HOW MANY PEOPLE TELL ME, THERE IS NO WAY I CAN DO 150 MINUTES THIS WEEK. SO, I'M NOT GOING TO WORRY ABOUT IT. I THINK -- >> I'M ALL FOR INCLUDING LITERATURE AND A FIGURE THAT WOULD BE BASED ON RESPONSES TO ACUTE EXERCISE BUT I DON'T SEE HOW TO INTEGRATE THAT INTO A FIGURE THAT IS BASED PRIMARILY ON CHRONIC WEEKLY, MONTHLY, YEARLY EXPOSURE TO ACTIVITY. I THINK IT HAS TO BE A SEPARATE FIGURE. >> THE LET'S TAKE OUT THE ACUTE STUFF AND MAYBE THAT WOULD BE SEPARATE. >> ARE THERE OTHER KINDS OF BENEFITS? >> HOW CAN WE ILLUSTRATE A CONTINUUM OF BENEFIT? >> TO DO THAT, YOU NEED MULTIPLE ASSESSMENTS. MANY RANDOMIZED TRIALS AS DAVID SAID. DON'T DO MULTIPLE DOSES. SO YOU'RE RELYING MOSTLY ON PROSPECTIVE OR -- LONGITUDINAL COHORT STUDIES WOULD GIVE US THE BEST INFORMATION BECAUSE THEN YOU COULD SLICE UP GIVEN DOSE IF THEY HAVEN'T ALREADY DONE THAT. VERY SIMILAR TO THE PAPER. THEY MANUFACTURED THE DIFFERENT LEVELS. I'M JUST ALL FOR WHAT YOU'RE SAYING. I'M JUST, IN MY HEAD, THINKING WITH THE LITERATURE THAT WE REVIEWED, THERE WERE THREE COHORT STUDIES. JUST OUT OF INJURY FROM A FALL THERE WAS THREE COHORT STUDIES THAT LIKE MIGHT BE ABLE TO GIVE US THAT INFORMATION. I'M NOT SAYING IT'S NOT POSSIBLE. AND MANY TIMES, THE LOWER END OF THE SUSPECT RUM ISN'T EVEN CONSIDERED IN MANY TIMES. AND ESPECIALLY NOT IN TRIALS. I MEAN, IT'S ALL MODERATE TO VIGOROUS. >> BUT MOD VAT OKAY. SO I'M HEARING THE LITERATURE LEASHED US TO 150 MINUTES OR MORE? CAN WE -- GO AHEAD. >> I'M JUST LOOKING AT LIKE TRYING TO CREATE THIS FIGURE. AND I THINK ALL OF US HAVE TRIED TO EXAMINE THIS DOSE RESPONSE QUESTION, WHETHER OR NOT IT'S THERE OR NOT IS A WHOLE OTHER ISSUE. BUT BECAUSE SOME STUDY -- SOME OF US HAVE BEEN ABLE TO LOOK AT MULTIPLE POINTS ALONG THAT CONTINUUM OF NET HOURS PER WEEK OR WHATEVER IT IS, IT SEEMS LIKE THERE ISAISE POINT THERE FOR MANY OF US, THAT THAT IS WHERE THERE IS SAY SIGNIFICANT EFFECT. AND THEN ASSUMING THAT SOME OF THESE -- AND THEY WILL BE LOWER THAN THAT 150. RUSS YOU HAVE BEEN HITTING AT THIS. THERE IS POINTS BELOW 150 WHERE THESE THINGS BECOME SIGNIFICANT, STATISTICALLY SIGNIFICANT. AND THEY ARE PROBABLY NOT PREVENTION OF HEART DISEASE NECESSARILY. MAYBE THEY ARE. BUT MAYBE THERE IS FUNCTION. AND SO WHAT I WAS ENVISIONING IS THAT YOU HAVE THE CONTINUUM ON THE BOTTOM AND THE POINT WHERE IN GENERAL THE STUDIES IN AN AREA START TO SUGGEST THERE IS SOME OF THAT. THAT IT STARTS THERE AND THEN IT'S LIKE ORANGE, LIKE FUNCTION FOR EXAMPLE, ORANGE THAT HITS RIGHT THERE AND THEN IT GOES OUT ORANGE ALL THE WAY TO THE END OF THE CONTINUUM. AND THEN FOR WEIGHT, IT MAY BE MORE TO THE RIGHT AND STARTS THERE AND GOES -- AND THEY ARE STACKED ON TOP OF ONE ANOTHER. AND YOU GO 8-10 THINGS THESE GUYS LOOKED AT ARE ON LINE. EVEN IF IT'S NOT A WHOPPING EFFECT, WE GO WOW! >> AND THAT'S WHAT I ENVISION TOO. I'M TRYING TO LOOK FOR SOME EXAMPLES FROM THE SUB COMMITTEES WHERE WHEN THINGS START TO COME ON LINE -- >> LIKE FOR EXAMPLE, I'M LOOKING THAT THE FIGURE THAT I CREATED OVER THE LAST 24 HOURS AND IT TELLS ME IF I TAKE A LOOK AT NORMAL WEIGHT PEOPLE -- AND THESE ARE RANGES THEY GIVE US THAT'S THE PROBLEM. I LOOK AT NORMAL WEIGHT PEOPLE AND I'M TRYING TO PREVENT THEM FROM MOVING TO OVERWEIGHT OR& OBESITY. IT'S COMING ON LINE AT NOT THAT 99 NET HOURS PER WEEK. BUT IF I'M LOOKING AT TRYING TO PREVENT FURB.5KGs OF WEIGHT GAIN, THAT'S COMING ON LONGER. -- 4.5 -- SO THERE IS THESIS THINGS THAT ARE COMING ONBOARD RELATIVELY EARLY ON THAT ARE LESS THAN 150. I'M NOT SURE BLOOD PRESSURE IF THAT IS WHAT WE ARE SEEING AS WELL. I DON'T KNOW IF WE SAW THAT THERE. >> IT'S PROBABLY GOING TO BE AT THAT 150 MARK JUST BECAUSE THAT'S WHAT THEY USED. BUT IT IS STILL NEW INFORMATION. THAT WAS NOT IN THE PREVIOUS REPORT. IF WE CAN DO SOME OF THE MANIPULATIONS WE TALKED ABOUT WHEN WE PRESENTED YESTERDAY AFTERNOON WHERE YOU TAKE THOSE METAS, TAKE THE AVERAGES, THEY USED WITH THEIR PHYSICAL ACTIVITY INTERVENTION AND ASSIGNED A NET VALUE, I THINK WE CAN SAY THINGS ABOUT BLOOD PRESSURE BEFORE 150. THE EFFECTS STARTS -- I MEAN, IT'S PROBABLY 90 MINUTES. >> SO METAHOURS PER WEEK SOUNDS LIKE THIS IS THE ANSWER TO CATHY'S QUESTION OF WHAT IS HERE ON THE X. I THINK IT'S MET HOURS PER WEEK AND IT SOUNDS LIKE WE HAVE SOME OUTCOMES WHERE WE CAN FIND SOME EVIDENCE -- AND I LOVE THE WAY JOHN IS THINKING ABOUT THIS. WHEN THINGS START TO COME ON LINE -- WHEN YOU CAN START TO GET SOME BENEFITS. AND THEN THAT CAN GROW. MAYBE IT CHANGES THE COLOR BECAUSE