Abstract
In spite of the numerous health promotion and disease prevention benefits of physical activity, national surveillance indicates that many American adults, adolescents, and children are not engaging in enough physical activity to achieve these health benefits. The National Physical Activity Plan (NPAP) was created as a "roadmap" to identify policies, practices, and initiatives that will increase population levels of physical activity to the national U.S. standards. The plan includes recommended strategies focused on nine sectors, and each sector presents strategies and tactics aimed at promoting physical activity. Organizational NPAP partners include federal agencies, advocacy agencies, nonprofit organizations, and professional organizations. Recognizing the importance of a strategic plan to improve population physical activity rates in the United States can help facilitate state and local implementation of the NPAP as well as encourage individuals to adopt and maintain a physically active lifestyle, both of which could yield large-scale declines in the prevalence and incidence of noncommunicable diseases.
Relationship to Existing APHA Policy Statements
APHA Policy Statement 9709: Promoting Public Health Through Physical Activity
- APHA Policy Statement 20044: Creating Policies on Land Use and Transportation Systems that Promote Public Health
- APHA Policy Statement 20058: Supporting the WHO Global Strategy on Diet, Physical Activity and Health
- APHA Policy Statement 200619: Urgent Call for a Nationwide Public Health Infrastructure and Action to Reverse the Obesity Epidemic
- APHA Policy Statement 20079: Building a Public Health Infrastructure for Physical Activity Promotion
- APHA Policy Statement 201514: Building Environments and a Public Health Workforce to Support Physical Activity Among Older Adults
- APHA Policy Statement 20137: Improving Health and Wellness through Access to Nature
- APHA Policy Statement 20121: Supporting the National Physical Activity Plan
Problem Statement
Physical activity plays an important role in population health.[1] There is strong evidence to support the association between physical activity and all-cause mortality.[2] Physical activity improves cardiorespiratory health,[3–5] contributes to metabolic[4,6] and musculoskeletal health,[4,7] helps prevent the development of breast and colon cancers,[4] and helps improve mental health.[4,8–12]
However, national surveillance indicates that many American adults do not engage in enough physical activity to achieve these health benefits. In 2015, 51.3% of U.S. adults met the target of 150 minutes of aerobic physical activity per week, and 30.2% engaged in muscle strengthening exercises on at least 2 days per week.[13] Only 20.3% of U.S. adults met both the aerobic and muscle strengthening guidelines.[13] Furthermore, 48.6% of adolescents in grades 9–12 reported participating in 60 minutes of physical activity on at least 5 days in the previous week, with 14% reporting no physical activity in the past 7 days.[14] The United States was assigned a grade of D on the 2016 U.S. Report Card on Physical Activity for Children and Youth for the proportion of children and young people attaining 60 minutes or more of moderate to vigorous physical activity on at least 5 days each week.[15]
There are also disparities in physical activity prevalence among population subgroups. In 2015, 22% of White U.S. adults achieved the physical activity guidelines for both aerobic and muscle strengthening activity, along with 22% of Black adults and 16.8% of Hispanic adults.[16] Non-White populations consistently report lower levels of physical activity and less access to places to engage in physical activity.[17] Lower educational attainment is associated with higher proportions of physical inactivity,[18,19] and people with disabilities are less likely to engage in physical activity than those without disabilities even though the two groups have similar needs to improve their health and prevent disease.[20]
Low levels of physical activity lead to high health care costs and have a negative impact on workplace productivity. One in 10 premature deaths could be prevented if individuals met the national physical activity recommendations.[21] In addition, bicycle commuting three times per week is linked to 46% lower odds of metabolic syndrome, 32% lower odds of obesity, and 28% lower odds of hypertension.[22] The financial returns in terms of workplace absenteeism and medical benefits are positive when worksite health promotion programs aimed at increasing physical activity are implemented.[23]
Subsequent to the launch of the original National Physical Activity Plan (NPAP) in 2010, advances in physical activity promotion at the state and local levels have been made.[24] For example, the state of West Virginia and the city of San Antonio, Texas, developed physical activity plans based on the NPAP. Also, the NPAP has informed 42 proven programs across multiple societal sectors,[25] but significant work can be done to influence lawmakers on the importance of physical activity in public health.[26]
Evidence-Based Strategies to Address the Problem
In 2008, the U.S. Department of Health and Human Services released the Physical Activity Guidelines for Americans to support improvements in population health.[4] The NPAP was developed in May 2010[27] and updated in April 2016 to help increase population physical activity levels to the guidelines standards. The NPAP provides a clear roadmap for policies, practices, and initiatives that support short- and long-term progress in increasing physical activity levels[27,28] and it has been updated with particular attention to addressing vulnerable and at-risk populations.[15] The NPAP aligns with the 2011 National Prevention Strategy and includes active living as one of its priorities.[29] The U.S. Department of Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities also outlines physical activity promotion goals, strategies, and actions that increase noncommunicable disease prevention efforts.[30]
The 2016 NPAP identifies nine sectors (the 2010 plan had eight sectors), each of which includes several recommended strategies based on the newest evidence, emerging evidence, or best practices to promote physical activity.[15,28] Each sector also includes a brief description of changes made and successes experienced between the 2010 and the 2016 NPAP.
