American Fitness Index

Frequently Asked Questions – ACSM American Fitness Index™

Q: What is the ACSM American Fitness Index™?
The ACSM American Fitness Index™ (AFI) is a program, created in partnership with the WellPoint Foundation, to improve community fitness, health and quality of life for all Americans by promoting and encouraging a physically active society.

The program features a data report that ranks and assigns a score to the 50 most populous metropolitan areas in the United States. The AFI data report reflects a composite of preventive health behaviors, levels of chronic disease conditions, health care access, as well as community resources and policies that support physical activity. In addition to a data report, AFI is a program designed to help communities identify opportunities to improve the health of their residents and expand community assets to better support active, healthy lifestyles.

The program links communities, government agencies, health promotion groups, health care providers, and others with best practices and partner organizations to improve a community’s score/rank.

Q: Why was the ACSM American Fitness Index™ created?
ACSM created the ACSM American Fitness IndexTM (AFI) program to help communities identify opportunities to improve the health of their residents and expand community assets to better support active, healthy lifestyles.

The overall goal of the ACSM American Fitness Index™ program is to improve the health, fitness and quality of life of citizens through promoting physical activity and healthier lifestyles.

Q: What does the ACSM American Fitness Index™ data report measure?
The AFI data report reflects a composite of community indicators for preventive health behaviors, levels of chronic disease conditions, access to health care, community supports and policies for physical activity. In addition, demographic and economic diversity, and levels of violent crime are shown for each metropolitan area. A complete breakdown of the data is available in the data report.

Q. What makes this study unique? How is this study different?
The AFI program is unique for several reasons:

Cities, communities and metropolitan areas are defined by Metropolitan Statistical Areas (MSA) of the U.S. Census Bureau;
Personal health status indicators, as well as community and environmental indicators, are included in the AFI data report;
Data from reputable sources and scientific methodology were used to develop the AFI data report to increase its validity and reliability;
To help guide community action, areas of strength for each MSA, such as lower smoking rates, are shown, along with opportunities for improvement, such as including more playgrounds per capita;
Materials, resources, and connections to health promotion partners, provided by the AFI program, are designed to help communities improve their indicators; and
Local, state, and national health promotion partners are forming a network to support collaborative program efforts.

Q: What is a MSA (Metropolitan Statistical Area)?
According the U.S. Census Bureau, the United States Office of Management and Budget (OMB) defines metropolitan statistical areas (MSAs) according to published standards that are applied to Census Bureau data. The general concept of a MSA is that of a core area containing a substantial population nucleus, together with adjacent communities having a high degree of economic and social integration with that core.

Each metropolitan statistical area must have at least one urbanized area of 50,000 or more inhabitants. If specified criteria are met, a MSA containing a single core with a population of 2.5 million or more may be subdivided to form small groupings of counties referred to as “metropolitan divisions.”

The largest city in each MSA is designated a “principal city.” Additional cities quality if specified requirements are met concerning population size and employment. The title of each MSA consists of the names of up to three of its principal cities and the name of each state into which the MSA extends. Titles of metropolitan divisions also typically are based on principal city names but in certain cases consist of county names.

Q: Why use MSAs (Metropolitan Statistical Areas)?
Defining a “city” by its city limits overlooks the interaction between the core of the city and the surrounding suburban areas. Residents outside the city limits have access to fitness-related resources in their suburban area as well as the city core; likewise, the residents within the city limits may access resources in the surrounding areas. Thus, the metropolitan area, including both the city core and the surrounding suburban areas, act as a unit to support the wellness efforts of residents of the area. In this report, the terms metropolitan area, community and city are synonymous.

Q: What is the difference between a city, a metropolitan area and a community?
For the purpose of the American Fitness Index, the data report evaluates Metropolitan Statistical Areas (MSAs) according the U.S. Census Bureau. An MSA can also be referred to as a “community” and/or a “city.” If referred to by city, the report is referencing the entire MSA or metro area, but uses the name of the largest principal city. For example, Atlanta is the principal city of the Atlanta-Sandy Springs-Marietta MSA. The Atlanta community and the nickname Metro Atlanta refer to the Atlanta-Sandy Springs-Marietta MSA.