THE OPTIMAL IS AT 150 OR WHATEVER. BUT AT LEAST TO START THINGS GROWING. >> SO JOHN, THE WAY YOU DESCRIBED THAT WAS HELPFUL FOR ME. I DON'T KNOW IF I HAD IT THE SAME WAY YOU HAD IT. BUT STACKED COLORS. SO I HEARD THAT AT WHAT POINT DO YOU START GETTING BENEFITS. WHAT BECOMES DIFFICULT IS WHAT HAPPENS AFTER THAT FOR THAT SPECIFIC OUTCOME. AND IF THAT DATA IS AVAILABLE BUT WHAT I SEE IS, THAT IS HELPFUL FOR THESE DIFFERENT OUTCOMES THAT HERE IS LIKE A -- I DON'T KNOW IF IT'S A MINIMUM OR THE DATA SHOWING US. WHAT I LIKE IS THAT IT SHOWS THE LOWER RANGES, LOWER STARTING POINT THAN THE 150 OR GREATER. >> ANOTHER WAY -- THE IT'S COMPLEX AND SOMEONE WOULD HAVE TO HELP US. BUT IF SOMETHING IS COMING ON LINE AT A CERTAIN LEVEL BUT CONTINUES TO IMPROVE, LIKE WHAT BILL COAL'S FIGURE STARTS TO LOOK LIKE BUT GETTING THE COVERS OUT OF THERE AND MAKING THEM STRAIGHT LINES, NOT THAT YOU WANT TO START WITH RED, BECAUSE RED HAS A BAD CONNOTATION TO IT. BUT YOU START WITH YELLOW, LIKE THERE IS SOMETHING THERE AND THEN MOVES TO GREEN AND MORE COMPLETE GREEN AS YOU GO ACROSS THAT LINE. SO, SUGGESTING THAT THERE IS ADDED BENEFIT OR SOMETHING. AND NOW WE ARE GETTING INTO GRAPHICAL DESIGN WHICH BECOMES COMPLEX. BUT I JUST ENVISION STACKING THESE THINKS TO SEE LIKE, WHEN ARE THEY COMING ON LINE? >> IN 2008, FOR CARDIOVASCULAR MORTALITY AND ALL CAUSE MORTALITY, WE TOOK THREE TRIALS. NELSONS WAS ONE. THESE WERE TRIALS AND COHORTS. AND IF YOU PUT THE MEAN RISK REDUCTION AND THEN THE STANDARD DEVIATIONS OR ERRORS, RIGHT? YOU CAN SEE IMMEDIATELY, IT STARTED TO MOVE. IT DIDN'T BECOME SIGNIFICANT UNTIL YOU GOT TO ABOUT CONSISTENTLY SIGNIFICANT TO HIGHER THAN 150. BUT IT WAS A CONSENSUS THAT 150 MET HOURS, YOU GOT A CONSISTENT ACROSS ALL THREE STUDIES, A CONSISTENT BENEFIT IS THAT DID NOT CROSS ONE. AND THAT IS HOW KIND OF WHERE WE GOT THAT LEVEL IS BASED UPON THAT. BUT YOU COULD SEE A MOVEMENT EARLY. AND THAT YOU COULD SEE HOW IT WOULD GO DOWN TO THAT EARLY LEVEL. SO DOT CONCLUSION THAT ANY EXPOSURE, BASED UPON NOT SEDENTARY, IS GOING TO HAVE A PATH. >> SO THE ISSUE WE WILL CONFRONT, MAYBE WE ALREADY ARE, IS THAT WE ARE LOOKING AT A LOT OF DIFFERENT OUTCOMES AND A LOT OF VARIABILITY IN THE VOLUME OF EVIDENCE THAT IS AVAILABLE TO DESCRIBE NOSE DOSE RESPONSE CURVES AND IT WILL GO ALL THE WAY FROM CARDIOVASCULAR DISEASE MORTALITY WHERE THEY ARE HIGHLY DEVELOPED METANALYSIS THAT LAY THIS ALL OUT AND YOU CAN SAY, JUST TAKE ONE OF THOSE AND WE WOULD BE HIGHLY CREDIBLE, TO OTHER OUTCOMES WHERE THERE EITHER IS NO METANALYSIS OR, A SUFFICIENT BODY OF EVIDENCE TO SUPPORT ONE. AND I THINK WE ARE GOING TO HAVE TO DECIDE WHERE IS THE BAR HERE. BECAUSE WE ARE GOING TO BE LOOKING AT OUTCOMES WHERE THERE MAY WELL BE A SEMINOLE STUDY, INDIVIDUAL STUDY, THAT IS DONE EXACTLY WHAT WE ARE LOOKING TO DO. AND I THINK WE ARE GOING TO HAVE TO DECIDE, WILL WE TAKE THAT CURVE? EVEN THOUGH THERE AREN'T 10 STUDIES THAT LOOKED AT IT IN THE METANALYSIS AND THE WHOLE THING IN THE OUTSIDE. I THINK THAT'S A DECISION WE WILL HAVE TO MAKE AT SOME POINT. >> I THINK VISUALLY, WE COULD PROBABLY FIND WAYS TO SHOW THAT IN TERMS OF CONFIDENCE IN THE EVIDENCE. IN TERMS OF STRONG BLACK LINES VERSUS DOTTED LINES OR SOMETHING, TO SAY THIS IS OUR BEST GUESS BASED ON THE LITERATURE, BUT IT MAY NOT BE AS STRONG. >> AT ONE POINT HOW HAPPY YOU WOULD BE WITH INCLUDING DATA FROM ONE STUDY WOULD DEPEND ON WHAT YOU'RE TRYING TO ACCOMPLISH WITH THE FIGURE. I THINK IF YOU BECOME TOO RIGID AND LITERAL AND JUST YOU'RE TRYING TO SAY IS THIS IS THE PICTURE, THEN YOU WOULDN'T WANT TO DO THAT. IF YOU'RE JUST TRYING TO MAKE A POINT HERE, THAT THESE CURVINGS ARE PROBABLY DIFFEREN FOR DIFFERENT OUTCOMES AND THIS IS GENERALLY WHAT THEY LOOK LIKE, AND IF YOU CAN POSITION THAT IN A WAY THAT PEOPLE UNDERSTAND WHAT YOU'RE TRYING TO ACCOMPLISH , THEN MAYBE YOU WOULD BE MORE COMFORTABLE INCLUDING& DATA FROM A SINGLE SEMINOLE STUDY. >> FOR ME, THIS IS A CONCEPTUAL PICTURE, A FRAME. IT'S MORE CONCEPTUAL THAN IT IS -- HERE IS THE HARD DATA AND THAT WE MAY HAVE IN OUR SECTIONS. THOSE KINDS OF FIGURES. I THINK THAT KEN WAS SHOWING, THOSE TO ME, ARE THE SCIENCE THAT GOES IN THE DIFFERENT SECTIONS. THIS IS MORE OF A CONCEPTUAL FRAMEWORK TO TRY TO MESSAGE, COMMUNICATE, HOW THIS DIFFERENT, HOW 2018 THINKING AROUND THIS FIELD HAS PROGRESSED AND ADVANCED. HOW WE ARE BUILDING ON PAST THINGS BUT BROADENING SOME OF THESE CONCEPTS. THAT IS HOW I'M THINKING ABOUT THIS. AND I LOVE WHAT YOU