Public health: The first five strategies in this category remain unchanged in the 2016 NPAP, but a sixth strategy has been added to reflect the evolving role of public health in promoting physical activity. The five remaining strategies are to (1) develop a competent workforce with ethnic, cultural, and gender diversity; (2) leverage partnerships and coalitions to implement evidence-based strategies to promote physical activity; (3) expand and monitor policy and advocacy efforts to prioritize physical activity in public health practice, policy, and research; (4) improve surveillance and evaluation of physical activity programs; and (5) disseminate tools for physical activity programs and initiatives. The new strategy added in 2016 is to invest in physical activity commensurate with its impact on disease prevention and health promotion. Within each strategy, there are specific tactics to identify and engage with underserved populations and communities of diverse racial, ethnic, and cultural backgrounds.
Health care: A number of health care–based initiatives have emerged since the 2010 NPAP. For example, one strategy is to make physical activity a patient "vital sign." Since 2010, the Centers for Disease Control and Prevention has released two physical activity–related vital signs reports: More People Walk to Better Health (2012) and Adults with Disabilities (2014). Programs such as Walk with a Doc and Exercise is Medicine® have continued to grow and to enhance efforts to promote physical activity. This sector has been reduced from six strategies to four: (1) prioritize health care efforts to assess and promote physical activity; (2) recognize physical inactivity as a preventable and treatable condition; (3) develop diverse partnerships to improve access to physical activity–related services, particularly for disadvantaged populations with limited health care access; and (4) expand education on physical activity in training health care professionals.
Education: Education settings (i.e., preschool, K–12, and postsecondary education) have the capacity to strongly influence health. In the process of revising the NPAP, many of the original seven strategies listed were viewed as tactics of new, broader strategies. The 2016 NPAP also references the new federal education policy, the Every Student Succeeds Act, as an important vehicle to ensure that physical education is part of a “well-rounded” education. New strategies emphasize the development of physical activity programs that are safe, developmentally and culturally appropriate, and inclusive of all populations. The seven new strategies are as follows: (1) adopt policies that support implementation of the Comprehensive School Physical Activity Program, (2) provide high-quality physical education programs, (3) encourage after-school programs to adopt policies and practices that ensure participants are physically active, (4) adopt physical activity standards for child-care and early childhood education programs, (5) promote opportunities and incentives for college students and staff to adopt an active lifestyle, (6) provide educators with professional development opportunities so that they can deliver effective physical activity programs to students, and (7) develop policies that promote physical activity among all students.
Transportation, land use, and community design: The 2016 NPAP emphasizes creation of land use, community, transportation, and economic development projects that improve the environments of low-income and rural community residents. Strategies were adjusted to reflect recent support from the National League of Cities and Let’s Move Cities and Towns. The 2016 NPAP strategies in this category include (1) integrating active design principles into the community planning process; (2) adjusting zoning laws to favor mixed-use developments that encourage physical activity; (3) advocating for funding and policies that increase active transport and physical activity; (4) investing in data collection to inform policies and measure the effects of active transportation on physical activity, population health, and health equity; and (5) implementing initiatives to encourage and reward active transportation.
Community, recreation, fitness, and parks: This sector was previously titled "community, recreation, fitness, and sports" in the 2010 NPAP. The name change better captures growing evidence associated with physical activity improvements and access to parks and green spaces. The 2016 NPAP encourages interdisciplinary partnerships to propel improvements in the safety and security of facilities in low-resource, geographically isolated, and high-crime communities. The number of strategies has been reduced from six to five: (1) improve availability of and access to safe facilities and affordable community recreation programs, (2) develop and enhance physical activity programs for diverse users across the life span, (3) recruit and train a diverse cadre of parks and recreation staff and volunteers, (4) advocate for increased and sustainable funding to create or enhance physical activity facilities and services in areas of high need, and (5) improve monitoring and evaluation of participation in community-based physical activity programs.