Q: Why do we need another study to tell us to get more active?
A better understanding of the prevalence rates for physical activity, obesity, and chronic disease related to physical inactivity as well as the communities’ built environment and resources are needed to approach the physical inactivity and obesity epidemic using a public health systems approach.

Moving a community toward increasing physical activity and improving community fitness involves an understanding of the individual and societal behaviors and social norms related to physical activity. The key fundamentals for improving physical activity behaviors involve increasing awareness and motivation at the personal level, providing a built environment and resources that encourage physical activity, as well as setting policies to better enable individuals and communities to engage in physical activity as part of a healthier lifestyle. Researching and understanding the scope of the problem is the first step toward developing programs, initiatives, and policies to increase physical activity, which would ultimately result in a reduction of the prevalence rates of obesity and other chronic diseases.

Q: What is WellPoint, Inc.’s involvement in the American Fitness Index™?
The ACSM American Fitness Index™ program is funded by the WellPoint Foundation, which is committed to improving the health of communities through health and wellness initiatives. The AFI program expands on WellPoint Inc.’s State Health Index which tracks key indicators of public health to underscore its commitment to driving measurable improvements in the health of the communities it serves.

Q: How were the data elements used in the Index decided upon?
The first step in creating the data report for the AFI program involved developing a strategy to gather, analyze and present metro-level population, health, and built environment data. Data were identified, assessed and scored by a national expert panel for inclusion into an index to compare each metro areas’s attributes with the U.S. values and with the other large metropolitan areas.

Elements included in the data index must:

Be related to the level of health status and/or physical activity for a community;
Have recently been measured and reported by a well respected agency or organization at the metropolitan level; and
Be modifiable through community effort (for example, “smoking rate” is included, but “climate” is not).

Publicly available data sources from federal reports and past studies provided the information used in this version of the data index. To be incorporated in the development of the index, the selected data sources must provide recent data and have an established history of appropriately collecting and disseminating the data.

Q: From what sources were the data derived?
Publicly available data sources from federal reports and past studies provided the information used in this version of the data index. The largest single data source for the personal health indicators was the Selected Metropolitan/Micropolitan Area Risk Trends Behavioral Risk Factor Surveillance System (SMART BRFSS). Through an annual survey, conducted by the Center for City Park Excellence the Trust for Public Land provided many of the Community/Environmental Indicators, and the U.S. Census American Community Survey was the source for most of the MSA descriptions. The U.S. Department of Agriculture; State Report Cards (School Health Policies and Programs Study by the CDC); the Health Resources and Services Administration’s (HRSA) Area Resource File; and the Federal Bureau of Investigation’s (FBI) Uniform Crime Reporting Program also provided data used in the MSA description and index. In all cases, the most recently available data (typically 2007) were used.

Q: Are there future plans for American Fitness Index™ program?
This version of the AFI data report incorporates the many valuable suggestions and comments ACSM received after the pilot phase release in 2008 and the first full version introduced in 2009.

The long-range vision for the AFI program is to provide annual updates to the rankings so communities can monitor their progress in improving health and active living fitness indicators.

Future versions will included refined data points.

Additionally, the AFI program will assist U.S. communities …

By creating unique partnerships and alliances at the national and local levels.
By providing tools, strategies and expertise to communities interested in making progress toward improved health, fitness and quality of life.
By connecting scientific knowledge with practices and policies that work.

Q: Why is my community not included in the report?
The AFI data report ranks and scores the 50 largest metropolitan areas in the United States. This is a significant expansion from the 16 MSAs included in the pilot phase in 2008. At this time, the program does not have definitive plans to measure additional MSAs in future versions of the report.

ACSM recognizes that numerous other U.S. cities and their surrounding communities are taking great steps toward improving their community health. All cities can use the resources provided by AFI to improve their community’s health and fitness. Additionally, the AFI has been designed so that any community, regardless of size, could locate the publicly available indicators and derive an assessment of their community’s health and fitness.

Q: Is the American Fitness Index a competition?
No, the ranking merely points out that relative to each other, some metro areas scored better on the indicators than the other. While ACSM recognizes that there will be a natural tendency to view comparisons as a competition, the AFI was created for communities to assess their level of health and fitness, assess areas that could use improvement, and to increase their scores over time.

In the AFI data report, it is important to consider both the score and rank for each city. While the ranking lists the MSAs from the one with the highest score to the one with the lowest, the scores for many cities are very similar, indicating that there is relatively little difference between them.