HAVE BEEN SAYING ABOUT IT. IT SOUNDS LIKE WHAT WE ARE GOING TO NEED EACH OF THE SUB COMMITTEES TO DO THE WAY JOHN HAS DONE IT, RUSS HAS DONE IT, WE MAY NEED TO HAVE A YOUTH ONE THAT IS SEPARATE FROM ADULTS BECAUSE OF THE DIFFERENT OUTCOMES, BUT TO JUST START TO TALK ABOUT WHEN THINGS START TO COME ON SHRINE HOW YOU CAN MOVE THOSE. AND THAT WAY, EVERYBODY IN THE U.S. CAN FIND THEMSELVES I'M DOWN HERE AND THE WORST THING, OF COURSE, IS NOBODY GETS WHAT METAHOURS ARE. TRYING TO TEACH THE AMERICAN PUBLIC ABOUT THAT IS GOING TO BE VERY, VERY DIFFICULT. WE WILL HAVE TO THINK OF MINUTES PER WEEK, SOMETHING ADOYNE BRISK WALKING. I THINK EVERYBODY CAN GET THAT. JUST FOR OUR START PLACE, PERHAPS, WE CAN CALIBRATE WHAT WE ARE DOING. MET HOURS MIGHT BE THE BEST WAY TO GO, BUT SO TO JUST TAKE THE TEMP OF THE SUB COMMITTEES, JUST THE WAY JOHN DESCRIBED WHAT HE DID IN TERMS OF THINKING ABOUT HIS SUBCOMMITTEE, COULD OTHER SUB COMMITTEES DO THAT TO HELP US THINK ABOUT -- AND MAYBE IT'S JUST ONE OUTCOME. >> I THINK THERE IS SAY FEW LIKE WE MENTIONED IN MY PRESENTATION ON DEMENTIA. I THINK THERE MIGHT BE SOMETHING THERE THAT WE CAN HIT ON. BUT CHUCK AND I WERE TALKING THIS MORNING A LITTLE BIT ABOUT THIS AND ONE IDEA WE HAD WAS TO, IF WE ADJUSTED WERE COG INNICENT, FOR EXAMPLE, THOSE STUDIES WHEN WE ARE NOT LOOKING AT DEMENTIA, WHEN WE ARE LOOKING AT THE QUESTION OF WHETHER PHYSICAL ACTIVITY IMPROVES COGNITIVE FUNCTION IN HEALTHY PEOPLE, THOSE ARE CTs AND SPECIFIC TO A PARTICULAR DOSE TYPICALLY. AND SO, LIKE DAVID MENTIONED EARLIER, THERE HASN'T BEEN REALLY ANY STUDIES THAT HAVE SYSTEMATICALLY MANIPULATE THED DOSE IN THESE RCTs. BUT THAT BEING SAID, WHAT WE DISCUSSED JUST A LITTLE BIT AGO WAS TO TAKE SOME STUDIES THAT HAVE BEEN SUCCESSFUL AND EXAMINE WHAT DOSE THEY USED AND MAYBE COMPARE THEM TO A FEW STUDIES THAT MAY BE WEREN'T SUCCESSFUL AND SO WE MIGHT BE ABLE TO PULL THAT APART A BIT MORE. IT WOULD TAKE SOME DIGGING ON OUR SIDE BUT I THINK WE MIGHT BE ABLE TO DO THAT. I THINK THE SAME THING WE COULD DO IN TERMS OF -- I DON'T KNOW, I WOULD HAVE TO ASK OTHERS ABOUT QUALITY OF LIFE. DEPRESSION, WE COULD THINK ABOUT THAT IN TERMS OF RISK FOR DEPRESSION OR ANXIETY DISORDERS, BUT ALSO HOW MUCH PHYSICAL ACTIVITY IS NEEDED TO PRODUCE SOME CHANGES IN EFFECT. THERE TOO WE ARE TALKING ABOUT RCTs AND I'M ASSUMING THERE WILL BE LIMITED INFORMATION BUT WE MIGHT BE ABLE TO PULL SOME STUDIES THAT WERE SUCCESSFUL, VERSUS NOT SUCCESSFUL, AND SEE IF WE CAN PUT SOMETHING ON THIS GRAPH. >> THAT WOULD BE REALLY EXCITING. AND SO I THINK THERE IS ALWAYS AN RCTs A DOSE, THE DOSE THAT THE INVESTIGATORS ARE SHOOTING FOR AND THEN THE REALITY OF WHAT PARTICIPANTS DID. WHICH IS VIRTUALLY ALWAYS BELOW THAT GOAL DOSE. AND BY LOOKING AT THE MEANS AND THE STANDARD DEVIATIONS, YOU CAN GET A MUCH BETTER SINCE OF WHAT DID PEOPLE ACTUALLY DO IN THESE STUDIES? AND USUALLY IT'S MUCH LOWER. SOMETIMES SIGNIFICANTLY LOWER THAN WHAT THE INVESTIGATORS HAVE CELT TOUT TRY TO DO AND PEOPLE STILL GET BENEFITS. SO THAT IS WHAT WE ARE TALKING ABOUT HERE. >> WITH THESE CURVES, WHICH I THINK ARE A GREAT IDEA. WHAT ARE WE PLOTTING ON THE X AXIS? >> THE X AXIS WAS THE MET HOURS PER WEEK. >> I'M SORRY, THE Y. >> THE Y -- JOHN? >> IS IT CARDIOVASCULAR, DIABETES? EACH ONE OF THOSE LINES -- SO START WITH CARDIOVASCULAR AND DIABETES AND START WHATEVER IS AT THE TOP IS THE FIRST ONE YOU SEE. OR START AT THE BOTTOM. WHATEVER. >> AND THE REASON I ASK THAT FOR MY PARTICULAR AREA, THIS IS WHERE I COULD BLEND BOTH. BECAUSE IT'S DISEASE PROGRESSION DEFINED THREE DIFFERENT WAYS. SO, BUT THERE IS SAY CONTINUUM GOING ON DEPENDING ON WHICH MARKER OF DISEASE PROGRESSION YOU USE. SO AS LONG AS IT IS -- SEE THAT IS WHY -- WHAT IS THE Y? >> SO, I MEAN, FROM MY PERSPECTIVE OF THINKING ABOUT IT, I'M NOT WORRIED ABOUT WHETHER -- WE CAN WORRY ABOUT IT BUT JUST TO SIMPLIFY. I'M NOT WORRIED ABOUT WHETHER WHEN YOU GET OUT TO THE RIGHT THAT THE RELATIVE RISK IS .ICS AND IF YOU'RE THREE STEPS IN, IS IT .8? I WANT TO KNOW, AT WHAT POINT DOES IT BECOME SIGNIFICANT? BECAUSE EVERYTHING BEYOND THAT AS LONG AS IT IS IN THE RANGE OF SIGNIFICANCE, IT'S IN THE RANGE OF SIGNIFICANCE. THE MAGNITUDE OF THE SIGNIFICANCE ISN'T IMPORTANT TO ME TO CONCEPTUALIZE IT. IF YOU GET ALL THE WAY OUT TO THE END AS BILL SHOWED, MAYBE IT GOES BACK THE OTHER WAY. MAYBE WE CAN SIGNIFY THAT. ONCE YOU GET HERE, MAYBE THERE IS DETRIMENT TO GOING BEYOND THIS. BUT BEYOND THAT, I THINK WE NEED TO KEEP THIS