New HHS Guideline on Physical Activity for Americans

CHICAGO — The US Department of Health and Human Services (HHS) today released a second edition of the Physical Activity Guidelines (PAG) for Americans, with recommendations on physical activity for those starting as young as 3 years of age.

The new document for the first time includes recommendations for this youngest group, 3 to 5 years of age, and reviews the evidence supporting a variety of newly established benefits of physical activity across a variety of populations.

The guideline was presented here at the American Heart Association (AHA) Scientific Sessions 2018, to coincide with their publication online November 12 in JAMA.

“Our overarching vision is to transform the present sick care system into a health promoting system,” Admiral Brett P. Giroir, MD, Assistant Secretary for Health, HHS, told a press conference here. “The new guideline is a unique opportunity to implement this vision directly to affect every single person across the country.”

Inactivity causes 10% of the premature mortality in the United States, Giroir said. “That means if we can just get 25% of inactive people to be active and meet the recommendations, almost 75,000 deaths would be prevented in the United States.”

Low levels of adherence to the guidelines currently in the United States mean that nearly $117 billion in annual healthcare costs are “directly attributable” to not meeting the guidelines, he said, and further, represent a “threat to our national security, because obesity disqualifies nearly one-third of American youth aged 17 to 24 years for military service.”

The new recommendations first advocate simply “moving more and sitting less,” Giroir said. One change aims to make meeting the guidelines easier by removing assertion in the previous guideline that only activity in at least 10 minute increments would count toward the 150- to 300-minute goal, he noted.

“The new guidelines demonstrate based on the best science, everyone can dramatically improve their health, just by moving, anytime, anywhere and my any means that get you active.”

New evidence has also further emphasized not only the health risks from sedentary behaviour, but provides support for previously unknown benefits of physical activity, independent of other healthy behaviors like good nutrition.

Evidence shows, for example, that physical activity has immediate benefits, Giroir said. “A single episode of physical activity can reduce anxiety and blood pressure and improve quality of sleep and insulin sensitivity,” he said.

Further, physical activity can help manage health conditions that are already present, including decreasing pain for those with osteoarthritis, reducing disease progression in people with hypertension or type 2 diabetes, reducing symptoms of anxiety and depression, and improving cognition in patients with Alzheimer’s disease, multiple sclerosis, ADHD, and Parkinson’s disease, he said.

The previous document recognized the benefit of physical activity in preventing chronic diseases, including cardiovascular disease, diabetes and breast and colon cancers, he said.

“We now know about even more long-term health benefits from physical activity, including improved brain health, reduced risk of Alzheimer’s disease, reduced risk for fall-related injuries in older adults, and reduced risk for eight types of cancer,” he noted, now including, besides breast and colon malignancies, bladder, endometrial, esophageal, kidney, stomach, and lung cancers.

Systematic Review

The new recommendations are based on a systematic review of the science supporting physical activity and health, he said. The 2018 PAG Advisory Committee addressed 38 questions and 104 subquestions, grading the evidence “based on consistency and quality of research,” the authors write. “Evidence graded as strong or moderate was the basis of the key guidelines.”

The main recommendations include:

• A new recommendation for pre-school aged children (aged 3 through 5 years) to be physically active throughout the day, with a target of 3 hours per day of activity. This is based on average activity observed in this age group, and is consistent with physical activity guidelines from Australia, Canada, and the United Kingdom, Giroir noted.

• Recommendations for children and adolescents aged 6 through 17 years are the same as the last guideline; they should do 60 minutes or more of moderate to vigorous physical activity daily.

• The recommendations for adults have also not changed, with at least 150 to 300 minutes per week of moderate-intensity or 75 to 150 minutes of vigorous-intensity aerobic physical activity, or an “equivalent combination of moderate- and vigorous-intensity aerobic activity,” the authors write. “They should also do muscle-strengthening activities on 2 or more days a week.”

• Older adults are recommended to do multicomponent physical activity, including balance training and aerobic and muscle-strengthening activities.

• Pregnant and postpartum women should do at least 150 minutes of moderate-intensity aerobic activity per week.

• Adults with chronic conditions or disabilities, as they are able, “should follow the key guidelines for adults and do both aerobic and muscle-strengthening activities.”

“Health professionals and policy makers should facilitate awareness of the guidelines and promote the health benefits of physical activity and support efforts to implement programs, practices, and policies to facilitate increased physical activity and to improve the health of the US population,” the authors conclude.

