Amplifying Support for Physical Activity: The National Strategy on Hunger, Nutrition, and Health

In September 2022, the White House released the National Strategy on Hunger, Nutrition and Health (the National Strategy).1 As the title implies, the National Strategy has a strong focus on ending hunger and improving population nutrition for health. Of the five pillars of the strategy, four are focused on improving food access and nutrition, while one pillar is devoted to “supporting physical activity for all”. The inclusion of support for promoting physical activity in the National Strategy is a timely and welcome addition, and highlights the strong interaction between dietary behavior, physical activity, and health. Furthermore, the physical activity pillar elevates the importance of physical activity as a national public health priority. The 2018 Physical Activity Guidelines Advisory Committee Scientific Report provided an up-to-date authoritative review of the health benefits associated with physical activity, which includes a reduced risk of premature mortality and the development of a host of noncommunicable diseases (NCDs) such as cardiovascular disease, type 2 diabetes, obesity and several cancers.2 Physical activity also improves several aspects of mental health and quality of life.2 A detailed analysis of this evidence led to the current Physical Activity Guidelines for Americans, which recommend that adults should undertake regular aerobic and muscle-strengthening activity to achieve health benefits.3 However, it is concerning that 76% of Americans are not currently meeting the physical activity guidelines for aerobic and muscle strengthening activity.4 While physical activity carries some risk for adverse events such as musculoskeletal injuries, these risks are very low for popular activities such as walking, and the health benefits from physical activity outweigh the risks.2 While there is irrefutable evidence for substantial NCD risk reduction and improvements in mental health associated with physical activity,2 new evidence is accumulating on the role of physical activity in improving infectious disease outcomes. For example, an analysis of more than 48,000 patients from a large integrated healthcare system demonstrated that patients with COVID-19 who were consistently inactive had a greater risk of hospitalization, admission to the intensive care unit and death due to COVID-19 than patients who were consistently meeting physical activity guidelines.5 Another recent analysis showed that meeting the guidelines for aerobic and muscle strengthening activity is associated with a 48% lower risk of influenza and pneumonia mortality, compared to not meeting either guideline.6 Thus, physical activity has the potential to address population and public health emergencies beyond its role in traditional cardio-metabolic risk factor reduction. The number of diseases and health conditions known to be associated with physical inactivity is expanding at a rapid rate.2 Physical inactivity is also associated with substantial public health burden. For example, global physical inactivity-attributable healthcare costs were estimated to be $53.8 billion in 2013, of which $31 billion was paid by the public sector.7 More recent estimates suggest that, in the absence of any changes in physical inactivity, approximately 500 million new cases of preventable NCDs and $520 billion in associated health-care costs would be realized between 2020 and 2030 globally.8 Table 1 provides a summary of the goals and approaches for physical activity promotion in the National Strategy. The proposed approaches include several evidence-based strategies for improving levels of physical activity in the population, including improving access to outdoor spaces for physical activity, the promotion of active transportation and built-environment policies to improve opportunities for physical activity, expanding school and youth physical activity programs, expanding the public health messaging regarding physical activity guidelines, especially among specific demographic groups, and expanding the use of physical activity prompts in government buildings. Furthermore, there is a goal to expand funding for the Centers for Disease Control and Prevention's (CDC's) State Physical Activity and Nutrition (SPAN) program to all states, which provides overarching support to implement evidence-based strategies to improve nutrition and physical activity at state and local levels. It is heartening to see these commitments, which are consistent with public health approaches which have demonstrated evidence of effectiveness as outlined in The Guide to Community Preventive Services.9Table 1Approaches to Improve Physical Activity in the National Strategy on Hunger, Nutrition, and HealthGoalApproachExpand CDC State Physical Activity and Nutrition (SPAN) programs to all states & territories.CDC currently funds SPAN in 16 states; the Biden-Harris Administration will work with congress to increase funding to expand SPAN to all states and territories.Connect people to parks & other outdoor spaces.Biden-Harris Administration will work with the NPS to increase park access; DOT will work with the NPS to promote car-free travel to parks; DOT, DOI, and EPA will work collaboratively to reduce number of people without access to parks; the Federal Interagency Council will work to increase access to public lands, and will work with the Every Kid Outdoors program.Promote active transportation & land use policies to support physical activity.Biden-Harris Administration is improving active transportation through the Bipartisan Infrastructure Law; IRA is funding projects to restore walkability in disadvantaged neighborhoods; DOT will provide technical assistance for transportation agencies to prioritize active travel; DOT will develop guidance to help recipients of federal aid prioritize the safety of people using streets; DOT will provide guidance on how modes other than