REALLY SIMPLE. >> SO ANY OTHER COMMENTS BEFORE -- SO I THINK THE CHARGE TO EACH SUBCOMMITTEE THE WAY WE HAVE BEEN HEARING FROM BRAIN, FROM THE METABOLIC, FROM YOUTH, FROM THE BLOOD PRESSURE PART OF IT, IS TO THINK ABOUT HOW YOUR SUBCOMMITTEE COULD CONTRIBUTE TO THIS KIND OF FIGURE, WHICH IS WHEN DOT BENEFITS START TO COME ON LINE? SO IS THAT SOMETHING THAT PEOPLE ARE WILLING TO LOOK AT? >> AND THIS MIGHT BE DIFFICULT BUT I WONDER IF IN OUR PROMOTION SUBCOMMITTEE AS THEY ARE THINKING ABOUT THAT, WE SHOULD BE THINKING ABOUT THE TYPES OF INTERVENTIONS THAT WOULD GET PEOPLE TO ACHIEVE THAT LEVEL OF ACTIVITY BECAUSE THAT COULD ALSO HELP WITH THAT CONTINUUM OF ACTIVITY PIECE. AND I WAS JUST TRYING TO DO EYE QUICK CHECK TO SEE HOW MUCH OF THAT WE MIGHT HAVE AND MAYBE A LITTLE BIT DIFFICULT BUT IF WE COULD GET CLOSE TO THAT, THAT MIGHT BE HELPFUL FOR PEOPLE TO FIGURE OUT TARGETS FOR WHAT THEY HAVE TO DO. >> I THINK THAT IS GREAT. AWESOME. I THINK WE CAN DO THAT TOO. THAT'S A GREAT IDEA. >> ONE OTHER THOUGHT ON HOW WE PRESENTED THE FIGURES. I THINK SO WE HAVE A TENDENCY TO EXTEND THE ACTIVITY CONTINUUM WAY OUT TO THE HIGH END AND I'M NOT SURE THAT THAT IS HELPFUL. WE ALL KNOW IT IS POSSIBLE THAT EXTREME LEVELS OF EXPOSURE, YOU GET SOME UNWANTED OUTCOMES. I'M NOT SURE THAT IS RELEVANT TO WHAT WE ARE DOING. I THINK I WOULD ARGUE FOR CUTTING OFF THE ACTIVITY CONTINUUM. IT IS SOMETHING THAT IS STILL WITHIN THE RANGE, THE WAY KEN WAS SHOWING IT WHERE 95 -- THIS IS WHERE 95% OF PEOPLE ARE WITHIN THIS SCALE. AND THERE MAY BE TRIATHLETES AND LONGSHOREMEN AND A HANDFUL OF PEOPLE THAT ARE WAY OUT THERE ON THE RIGHT BUT THAT IS ALMOST A DIFFERENT PARADIGM, I THINK. >> FOLLOWING UP ON RUSS'S COMMENT. IS IT USEFUL THERE IS LIMITED EVIDENCE TO GO TO ONE OF THE BEST SINGLE ARTICLES AND SAY, THIS IS WHERE WE THINK THE STATE-OF-THE-ART IS? AND ALONG THE LINES OF SAYING WE WANT TO DRAW THESE CURVES. SOME WE HAVE HIGH CONFIDENCE BUT LET'S LOOK AT THE LOW CONFIDENCE. BECAUSE IT SHOWS WHERE WE ARE. AND WE GET A LITTLE BIT OF INFORMATION. >> I HAVE ALONG THOSE LINES, I HAVE ACTUALLY MAYBE A LITTLE DIFFERENT THOUGHT. IF WE ARE GOING TO DRAW CURVES TO HAVE THEM ON THIS DATA, WE ARE THE MOST SOUND ON, THEN AS A RESEARCH INITIATIVE, WE ENCOURAGE OTHER PEOPLE IN THEIR OWN DOMAINS TO THEN HELP FILL IN THESE -- SEE WHERE THEIR OWN INTERESTS OR TOPICS FITS INTO THESE CURVES. BECAUSE I'M ANTICIPATING THAT THERE IS GOING TO BE, FOR MANY OUTCOMES, A CONTINUITY OF THE CURVE BUT THEN THERE WILL BE A SELECTED OUTLIER AND I WOULD HATE FOR US TO FIND AN OUTLIER WITH A LIMITED DATA AND THEN PUT SOMETHING OUT THERE THAT IS MAYBE SUSPECT DOWN THE ROAD. >> SO I HAVE TWO COMMENTS. ONE IS IN RESPONSE TO RUSS'S COMMENTED. SO EVEN LONGSHOREMEN DON'T DO THAT ANYMORE. [ LAUGHS ] AND THE OTHER WAS, SO WE HAVE AN EMBARRASSMENT OF RICHES IN THE CARDIOVASCULAR MORTALITY AND DISEASE. SO WE HAVE A NUMBER OF METANALYSIS. AND I BELIEVE WE ARE TRYING TO FIGURE OUT HOW TO INCORPORATE ALL OF THOSE INTO ONE METANALYSIS. AND WE ARE NOST GOING TO DO A STATISTICAL JOB OBVIOUSLY. WE DON'T TIME RESOURCES OR CAPABILITY OF DOING THAT. BUT WE'RE GOING TO TAKE A LESSON FROM WHAT I SAW ANN DO WHICH WAS INSTRUCTIVE ALONG THE LINES OF WHAT YOU WERE SAYING IS WHAT SHE PRESENTED. HERE IS THE BEST METEDDA ANALYSIS. AND HOW DO THE OTHERS COMPARE TO THAT? IS THERE ANY REASON TO NOT TAKE THAT AS THE GOSPEL TRUTH? TO WHICH WE CAN COMPARE: THESE ARE THE BEST DATA WE HAVE. AND NO REASON THO THINK IT IS DIFFERENT. >> OKAY. SO, JOHN, WILL YOU BE MY PARTNER IN CRIME TO HELP FACILITATE THIS? SO WE CAN TRY TO WORK WITH THE DIFFERENT SUBCOMMITTEES, MAYBE ON THE LEAD SUBCOMMITTEE? PAUL, WE CAN JUST TRY TO SEE WHAT PEOPLE CAN COME UP WITH. SEE WHAT WE CAN GET A CREATIVE HATS ON AND SEE WHAT WE CAN COME UP WITH. SO IN TERMS OF OTHER TYPES OF FIGURES, KEN TELLS ME HE THINKS RUSS HAS SOMETHING. >> RUSS, WHAT I THOUGHT I HAD HEARD YOU CONCEPTUALIZING WAS A FIGURE THAT MIGHT DISPLAY -- WHAT ARE THE BENEFITS THAT SEEM TO BE MOST IMPORTANT FOR THAT PARTICULAR AGE GROUP? AND THAT IS SOMETHING WE TALKED ABOUT AND IT SEEMS LIKE IT WOULD BE A FAIRLY DOABLE -- MAYBE SOMEBODY ALREADY DONE IT. >> YOU COULD ENVISION THREE FIGURES OR A FIGURE WITH THREE PANELS. KIDS, YOUNGER ADULTS, OLDER ADULTS, AND THEN SHOWING THE BEST OF OUR ABILITY THE DOSE RESPONSE RELATIONSHIPS FOR SELECTED OUTCOMES THAT ARE RELEVANT IN EACH OF THOSE THREE AGE GROUPS AND THAT LITERATURE WILL BE ROBUST FOR OLDER