In a Viewpoint article accompanying the publication of the new guideline in JAMA, Giroir and Don Wright, MD, MPH, Office of Disease Prevention and Health Promotion, HHS, look particularly at the evidence-based strategies suggested by the guidelines to help Americans become more active.

Among these are promoting physical activity within the medical care system, in effect “prescribing” activity based on what is known about how much physical activity is required for a specific patient’s health needs, and connecting them with programs and events in their community.

New technologiesm such as wearable devices and social media, could be leveraged, as well as facilitating physical activity in the workplace or increasing youth participation in sports, they write.

“Increasing the number of Americans who regularly achieve the PAG recommendations will require individuals, as well as community and national leaders across all sectors of society, to take action,” they conclude. “Physicians and other healthcare professionals should participate in, and indeed lead, this important call to Americans to make simple lifestyle changes that will improve longevity and quality of life.”

The “Best Buy in Public Health”

In an editorial accompanying the publication, Paul D. Thompson, MD, Hartford Healthcare, Hartford Hospital, Connecticut, and Thijs M.H. Eijsvogels, PhD, Radboud University Medical Center, Nijmengen, the Netherlands, look at the major changes in the new edition of the document.

“Probably the most important message from the 2018 guidelines is that the greatest health benefits accrue by moving from no, to even small amounts of, physical activity, especially if that activity is of moderate (e.g., brisk walking) or vigorous (e.g., jogging and running) intensity,” Thompson and Eijsvogels write.

Multiple studies show the steepest reduction in disease risk, such as for coronary heart disease, occurs at the lowest levels of physical activity, they note. “Patients need to understand that even small amounts of physical activity are beneficial and that reductions in the risk of disease and disability occur by simply getting moving.”

Clinicians and other healthcare professionals should have a major role in this “call to activity,” they write.

“The clinical examination should routinely include an assessment of physical activity. Indeed, several nationally respected healthcare systems, including Kaiser Permanente and Intermountain Healthcare, now include physical activity as a fifth vital sign during patient examinations,” they say. “This both shows the patient that physical activity is important to the clinician and helps to identify inactive patients, a group who can benefit the most.”

Finally, physicians and other educators in academic healthcare centers should ensure that there is sufficient training about the benefits of exercise and physical activity, “to make future practitioners comfortable with prescribing exercise as an important component of a healthy life,” they add.

“Physical activity has been described by Morris, a pioneering exercise epidemiologist and lead investigator of the London Transport Workers Study, as ‘the best buy in public health.’ Clinicians cannot afford to allow patients to miss out on this inexpensive path to healthier lives,” they conclude.

Ivor Benjamin, MD, current AHA president, moderated a press conference here during which the guidelines were discussed.

“The American Heart Association has long recognized physical activity as a proven and effective way to lower the chances of heart disease and live a longer, healthier life,” Benjamin said.

“Unfortunately research has shown few — only 26% of men, 19% of women and 20% of adolescents — report enough physical activity to make the physical activity recommendations,” he added. “This is of particular concern to the American Heart Association because low physical activity, combined with excessive sedentary behaviour, can impact the most prevalent and expensive medical conditions, including heart disease and stroke.”

The AHA will adopt the recommendation as the association’s official recommendations and leverage the new guidelines, “to amplify our efforts to develop programs and advocate for policies that make it easier for everyone to get more physical activity, regardless of where you live,” Benjamin said.

Also published today was a Perspectives article in the journal Circulation: Cardiology Quality and Outcomes, by lead authors of the guidelines, Katrina Piercy, Office of Disease Prevention and Health Promotion at HHS, and Richard P. Troiano, PhD, Division of Cancer Control and Population Sciences at the National Cancer Institute, Bethesda, Maryland.

In it, they review particularly the evidence supporting the cardiovascular benefits of and recommendations for physical activity in the new guidelines.

“The bottom line is this — the benefits of physical activity, not only on cardiovascular health, but on overall health and wellness cannot be overstated,” Piercy and Troiano conclude. “Some physical activity is better than none, and more physical activity is even better.”

The study was funded by the US Department of Health and Human Services. Thompson and Eijsvogels report no relevant disclosure. Piercy and Troiano report no disclosures.

JAMA. Published online November 12, 2018. Guideline, Giroir viewpoint, Thompson editorial

Circ Cardiovasc Qual Outcomes. Published online November 12, 2018. Perspective