Letter “grades,” which are often used to indicate a range from “excellence” to “failures,” were not assigned to the MSAs based on their score. While one metro area carried a rank of “1” and another carried a rank of “50,” this does not necessarily mean that the highest city has excellent values across all indicators and the lowest ranked city has failed the indicators.

Q: What is ACSM?
The American College of Sports Medicine is the largest sports medicine and exercise science organization in the world. More than 20,000 international, national, and regional members are dedicated to advancing and integrating scientific research to provide educational and practical applications of exercise science and sports medicine.

Q: What components does AFI measure and why?
A panel of 26 health and physical activity experts scored potential elements for relevance in the ACSM American Fitness Index™. Two Delphi Method-type rounds of scoring were used to reach consensus on whether each item should be in the data index and, if so, the weight it should carry.

The following chart lists each of the components that make up the ACSM American Fitness Index™ and why that indicator is included.

ACSM American Fitness Index™ Components
Personal Health Indicators
	Health Behaviors
		Percent any physical activity or exercise in the last 30 days	Regular exercise is important for optimal health and fitness.
		Percent physically active at least moderately	ACSM recommends that all healthy adults ages 18 to 65 years need moderate-intensity aerobic physical activity for at least 30 minutes on five days each week or vigorous-intensity aerobic physical activity for at least 20 minutes on three days each week
		Percent eating 5+ fruit/vegetables per day	The CDC recommends a daily intake of 5 or more fruits and vegetables for optimal health and fitness.
		Percent currently smoking	Smoking is harmful to one’s health and can lead to a variety of diseases including cardiovascular disease.

	Chronic health problems
		Percent obese	Obesity is a precursor to as asthma, diabetes and cardiovascular disease.
		Percent in excellent or very good health	Individuals answering yes to this criteria are more likely to exercise regularly and eat healthier foods.
		Any days when physical health, was not good during the past 30 days	Individuals answering yes to this criteria are less likely to exercise regularly.
		Any days when mental health, was not good during the past 30 days	Individuals answering yes to this criteria are less likely to exercise regularly and eat healthier foods.
		Percent with asthma	Individuals with asthma are at risk for obesity.
		Percent with angina or coronary heart disease	Individuals with angina or coronary heart disease are at risk for obesity.
		Percent with diabetes	Individuals with diabetes are at risk for obesity.
		Death rate/100,000 for cardiovascular (CV) disease	Provides an estimate of how this disease impacts a community. The second measure of CV disease helps reinforce the “percent with angina or coronary heart disease” figure.
		Death rate/100,000 for diabetes	Provides an estimate of how this disease impacts a community. The second measure of diabetes helps reinforce the “percent with diabetes” figure.

	Health care
		Percent with health insurance	Individuals with health insurance are more likely to have access to affordable health care.

Community/Environmental Indicators
	Built Environment
		Parkland as a percent of MSA land area	Indicates that there is a safe and affordable place for the community to be physically active.
		Acres of parkland/1,000	A second measure of safe and affordable places to be physically active.
		Farmers’ markets/1,000,000	Assumes individuals have access to the freshest fruits and vegetables with the most vitamins and nutrients.
		Percent using public transportation to work	Individuals have to walk to and from stops and stations. Fewer automobiles also make for improved air quality.
		Percent bicycling or walking to work	These activities indicate an individual gets regular exercise.

	Recreational Facilities
		Ball diamonds/10,000	Access to safe places to be physically active.
		Dog parks/10,000	Assumes the owner walks with their dog.
		Park playgrounds/10,000	Access to safe places to be physically active.
		Golf courses/100,000	Access to safe places to be physically active.
		Park units/10,000	Access to safe places to be physically active. More small parks indicate these areas are available to more of the community.
		Recreation centers/20,000	Access to safe places to be physically active.
		Swimming pools/100,000	Access to safe places to be physically active.
		Tennis courts/10,000	Access to safe places to be physically active.

	Park-related Expenditures per Capita		Indicates that a community is providing a safe and affordable place to be physically active. Community is also keeping these areas well maintained.

	Level of State Requirement for PE classes		This is a reflection on the community’s public policy towards the promotion of physical activity.

	Number of primary care providers per 100,000		Citizens are more likely to have access to a primary care provider for maintenance and preventative care.