ADULTS AND LESS SO FOR THE OTHER TWO AGE GROUPS BUT WE FIND THE BEST EXAMPLES WE CAN FINED FOR THE AGE GROUP WOULD YOU CONSIDER A FOURTH COLUMN? AND PUT IN, THINKING ABOUT. YOU'RE THINKING DOSE RESPONSE CURVES. >> SOME OF THEM WILL GO UP, NOT DOWN. POSITIVE HEALTH OUTCOMES AS OPPOSED TO AVOIDANCE OF NEGATIVE OUTCOMES. >> WHAT ABOUT SIMPLY LISTING? WE MIGHT HAVE TO DO CREATIVE THINKING TO DECIDE WHAT TO PUT HERE. SIMPLE ENOUGH? OKAY. WHAT ARE THE FIGURES? >> KEN, I DON'T THINK LIST HAVE THE IMPACT OF A FIGURE. >> THEY DON'T. >> I THINK THEY ARE INFORMATIONAL. WE'LL HAVE PLENTY OF LIST IN OUR DIFFERENT SUBCHAPTERS AND CHAPTERS AND EVERYTHING. UT IF WE REALLY WANT TO CAPTURE A CONCEPT, THAT RUSS IS TALKING ABOUT, I THINK IT NEEDS TO BE IN A FIGURE. >> TING IS PREFERRABLE TO SHOW THE CURVES. >> WILL IT HELP US -- RUSS, AS YOUTH IS FINISHING UP THE LIST REVIEW, AND EVIDENCE IF YOU ALL COULD COME UP WITH ONE FOR YOUTH, AND IF THERE IS ANY INFORMATION FOR YOUNG ADULTS THAT CAME OUT OF YOUR SEARCH, START US OFF ON THAT AND THEN THOSE WORKING AT THE DIFFERENT PARTS OF THE AGE CONTINUUM COULD THINK ABOUT SOMETHING SIMILAR. >> I HAVE CONSTRUCTED THAT AND I'M GOING TO E-MAIL IT TO YOU. >> CAN YOU DRAW IT? >> I SUPPOSE. >> COULD EVERYBODY SEE WHAT YOU'RE THINKING ABOUT AND GIVE US A CHANCE TO PONDER IT? >> I WANT TO ADMIT THAT -- THIS IS -- THIS IS NOT A THEN DIAGRAM. THIS IS A VERY, VERY SIMPLE PICTURE OF HOW PEOPLE MIGHT THINK OF, INSTEAD OF A UNI MODAL 150 MINUTES OR 10 METS TO THINK THERE IS A LITTLE BIT MORE TO IT. AND I'M GOING ABBREVIATE THIS TO SAY THAT THIS IS THE ENTRY INTO THE PHYSICAL ACTIVITY CONTINUUM. IT'S JUST A STEP 1. STEP 2 MAY BE PERSONAL FUNCTION, FITNESS FUNCTION AND HEALTH GOALS. AS STEP 2. AND AS A STEP 3, YOU ADJUST FOR SEDENTARY BEHAVIOR, MAY ADJUST FOR AGE, AND YOU MAY ADJUST FOR ABILITY/DISABILITY. SO PEOPLE ALL KNOW THEY CAN PARTICIPATE. AND THIS IS -- IT'S NOT THE KIND OF CURVES OR DIAGRAMS WE ARE EXPECTING BUT PEOPLE DON'T SOMETIMES THINK IN CURVES. THEY THINK IN, HOW DO I NEED TO THINK ABOUT THIS? I NEED TO ENTER INTO A PHYSICAL ACTIVITY CONTINUUM. AND MAYBE THEY THINK ABOUT IT AS 5 OR 7 MINUTES, 8 OR 9 MINUTES IN THE A ROW ADDS UP THROUGH THE DAY. AND ACTUALLY, THAT MIGHT HELP MY BLOOD PRESSURE AND IT MIGHT HELP MY COGNITIVE FUNCTION. SO, I'M THINKING THAT THERE ARE EFFECTS THAT WE ARE DESCRIBING DOWN HERE INTO THE ENTRY-LEVEL BUT THIS IS SAY CONTINUUM. AND I HAVE PERSONAL FITNESS GOALS. I DON'T WANT TO FALL. AND I'D LIKE TO SEE A 40% REDUCTION IN MY FRACTURES. SO I AM GOING TO DO THIS 30-60 MINUTE, 3-4 TIMES A WEEK, MULTICOMPONENT EXERCISE PROGRAM. AND I'M DISABLED WITH SOME CONDITION THAT MADE MY VO TWO PEAK 13.8, THE MEAN FOR STROKE. 17.5 IF YOU HAVE CONGESTIVE HEART FAILURE MAKES YOU DISABLED BASED ON U.S. SOCIALITY SECURITY. I WANT TO GET MY FITNESS LEVEL UM TO WHERE I CAN DO ACTIVITIES OF DAILY LIVING AND I HAVE A HEALTH GOAL OF BETTER GLYCEMIC CONTROL. AND YOU HAVE TO AJUST FOR SEDENTARY BEHAVIOR. AND ACTUALLY LORETTA JUST SHOWED DATA SHE PUT TOGETHER THAT SEDENTARY BEHAVIOR, PHYSICAL INACTIVITY VERSUS THE PHYSICAL ACTIVITY LEVEL INTERACT TO RELATE TO MOBILITY DISABILITY IN OLDER POPULATIONS. YOU HAVE TO AJUST FOR AGE AND YOU HAVE TO CONSIDER THE ABILITY AND DISABILITY OF THE PERSON. SO IF I WERE LOOKING AT A 3-STEP PROCESS MYSELF OF HOW I WOULD START TO DIGEST THE BIGGER PICTURE, I MIGHT THINK OF THAT SIMPLE STAIRCASE. IT'S NOT THE CURVES OR ANYTHING ELSE LIKE THAT. IT'S JUST A DIFFERENT WAY OF, A SIMPLE WAY OF PUTTING IT TOGETHER IF YOU'RE A CLINICIAN OR A CONSUMER. >> OKAY. ANY REACTIONS? THOUGHTS? COMMENTS? >> I LIKE IT. I'D LOVE IT IF YOU COULD WORK ON IT A BIT MORE MAYBE SEND US SOMETHING ON A SLIDE OR SOMETHING ON YOUR PLANE RIDE HOME OR WHEREVER. JUST TO START TO DEVELOP IT A LITTLE BIT MORE SO WE CAN GET A BETTER -- >> I HAVE AN E-MAIL READY TO SEND TO YOU ALREADY THAT HAS A VERY, VERY SIMPLE -- I JUST HAVE TO PRESS THE BUTTON. I HAVE TO THINK ABOUT IT MORE BECAUSE WE HAVE TO LOOK AT THIS FROM PEOPLE, FROM KIDS, THEIR PARENTS, ADULTS, INDIVIDUALS, MAYBE THAT ARE AT RISK OF COGNITIVE DECLINE. THEY HAVE TO LOOK AT THIS WHOLE AMALGAM AND THINK ABOUT THE GATE THEY HAVE TO GO THROUGH. SO I'LL PUT MORE THOUGHT IN IT BUT I WILL SEND YOU THAT E-MAIL RIGHT AWAY. >> WHO HAS ANOTHER FIGURE. >> I WANT TO FOLLOW-UP WITH PETER ON THE SEDENTARY PHYSICAL ACTIVITY INTERACTION. CAN YOU -- WHO WOULD BE BOAST WORK WITH YOU? YOURSELF? TO HELP US THINK ABOUT, SHOW