motor vehicles should be considered in roadway design.Support physical activity among children both in & out of school.ED will provide guidance to states and school districts on how they can use funds under the bipartisan Safer Communities Act grants and American Rescue Plan funds to support physical activity for children; ED will promote strategies to increase participation in physical fitness programs during summer and after-school programs; CDC and ED will partner to support districts in planning and organizing physical education and activities in schools; The ACF will help educators add activities to children's daily routines.Support regular updates & promotion of the Physical Activity Guidelines for Americans.Biden-Harris Administration will work with congress and the private sector to provide funding to support the Physical Activity Guidelines for Americans and the Move Your Way® campaign.Tailor physical activity messages to resonate with specific demographic groups.HHS will release evidence-based guidelines to increase physical activity among older adults; Indian Health Service will update its Physical Activity Toolkit and re-ignite the Just Move It campaign for Indigenous people; BOP will teach inmates to develop exercise and nutrition plans for those in need; BOP will launch the Women's Life Skills program which will include nutrition and physical activity sessions.Facilitate physical activity in federal facilities.GSA will reinvigorate the Consider the Stairs campaign in all federal facilities and post best practices on their website to encourage other employers to adopt the concept.ACF: Administration on Children and Families; BOP: Bureau of Prisons; CDC: Centers for Disease Control and Prevention; ED: Department of Education; DOI: Department of Interior; DOT: Department of Transportation; EPA: Environmental Protection Agency; GSA: General Services Administration; HHS: Health and Human Services; NPS: National Park Service. Open table in a new tab ACF: Administration on Children and Families; BOP: Bureau of Prisons; CDC: Centers for Disease Control and Prevention; ED: Department of Education; DOI: Department of Interior; DOT: Department of Transportation; EPA: Environmental Protection Agency; GSA: General Services Administration; HHS: Health and Human Services; NPS: National Park Service. As government agencies, non-governmental organizations, industry, and philanthropic organizations consider additional investments to the National Strategy in the coming months and years, it is important to consider evidence-based strategic priorities in physical activity. Several resources exist to provide a roadmap for investment, such as the U.S. National Physical Activity Plan (NPAP),10 CDC's Active People, Healthy NationSM,11 the World Health Organization's (WHO) Global Action Plan on Physical Activity,12 and the International Society for Physical Activity and Health's (ISPAH) Eight Investments that Work for Physical Activity.13 The NPAP, first released in 2010 and updated in 2016, is a comprehensive set of policies, programs, and initiatives designed to increase physical activity in all segments of the U.S. population.10 The NPAP is organized across a number of societal sectors, including 1) business and industry, 2) community recreation, fitness and parks, 3) education, 4) faith-based settings, 5) healthcare, 6) mass media, 7) public health, 8) sport, 9) transportation, land use and community design, and 10) military settings. Each sector presents strategies for promoting physical activity, and includes specific tactics that communities, organizations, agencies, and individuals can use. Active People, Healthy NationSM is an initiative led by the CDC to increase the level of physical activity in the population to improve health outcomes.11 Focusing on strategies that have sufficient or strong evidence of effectiveness according to The Guide to Community Preventive Services,9 Active People, Healthy NationSM recommend the following strategies: 1) creating activity-friendly routes to everyday destinations, 2) increasing access to places for physical activity, 3) implementing school and youth programs, 4) implementing community-wide campaigns, 5) building social support for physical activity, 6) implementing individually adapted health behavior change strategies, and 7) using prompts to encourage physical activity. The WHO Global Action Plan on Physical Activity (GAPPA) contains policy actions that can be deployed to create 1) active societies, 2) active environments, 3) active people, and 4) active systems.12 The implementation of GAPPA will require each country to identify a strategic combination of policies for implementation over the short term (2–3 years), medium term (3–6 years), and longer-term (7–12 years). The ISPAH's Eight Investments that Work for Physical Activity builds upon the WHO GAPPA, and provides the best evidence available to facilitate advocacy, and inform and lead physical activity policy development.14 The document identifies proven strategies that can be employed within a systems framework, which include 1) whole-of-school programs, 2) active transport, 3) active urban design, 4) healthcare, 5) public education, including mass media, 6) sport and recreation for all, 7) workplaces, and 8) community-wide programs. In summary, the resources described above provide a menu of evidence-based physical activity promotion strategies that are ripe for investment. In general, these strategies need to be tailored to specific population groups, which may add to the complexity and costs associated with programming. However, strategic investments in these priority areas will undoubtedly lead to synergistic public health benefits alongside the investments being made in nutrition, and contribute to the Healthy People 2030 goal of improving health, fitness, and quality of life through regular physical activity.15 It is widely acknowledged that a poor diet and lack of physical activity, along with tobacco