Business and industry: The 2016 NPAP addresses the broader role of business and industry leaders with respect to the health of employees and their families. Emphasis is placed on developing and using surveillance systems that monitor both employee physical activity levels and workplace wellness programs, in addition to supporting the needs of employees of diverse socioeconomic, racial, and ethnic backgrounds. This sector’s strategies are as follows: (1) provide employees with opportunities to adopt and maintain an active lifestyle, (2) foster diverse partnerships to promote physical activity in the workplace and the community at large, (3) encourage practitioners and researchers to help build a business case for investments in physical activity promotion at worksites, (4) encourage professional and scientific societies to develop and advocate for policies that promote physical activity in workplace settings, and (5) use evidence-based surveillance systems to monitor workplace wellness programs and employee physical activity.
Faith-based settings: This sector is an exciting new addition to the 2016 NPAP. Faith-based settings are well positioned to use their internal social systems and facilities to support physically active lifestyles. The six strategies of this sector are to (1) include physical activity promotion in health ministries; (2) collaborate with diverse partners to promote physical activity in a manner consistent with a congregation’s values, beliefs, and practices; (3) institutionalize physical activity programs for faith-based employees; (4) develop marketing materials about physical activity tailored to faith community leaders; (5) collaborate with diverse organizations to develop and deliver accessible and tailored physical activity programs for diverse constituents; and (6) maintain a repository of evidence-based programs and best practices for promoting physical activity in faith-based settings.
Mass media: This 2016 NPAP sector strongly underscores strategic and collaborative development of a national physical activity promotion campaign and highlights the importance of communicating with mass media professionals and key decision makers (business leaders, elected officials) about the benefits of physical activity. The new NPAP eliminates redundancy and stresses a coordinated, streamlined approach by reducing the number of strategies from eight to four: (1) develop a national physical activity campaign, (2) establish a standardized brand for promoting physical activity, (3) educate media professionals about the effects of physical activity on health, and (4) optimize the application of both traditional and new media. The overarching goal is to promote efficient and effective use of diverse media outlets as a means of influencing health behaviors at the community, state, and national levels.
Sports organizations: In the 2010 NPAP, sports were included as part of the “parks, recreation, and fitness” sector. Sports organizations became a stand-alone sector in the 2016 NPAP because they represent a powerful opportunity to make progress in youth and adult physical activity levels. In the United States, more than 200 million young people and adults participate in some form of sports.[31] This sector’s eight strategies are to (1) establish a national policy that emphasizes the importance of sports as a vehicle for promoting and sustaining physical activity; (2) establish a central resource to unify and strengthen stakeholders in the sports sector; (3) expand access to recreational spaces and sports programs while eliminating disparities in access based on race, ethnicity, gender, disability, socioeconomic status, geography, age, and sexual orientation; (4) encourage sports organizations to adopt policies and practices that promote physical activity and physical literacy; (5) ensure the safety and care of sports participants; (6) improve surveillance systems to monitor sports participation; (7) ensure that parents, coaches, and sport program personnel create an inclusive environment for participation among all people; and (8) find creative ways to integrate technology to enhance the quality of the sports experience for participants.
Opposing Arguments/Evidence
Opposition to the NPAP may come from fiscal conservatives who believe that spending tax dollars to promote physical activity is not a financial priority. While physical activity promotion may not lead to immediate economic benefits, there is vast potential for future savings from reduced health care costs related to conditions for which physical inactivity is a known risk factor, such as cardiovascular disease, diabetes, obesity, and cancer. For example, a recent study in Minnesota showed that bicycle commuting prevents 12 to 61 deaths each year, saving $100 million to $500 million annually.[22] An estimated 11% of U.S. healthcare expenditures ($131 billion) are attributable to physical inactivity.[32] In addition, an estimated $5.6 billion in costs associated with heart disease would be saved if 10% of U.S. adults began a walking program.[21] Estimates indicate that if 50% of elementary school students in the United States participated in 25 minutes or more of physical activity 3 days per week, this would avoid $21.9 billion in medical costs and lost wages over the course of their lifetimes.[33] It is also worth noting that physical inactivity is recognized by the U.S. Department of Defense as a threat to military readiness and national security.[34,35]
Others may oppose the plan because they believe that active living is a matter of personal choice. This controversy represents the fundamental dispute between the role of the individual and the role of society in health promotion. Research has endorsed an ecological model that underscores the complexities of behavior change and describes the various factors that influence individual behavior across various domains, including government policies and programs.[36] For example, use of public transit is associated with increased walking and biking,[37] and enhancements of public transit systems could encourage more walking.[38] Studies have also shown that park access and availability of related programming are associated with greater physical activity.[39] Communicating costs and disseminating evidence to stakeholders can aid in promoting physical activity as an ongoing health priority.