IN A GRAPHIC SORTS OF WAY THIS INTERACTION OR WHATEVER BETWEEN THE TWO. >> THE FIGURE I SHOWED FROM THAT METANALYSIS, THAT IS FIGURE 3 IN OUR CHAPTER ALREADY. SO, IN ADDITION TO THAT, ON OUR CALL, WE DISCUSSED A 3D FIGURE, THE KIND WHERE YOU HAVE ONE RISK FACTOR ON ONE SIDE AND THE OTHER THERE, WHICH WE THOUGHT MIGHT GO WELL IN THE INTEGRATION CHAPTER. IT DOESN'T SHOW THAT INTERACTION AS CLEARLY BUT IT INTRODUCES THE TOPIC IN A WAY THAT A LOT OF PEOPLE CAN UNDERSTAND THAT. AND KEN HAS THOSE FIGURES. IT'S FROM THE SAME PAPER. >> THAT'S GREAT. THAT SOUNDS GREAT. WHAT OTHER CONCEPTS DO WE THINK WE NEED TO -- ARE THERE ANYTHING ELSE? ANYTHING ELSE THAT WE HAVE BEEN DISCUSSING OR PEOPLE HAVE BEEN THINKING ABOUT THAT ARE HARD CONCEPTS FOR PEOPLE TO UNDERSTAND? THAT WE SHOULD BE TALKING ABOUT? >> SO THE CONCEPT THAT THE ELEPHANT IN THE ROOM IS, WE GOT MVPA AND SEDENTARY AND LIGHT. LIGHT. >> [ OFF MIC ] THE ISSUE OF THE WHOLE PHYSICAL ACTIVITY EXPOSURE, I DON'T HAVE AN ANSWER TO THAT BUT I THINK WE NEED SOME VISUAL CONCEPT ABOUT HOW TO REPRESENT THAT. >> I THINK ABOUT THE BEST WE CAN DO IS SET IT UP FOR 10 YEARS FROM NOW AND HOPEFULLY THERE WILL BE ANOTHER GUIDELINE. IT'S JUST SUCH A BLACK BOX RIGHT NOW. PEOPLE ARE JUST REALLY BEGINNING TO LOOK SERIOUSLY AT IT AND I MEAN, I'M ALL FOR ACKNOWLEDGING THE ISSUE, WHICH I THINK IT WOULD BE HONEST BUT I DON'T THINK WE SHOULD PRETEND THAT WE CAN JUST NAIL THE ISSUE AT THIS POINT. I DON'T THINK WE CAN DO IT YET. >> IT SEEMS TO ME SOME OF THE BETTER EVIDENCE RIGHT NOW FOR THAT IS REALLY IN THE AGING DOMAIN WITH PEOPLE LOOKING AT THAT, PUBLISHING AROUND LIGHT ACTIVITY AND EXTENSION OF GUIDELINES TO INCLUDE IT AND EVERYTHING ELSE. SO I'M WONDERING, AND I DON'T KNOW IF ANY OF YOUR QUESTIONS HAVE BEEN ABLE TO CAPTURE THAT DIRECTLY, BUT THAT IS WHERE I SEE MORE EVIDENCE IS WITH OLDER POPULATIONS. >> DO WE HAVE ANY DATA FROM ED HANES ABOUT WHAT THE CONTRIBUTION IN AVERAGE AMERICAN TO TOTAL PHYSICAL ACTIVITY IS FROM VIGOROUS, MODERATE AND LIGHT ACTIVITY? AND MAYBE ACROSS THE AGE SPAN? I MEAN, WE HAVE THOSE, RIGHT? >> THAT PAPER I USED, INCLUDED THOSE GRAPHS FOR LIGHT, MVPA, TOTAL AND SEDENTARY AND THE BIG CONCLUSION WAS THAT LIGHT AND SEDENTARY FLIP EACH OTHER OUT IN TERMS OF WHERE CHANGE OCCURS. >> WE DON'T EACH HAVE TO GO THAT FAR. IT'S JUST ACKNOWLEDGE TO THE READER THAT THERE IS THIS BIG THINKS SUPPOSURE THAT WE DON'T EVEN KNOW HOW -- WHATEVER. BUT -- EXPOSURE -- BUT CONTRIBUTE. #*Z. >> WHERE DO YOU WANT MVPA TO BE? TOP OR THE BOTTOM OF THIS FIGURE? TOP. OKAY. I DON'T KNOW HOW TO DO IT FOR CHILDREN BUT LET'S JUST SAY IT'S NOT A BIG PART. IT GOES ACROSS HERE AND IF WE ARE USING ABSOLUTE OR RELATIVE ESTIMATES HERE. RELATIVE ESTIMATES? >> YOU JUST KILLED ED HANES THEN. >> ABSOLUTE. >> WE HAVE THE ACCELEROMETER DATA SO YOU COULD DO THIS WITH THE ACCELEROMETER DATA THRESHOLDS TO BE DETERMINED. >> THIS WOULD BE DIFFERENT. THERE WILL BE MORE UPS AND DOWNS AND THEN, WE HAVE THIS OTHER TWO. I DON'T KNOW EXACTLY WHAT THESE THINGS WOULD LIKE LIKE, BUT HERE IS THE WAKING HOURS. AND WE HAVE SEDENTARY HERE. WE HAVE LIGHT HERE. AND WE HAVE MVPA HERE. SO THIS IS SOARED OF WHAT YOU'RE THINKING ABOUT? I THINK THAT WOULD BE A REALLY INTERESTING THING TO DO. >> BILL, I WANTED TO REMIND YOU WHAT PEDRO IS DOING. SO WE'LL GET A LITTLE BIT OF THIS AND THAT IS FOR EVERYBODY ELSE LOOKING AT ANALYSIS OF THE MORTALITY RELATIONSHIP WITH TOTAL ACTIVITY AND THEN THE CONTRIBUTION OF LIGHT AND MODERATE TO VIGOROUS. AND PART OF THAT IS TO LOOK AT HOW THE DIFFERENT COMBINATIONS ARE IN THERE. BUT WE CAN EASILY -- WE CAN -- I'LL TAKE OUT EASILY, PROVIDE SOME KIND OF A POPULATION DISTRIBUTION LIKE YOU'RE ASKING HERE. RECOGNIZING THAT IT WILL BE AN AVERAGE AND THAT OF COURSE ACROSS INDIVIDUALS IT IS REALLY DIFFERENT. >> TO BE HONEST, IT DOESN'T EVEN HAVE TO BE THAT ACCURATE. IT JUST HAS TO SHOW THE CONCEPT THAT THIS IS WHAT HAPPENS IN REAL AMERICANS. >> BILL, JUST TO FOLLOW-UP ON WHAT THE GOAL IS FOR THIS. IS IT TO SHOW -- HOW YOU BALANCE BETWEEN SHOWING WHAT PEOPLE ACTUALLY ACCOMPLISH -- DO, VERSUS WHAT IS RECOMMENDED. >> NOTHING TO DO ABOUT RECOMMENDED. THIS IS THE FACT THAT THIS IS WHERE WE ARE. THESE ARE REAL HUMANS. AND WE, THE GUIDELINES HAVE DEALT WITH THAT SLIVER UP THERE AT THE TOP UNTIL 2018. >> OKAY. >> AND NOW WE ARE STARTING TO RECOGNIZE THAT THERE IS SAY WHOLE SEDENTARY THING AND THAT THERE IS SAY CONTRIBUTION OF JUST MOVING. WE SAY SIT LESS, MOVE MORE. WE ARE DEALING