use and excessive alcohol consumption, are major risk factors for cardiovascular disease, cancer, and diabetes.16 Addressing multiple risk factors together has the potential to optimize health outcomes. For example, a healthy diet and a physically active lifestyle when combined have additive effects on health, and in some circumstances, there is a need for physical activity to enhance the effectiveness of a healthy diet on improving health outcomes. The results of a systematic review of 12 studies revealed that there was little evidence that diet alone or physical activity alone were effective at reducing the risk of diabetes, but that diet-plus-physical activity interventions delay the incidence of diabetes in people with impaired glucose tolerance.17 Furthermore, a meta-analysis of 18 studies demonstrated that diet-plus-exercise programs result in greater long-term weight loss compared to diet-only programs.18 These results highlight the synergistic effects of addressing diet and physical activity to optimize health outcomes. Given that improvements in diet quality and physical activity result in substantial health improvements, it makes sense to consider these risk factors together when designing public health interventions at all levels, including policy, built-environment, and individual-level programs. Where we see investment in nutrition, we should be thinking about how co-investment in physical activity can optimize outcomes, amplify impact and increase return on investments. Table 2 summarizes some of these synergies. For example, there is growing momentum in the “Food as Medicine” concept, which highlights the potential of using medically tailored meals and other healthy food prescription as therapeutic agents in the treatment of NCDs.19 In a similar manner, the “It's Time to Move” initiative10 and Exercise is Medicine®20 have a goal to make physical activity assessment, prescription and referral a standard in health care delivery. While there is strong scientific evidence of the associations among diet, physical activity and health, these new initiatives are bridging the science-to-practice gap, by connecting resources with mainstream clinical medicine. This concept can also be applied to public health surveillance, where standardizing the assessment and tracking of dietary and physical activity behaviors can pay dividends in the identification of high-risk populations and those most in need of intervention.Table 2Examples of Potential Integration across Nutrition and Physical Activity Policy and Systems ChangesIssueNutritionPhysical ActivitySame Policy Levers to AddressIntegration of Healthy Food and Physical Activity Prescription into Health Care DeliveryMedically tailored mealsMedically prescribed groceriesFruit and vegetable vouchersPhysical activity assessment, prescription and referral to a qualified exercise professional or evidence-based programStandardized assessment tools and measures that can be integrated into electronic health records and clinical workflowQuality and performance measures that incentivize health systems, payers, clinicians to integrate these strategies into their patient care plansResources to health systems to integrate into workflow and train cliniciansReimbursement/coverage for healthy food and physical activity assessment, prescription, and referral, including to qualified professionals and community-based organizations that deliver the prescriptions to clientsSchool-Based InterventionsNutrition standards in school meals and for foods and beverages sold outside of school meal programsRobust nutrition educationAvailability of safe, free drinking waterComprehensive school physical activity programs (CSPAP), including robust physical educationFunding and technical assistance to schools to implement The Whole School, Whole Community, Whole Child (WSCC) model that includes physical activity, physical education, and nutrition and CSPAPsIncentivize states/districts to have plans, committees and partnerships with a dedicated funding stream to support implementation of WSCC models and CSPAPsProfessional education/training to support nutrition education and physical activity across the school dayCommunity InfrastructureHealthy food retailersActive transportation infrastructure and parks and recreational spacesHealthy food procurement in parks and recreational spaces that also offer the opportunity for physical activityBike/pedestrian infrastructure funding and complete streets policies that connect to key community destinations, including healthy food retailersTax incentives or grant programs for healthy food retailers and physical activity infrastructure to locate in historically under-resourced communitiesHealthy WorkforceFood service guidelines in workplacesHealthy physical activity promotion and opportunities to reduce occupational sitting timeTax incentives to employers to offer robust worksite health promotion, healthy worksite environments including physical activity offerings and healthy foods and beverages.Comprehensive integration of evidence-based preventive services into employer-sponsored health insurance with no co-pay Open table in a new tab It is a critical moment in time to leverage momentum from the National Strategy on Hunger, Nutrition and Health and build upon the physical activity strategies to work across the various sectors of the NPAP and implement policy and systems changes across healthcare, schools, transportation, community, and workplaces, supporting equitable access to physical activity for all. Public health initiatives related to nutrition and physical activity can be expensive. We should be integrating physical activity alongside nutrition priorities in policy and systems change, especially where there are synergies and economies of scale. In resource-constrained environments, we need to maximize funding streams across the National Strategy and beyond to optimize population health and well-being. Now is our opportunity to be bold.