Action Steps
The proposed action steps are designed to be culturally responsive to all groups, including underrepresented and underserved populations. APHA urges:
- The NPAP Alliance and the NPAP Board of Directors to continue reviewing and updating the NPAP at least every 5 years. In addition, the NPAP should incorporate new strategies and/or tactics that create environments limiting sedentary time to demonstrate the relationship between prolonged sedentary time (i.e., 6 continuous hours of sitting) and health (independent of physical activity level).
- Leaders within each sector identified in the NPAP to collaborate and share their expertise and resources with one another as a means of catalyzing physical activity promotion efforts in high-poverty neighborhoods to improve population health outcomes.
- Leading researchers to collaborate with the U.S. Department of Health and Human Services and the Centers for Disease Control and Prevention to establish a comprehensive surveillance system to monitor compliance with physical activity guidelines and the status of environments, policies, and programs designed to promote physical activity.
- The U.S. Department of Health and Human Services to take the lead in developing and disseminating a comprehensive physical activity report card that evaluates the status of physical activity and physical activity promotion efforts in the United States.
- Practitioners and private and public policymakers to create physical activity plans and policies at the local, state, and national levels.
- Federal agencies to collaborate with nonprofit and for-profit media agencies to launch a physical activity campaign coordinated with state and local resources to guide Americans toward effective behavioral strategies and programs for increasing physical activity.
- Congress and leaders within each sector identified in the NPAP to advocate for increased funding to implement the physical activity promotion strategies identified in the NPAP.
- Signatory partners that supported APHA’s Promote Healthy Communities Joint Call to Action to collaborate with APHA in implementing this policy at the local, state, and national levels.
References
1. Centers for Disease Control and Prevention. Guide to community preventive services—promoting physical activity: environmental and policy approaches. Available at: https://www.thecommunityguide.org/. Accessed December 30, 2017.
2. U.S. Department of Health and Human Services. Physical Activity Guidelines Advisory Committee Report. Washington, DC: Office of Disease Prevention and Health Promotion; 2008.
3. Swain DP, Franklin BA. VO(2) reserve and the minimal intensity for improving cardiorespiratory fitness. Med Sci Sports Exerc. 2002;34:152–157.
4. 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services; 2008.
5. Williams MA, Haskell WL, Ades PA, et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update—a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;116:572–584.
6. Lakka TA, Laaksonen DE. Physical activity in prevention and treatment of the metabolic syndrome. Appl Physiol Nutr Metab. 2007;32:76–88.
7. Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2008;7:CD000333.
8. Beard JR, Heathcote K, Brooks R, Earnest A, Kelly B. Predictors of mental disorders and their outcome in a community based cohort. Soc Psychiatry Psychiatr Epidemiol. 2007;42:623–630.
9. Lubans DR, Plotnikoff RC, Lubans NJ. A systematic review of the impact of physical activity programmes on social and emotional well‐being in at‐risk youth. Child Adolesc Ment Health. 2012;17:2–13.
10. Johnson KE, Taliaferro LA. Relationships between physical activity and depressive symptoms among middle and older adolescents: a review of the research literature. J Specialists Pediatr Nurs. 2011;16:235–251.
11. Stanton R, Happell BM. An exercise prescription primer for people with depression. Issues Ment Health Nurs. 2013;34:626–630.
12. Kim YS, Park YS, Allegrante JP, et al. Relationship between physical activity and general mental health. Prev Med. 2012;55:458–463.
13. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, United States, 2015. Available at: https://www.cdc.gov/brfss/brfssprevalence/. Accessed December 30, 2017.
14. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance—United States, 2015. MMWR Surveill Summ. 2016;65:1–174.
15. National Physical Activity Plan Alliance. 2016 United States report card on physical activity for children and youth. Available at: http://www.physicalactivityplan.org/reportcard/2016FINAL_USReportCard.pdf. Accessed December 30, 2017.