WITH THAT 90% OF THE THING WE HAVEN'T EVEN -- THE GUIDELINES SAY IT BUT WE DON'T -- NOT GUIDELINES. OUR MESSAGES SAY IS IT BUT WE HAVEN'T EVEN DEALT WITH IT. AND YOU'RE TALKING ABOUT CREATING PLACES TO WALK? YOU'RE NOT REALLY TALKING ABOUT THAT SLIVER. YOU'RE TALKING ABOUT THAT PART RIGHT THERE. AND I THINK WE NEED TO RECOGNIZE IT. >> THERE IS ABOUT TO BE AN EXCEPTION HERE AND THAT IS UNDER 6. SO FOR THAT AGE GROUP, NOBODY HAS EVER THOUGHT THAT MODERATE TO VIGOROUS ACTIVITY MADE ANY SENSE AS A CONCEPT. SO THE DATA THERE ARE REALLY BASED ON TOTAL PHYSICAL ACTIVITY AS RELATED TO HEALTH OUTCOMES AND THAT HAS BEEN OPERATIONALLY DEFINED AS EVERYTHING ABOVE SEDENTARY. >> SO BILL, ARE YOU LOOKING AT WALKING JUST PLAIN WALKING, TOTAL STEP ACTIVITY? BECAUSE LOOKING AT TASMANIA COHORT STUDY FOR 5 YEARS THAT SHOWS LINEAR RELATIONSHIP BETWEEN PREDOMESTIC TERCOUNTED STEPS AND MORTALITY. AND WHEN YOU GET TO 10,000 STEPS, IT'S .5 FOR THE EFFECT SIZE. SO MAKE WE CAN MAKE SOME POINTS IF WE HAVE ENOUGH OF THAT INFORMATION, AND SOME OF THE NEW MATERIAL THAT RICK HAS ALLUDED TO TO BE ABLE TO SAY THAT WALKING AND MAYBE EVEN A LINEAR FASHION. AND A LOT OF PEOPLE DON'T THINK OF THAT AS JUST THE REGULAR EXERCISE. AND THAT YOU GET SAY DOSE OF THAT AND SOMETIMES IT IS LIGHT AND THIS IS TOTAL AND FREE-LIVING ADULTS. >> I JUST DON'T REMEMBER WHO I WAS TALKING TO YESTERDAY. EVERYBODY. BUT SOMEBODY WHO WAS INSTRUCTING ME THAT THE PART OF THIS MESSAGE ABOUT PARKING FURTHER FROM YOUR WORKPLACE WAS TO GET A BOUT OF MVPA INTO THE LIFESPAN. WELL, THAT'S NOT WHAT PEOPLE DO. THEY DO PARK FURTHER AWAY BUT THEY DON'T DO MVPA TO GET THERE. THEY STROLL ALONG WITH THEIR BAG AND -- BUT THAT -- THERE IS A HEALTH BENEFIT TO THAT BECAUSE YOU'RE NOT SITTING, RIGHT? AND WE ARE NOT ADDRESSING THAT PART. WE ARE NOT ADDRESSING -- WE HAVEN'T HAD THE PREVIOUS CAPABILITY TO DO IT BUT WE WILL HAVE THE CAPABILITY TO DO IT AND WE ARE STARTING TO GET THERE WITH OUR WITH OUR SCIENCE AND A VISUAL ABOUT THAT WOULD BE HELPFUL. >> I WANT TO BE CLEAR THAT ON WHAT THE SCOPE OF WHAT YOU'RE PROPOSING. ARE YOU LOOKING THAT THE AS PART OF THE PHYSICAL ACTIVITY OR THE ENERGY EXPENDITURE OF PHYSICAL ACTIVITY ON A DAILY BASIS? >> IT IS PART OF THE ENERGY EXPENDITURE OF PHYSICAL ACTIVITY ON A DAILY BASIS. >> I KNOW BUT THAT'S THE Y AXIS? >> TIME SPENT IN -- IN THE WAKING DAY. >> SO IS TIME -- SO -- >> YOU COULD DO ENERGY. >> IT COULD BE MODIFIED -- >> THE DIFFERENCE MAY BE IN WHAT PROPORTION THAT YOU HAVEN'T FACTORED IN TOTAL ENERGY EXPENDITURE. >> GRANTED. >> AND THAT IS NOT A TRIVIAL THING WHEN YOU LOOK ACROSS THE AGE DATA. >> I'M NOT LOOKING TO PUT REAL WHAT I'M DOING IS, CREATING A CARTOON OF WHAT THE LANDSCAPE LOOKS LIKE THAT WE ARE DEALING WITH IN THIS REPORT. >> YES, AND I THINK THIS IS SOMETHING WE CAN DO AND IT WOULD BE INTERESTING. THIS KIND OF FIGURE, I THINK IT IS JUST -- [ LOW AUDIO ] IT COULD BE MODIFIED TO DO WHAT WAYNE IS THINKING OF, RATHER THAN MINUTES IN EACH OF THESE ROWS. GIVE AN ESTIMATE. >> WE DOCK THAT QUITE EASILY IF WE USE TOTAL ACTIVITY COUNTIES AS THE METRIC. NOT ENERGY. DON'T TRANSLATE TO ENERGY. BUT LOOK AT TOTAL MOVEMENT AND WHAT PROPORTION OF TOTAL MOVEMENT COMES IN THESE. AND YOU CAN DO A TIME BUT IT LOOKS VERY DIFFERENT. >> AND JUST -- I MEAN, TO EMPHASIZE THAT, THE BENEFITS OF THAT FOR BLOOD SUGAR CONTROL, I MEAN, ARE ASTOUNDING. SO, IT'S AN AREA THAT WE IGNORED BUT FOR SOME THINGS, ESPECIALLY IN OLDER AGE, THAT'S WHERE THE BANG FOR THE BUCK IS JUST GETTING UP AND WALKING AROUND. MAYBE NOT FOR OTHER OUTCOMES BUT FOR BLOOD SUGAR WHICH LAST TIME I CHECKED, A LOT OF PEOPLE HAVE ISSUES WITH -- >> AND I THINK IN ADDITION TO BACKGROUND, IT WOULD -- SOME OF IT WOULD GO INTO OUR FUTURE RESEARCH DIRECTIONS AS WELL. >> I CAN GO BACK FOR A MOMENT TO WHEN WE WERE TALKING ABOUT SEDENTARY BEHAVIOR AND ITS RELATIONSHIP TO MODERATE TO VIGOROUS PHYSICAL ACTIVITY AND BOTH ECK LAND'S PAPER ANDILANCE, AND I JUST SKETCHED OUT A FAIRLY SIMPLE CURVE WHERE THIS MIDDLE LINE, A RELATIVE RISK OF WOMB, THIS IS THE TRADITIONAL ALL CAUSE MORTALITY CURVE THAT WE HAVE BEEN DRAWING A LOT. NOW, THE WAY THAT THE GROUP DID THEIR ANALYSIS, THEY DID IT SO THAT WHAT I HAVE DRAWN HERE ISN'T WHAT THEY DID. THEY COULD HAVE DONE IT THIS WAY BUT THEY DIDN'T. AND WE HAD SOME DISCUSSIONS IN THE SEDENTARY COMMUNITY. SENT THEM AN E-MAIL AND SAID, AND IT TURNS OUT HE COULDN'T BECAUSE THESE CALCULATIONS HAD BEEN MADE BY ALL THE INDIVIDUAL PEOPLE CONTRIBUTING. ALSO