16. Centers for Disease Control and Prevention. National Health Interview Survey, 2015: summary statistics. Available at: https://www.cdc.gov/nchs/nhis/. Accessed December 30, 2017.
17. Sallis JF, Floyd MF, Rodriguez DA, Saelens BE. The role of built environments in physical activity, obesity, and CVD. Circulation. 2013;125:729–737.
18. Robert Wood Johnson Foundation. Persistent gaps in health behaviors: physical inactivity. Available at: http://www.commissiononhealth.org/PDF/ed_inactiv.pdf. Accessed December 30, 2017.
19. Stalsberg R, Pedersen AV. Effects of socioeconomic status on physical activity in adolescents: a systematic review of the evidence. Scand J Med Sci Sports. 2010;20:368–383.
20. Centers for Disease Control and Prevention. Physical activity and health: persons with disabilities. Available at: http://www.cdc.gov/nccdphp/sgr/disab.htm. Accessed December 30, 2017.
21. Centers for Disease Control and Prevention. preventing obesity and chronic diseases through good nutrition and physical activity. Available at: http://atfiles.org/files/pdf/CDC-HHS.pdf. Accessed December 30, 2017.
22. Qian X, Linscheid N, Tuck B, et al. Assessing the economic impact and health effects of bicycling in Minnesota. Available at: http://www.dot.state.mn.us/research/TS/2016/201636.pdf. Accessed December 30, 2017.
23. van Dongen JM, Proper KI, van Wier MF, et al. Systematic review on the financial return of worksite health promotion programmes aimed at improving nutrition and/or increasing physical activity. Obes Rev. 2011;12:1031–1049.
24. Esparza LA, Velasquez KS, Zaharoff AM. Local adaptation of the National Physical Activity Plan: creation of the Active Living Plan for a Healthier San Antonio. J Phys Activity Health. 2014;11:470–477.
25. Pate R, Buchner D. Implementing Physical Activity Strategies. Champaign, IL: Human Kinetics; 2014.
26. Eyler A, Zwald M. Governors’ priorities for public health and chronic disease: a qualitative analysis of state of the state addresses. Translational Behav Med. 2015;15:347–353.
27. U.S. National Physical Activity Plan Coordinating Committee. National Physical Activity Plan. Available at: http://www.physicalactivityplan.org/NationalPhysicalActivityPlan.pdf. Accessed December 30, 2017.
28. Pate R. A national physical activity plan for the United States. J Phys Activity Health. 2009;6:s157–s158.
29. National Prevention Strategy. Washington, DC: National Prevention Council; 2011.
30. U.S. Department of Health and Human Services. Action plan to reduce racial and ethnic health disparities. Available at: http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=285. Accessed December 30, 2017.
31. Physical Activity Council. 2016 participation report. Available at: http://www.physicalactivitycouncil.com/pdfs/current.pdf. Accessed December 30, 2017.
32. Carlson SA, Fulton JE, Pratt M, Yang Z, Adams EK. Inadequate physical activity and health care expenditures in the United States. Progr Cardiovasc Dis. 2015;57:315–323.
33. Lee BY, Adam A, Hetenstein D, et al. Modeling the economic and health impact of increasing children’s physical activity in the United States. Health Aff (Millwood). 2017;36:902–908.
34. Bornstein D, Ortaglia A, Clennin M, et al. Physical activity and military readiness: a new perspective on policy advocacy for active living. Paper presented at: Active Living Research Annual Conference, Clearwater, FL, 2016.
35. U.S. Department of the Army. Prevention and control of musculoskeletal injuries associated with physical training. Available at: http://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/tbmed592.pdf. Accessed December 30, 2017.
36. Sallis J, Owen N. Ecological models of health behavior. In: Glanz K, Rimer B, Viswanath K, eds. Health Behaviors and Health Education: Theory, Research, and Practice. San Francisco, CA: Jossey-Bass; 2015.
37. King A, King D. Physical activity for an aging population. Public Health Rev. 2010;32:401–426.
38. Frank L, Kavage S. A national plan for physical activity: the enabling role of the built environment. J Phys Activity Health. 2009;6:S186–S195.
39. Sallis JF, Floyd MF, Rodriquez DA, Saelens BE. Role of built environments in physical activity, obesity, and cardiovascular disease. Circulation. 2012;125:729–733.