SUGGESTED, I THOUGHT, LOOK, WE CAN JUST TURN HIS RISK ESTIMATES ON THEIR HEAD. AND THEN WE CAN DO THIS. AND HE SAID, FROM A STATISTICAL PERSPECTIVE, THAT IS ILLEGAL. >> WE DID IT ANYWAY. >> YOU JUST NEED TO ASK A DIFFERENT STATISTICIAN. >> BUT THAT'S WHAT I HAVE DONE HERE. I DID THAT ANYWAY. AND IF YOU DO THAT, THIS IS THE SORT OF THING THAT YOU GET. YOU TAKE THE GROUP THAT SITS THE MOST, AND AT THE VERY BEGINNING, THEIR RELATIVE RISK IS ACTUALLY HIGHER THAN THE AVERAGE RISK FOR THAT WHOLE GROUP. THAT IS NOT SURPRISING. THAT IS WHAT YOU EXPECT. AND THEN IT DROPS DOWN AND IN HIS ANALYSIS, IT DOES EVENTUALLY GET QUITE CLOSE HERE. AND HERE IS THE LEAST SEDENTARY GROUP AND THEY ARE GOING TO START OFF DOWN HERE AND WORK THEIR WAY OVER TO ESSENTIALLY THE SAME PLACE. >> SO, I LIKE THAT BUT, I JUST WANT TO MAKE SURE THAT THE ACCELERATED RISK IN THOSE THAT ARE THE LEAST ACTIVE AND SILT THE MOST, COMES OUT REALLY CLEAR. BECAUSE RIGHT THERE IT LOOKS PROPORTIONAL. AND -- >> [ OFF MICROPHONE ] >> IT'S NOT PROPORTIONAL. IT'S A CURVE, LINEAR ACCELERATION IN THOSE PEOPLE, AND AGAIN, I KNOW YOU CAN DO THAT BY FLIPPING BUT IF YOU LOOK AT THE CURVES, IT'S REALLY CLEAR AND ESPECIALLY WITH TELEVISION VIEWING. I THINK THAT IS SAY POINT THAT REALLY NEEDS TO BE EMPHASIZED. >> [ OFF MICROPHONE ] >> NOT A LINEAR KIND OF THING. IT GOES ACROSS. AND THE LEAST ACTIVE QUARTILE WITHIN THAT LEAST ACTIVE QUARTILE, THE RISK ASSOCIATED WITH INCREASING LEVELS OF SITTING -- IT'S NOT LIKE IT FLIES UP -- THAT IS AN IMPORTANT PUBLIC HEALTH ISSUE. >> MY INTENTION IS NOT TO MISREPRESENT THE DATA AND IF I HAVEN'T DONE IT WELL ENOUGH, MAYBE WE CAN TALK ABOUT THIS MORE AND FIGURE OUT HOW TO DO IT SO THAT IT PRESENTS THE CONCEPTS THAT YOU'RE TALKING ABOUT. >> ONE SMALL POINT IS THAT AS THESE GRAPHS ARE LAID OUT, IF WE HAVE A SIMPLE WAY OF PUTTING WHERE MOST AMERICANS FIT ACCORDING TO AAH, IT WOULD MAKE AN IMPACT GREATER IMPACTFUL IMPRESSION ON WHAT THEY MAY NEED TO DO TO CHANGE THINGS. >> I REALLY LIKE THAT, RICH. >> I THINK WHAT I'M GOING SAY IS NOT DIFFERENT THAN WHAT LORETTA SAID. BUT IN THIS CONTEXT, I LIKE PRESENTING THIS FROM THE PERSPECTIVE OF WHERE PEOPLE ARE ON THE ACTIVITY CONTINUUM. I THINK THE POINT IS, WHERE YOU DON'T WANT TOOK IS LOW ACTIVE AND HIGH SEDENTARY. SO, SEDENTARY SEEMS TO MATTER ACROSS THE ACTIVITY CONTINUUM BUT IT MATTERS PARTICULARLY WHEN YOU'RE BELOW THE PHYSICAL ACTIVITY GUIDELINE LEVEL. >> ONE, WE NEED TO BE SURE -- [ LOW AUDIO ] >> MAYBE THAT'S DONE BETTER A MATRIX. >> ARE THEY QUARTILES OF ACTIVITY AND SEDENTARY? ARE THEY QUARTILES? OF THE PHYSICAL ACTIVITY? ARE THEY TERTILES? -- [ OFF MICROPHONE ] >> BUT HOW MANY GROUPS? LET'S JUST SAY IT'S FOUR TO START WITH. YOU GOT 4 BY 4 MATRIX. YOU GOT SEDENTARY. YOU GOT HIGH SEDENTARY,. LET'S PULT THEM OVER HERE. AND THEN YOU GOT LOW PHYSICAL ACTIVITY AND HIGH. SO HIGH IS HERE.& AND THEN -- LET'S JUST DO THIS FOR NOW. THE IDEA IS THEN YOU COULD PUT THE RELEVANT RISKS AND SET STANDARDS FOR WHEN YOU'RE ABOVE OR BELOW WHAT COLOR YOU MAKE. SO YOU HAVE HIGH SEDENTARY, LOW PHYSICAL ACTIVITY. THAT WILL BE -- I SEE WHAT YOU'RE SAYING. LET'S DO THIS FOR NOW. THIS WILL BE VERY RED. AND THEN, HIGH PHYSICAL ACTIVITY AND LOW SAID WILL BE VERY GREEN AND YOU CAN COLOR IT. SO YOU DON'T WANT TO BE HERE. YOU WANT TO BE HERE. AND THEN YOU CAN MAKE THAT MESSAGE CLEARER THAT WAY. YOU CAN MAYBE THE SIDES OF THE BOXES PROPORTIONAL. -- MAKE. PROPORTIONAL TO THE MEMBERSHIP IN THAT BOX. SO THIS WOULD BE VERY BIG AND THIS WOULD BE VERY SMALL. >> WE NEED A GRAPHIC DESIGNEDDER IN TO HELP US. BUT I THINK THE CONCEPT IS REALLY GOOD. IT'S LIKE THE PROPORTIONAL MAPS OF THE WORLD WHERE WHERE IS THE MOST CANCER AND YOU SEE THE DISPROPORTIONATE. >> WE HAVE 5 MINUTES LEFT WE CAN USE IF WE WANT TO. ANYBODY GOT ANOTHER FIGURE THEY WANT TO PUT UP HERE? A NEW CONCEPT? >> I JUST HAVE A GENERAL CONCEPT. THIS IS WONDERFUL. IT ILLUSTRATES A WONDERFUL COMMENT AND CONCEPT AND MAINLY COHORT DATA. THIS IS IT RANDOMIZED TRIALS AND FIGURES APPROPRIATE TO SUMMARIZE IT AS WELL SO WE CAN BRING OUT THAT DATA WHICH WE WANT TO. >> THIS HAS BEEN A REALLY -- REALLY FINE MEETING. DID YOU RECEIVE THE FIGURE? [ LAUGHS ] OKAY. >> DO WE NEED TO HAVE OUR OFFICIAL PEOPLE CLOSING THE MEET ING? >> A FINE MEETING. THANKS TO EVERYONE FOR YOUR THOUGHTFUL COMMENTS AND SUGGESTIONS AND CREATED ACTIVITY. IT'S REALLY GREAT. WHO IS GOING TO FORMERLY CLOSE. >> BEING ADJOURNED, YOU WILL CONVENE AGAIN THE THIRD WEEK OF OCTOBER.