CDC’s Active People, Healthy Nation^SM: Creating an Active America, Together

Abstract

Physical activity can reduce the risk of at least 20 chronic diseases and conditions and provide effective treatment for many of these conditions. Yet, physical activity levels of Americans remain low, with only small improvements over 20 years. The Centers for Disease Control and Prevention (CDC) considered what would accelerate progress and, as a result, developed Active People, Healthy Nation^SM, an aspirational initiative to improve physical activity in 2.5 million high school youth and 25 million adults, doubling the 10-year improvement targets of Healthy People 2020. Active People, Healthy Nation^SM will implement evidence-based guidance to improve physical activity through 5 action steps centered on core public health functions: (1) program delivery, (2) partnership mobilization, (3) effective communication, (4) cross-sectoral training, and (5) continuous monitoring and evaluation. To achieve wide-scale impact, Active People, Healthy Nation^SM will need broad engagement from a variety of sectors working together to coordinate activities and initiatives.

Heart disease, cancer, stroke, and diabetes are leading causes of death in the United States.¹ Nearly half of adults live with a chronic disease.² The United States spends more than 80% of health care dollars on people with chronic medical conditions.² Physical activity can reduce the risk of at least 20 chronic diseases and conditions and provide effective treatment for many of these conditions.³

Lifestyle factors are a major cause of the costly burden of chronic disease. While most people know that eating a healthy diet⁴ and avoiding tobacco use⁵ leads to a decrease in their risk of chronic diseases, achieving population-level improvement can be challenging. Physical activity levels of Americans remain low, with only small improvements over the past 20 years.⁶ In 2015, approximately half of US adults and 3 quarters of US high school students (about 130 million people) did not meet minimum aerobic physical activity guidelines.⁶ The United States can reduce chronic disease by increasing physical activity.

Low population levels of physical activity have substantial health and societal costs. About 1 in 10 premature deaths can be attributed to physical inactivity accounting for approximately 280,000 US deaths in 2014.⁷ As much as 11% of US health care expenditures are associated with levels of physical activity inadequate to meet the aerobic guideline—totaling about $117 billion annually.⁸ To accelerate progress, the Centers for Disease Control and Prevention (CDC) developed Active People, Healthy Nation^SM, an initiative to improve the physical activity levels of Americans.

Goal of Active People, Healthy Nation^SM

The goal of Active People, Healthy Nation^SM is to achieve a major, sustained improvement in the physical activity levels of US youth and adults over the next decade. To meet our goal, we envision using a recognized public health strategy to improve population health through small shifts (or “pushes”) in the physical activity behavior of many people rather than from large shifts of fewer people.⁹ By doubling the improvement targets set forth in Healthy People 2020,⁶ Active People, Healthy Nation^SM will aim to improve the aerobic physical activity levels of 2.5 million high school youth and 25 million adults.

Is a major improvement possible? Concerted public health efforts have resulted in improvements in health behaviors such as cigarette smoking. Since the 1964 Surgeon General’s Report on Smoking and Health, the prevalence of cigarette smoking among adults aged 18 years or older has declined from 42.4% (1965) to 18.1% (2012).⁵ During this time, public health efforts in tobacco control have been comprehensive, sustained, and effective, and remain essential because the tobacco industry continues to introduce and market new products that establish and maintain nicotine addiction.⁵ In contrast, there are no market challenges to improving physical activity, and the task is to increase participation in normal, enjoyable human activities such as going for a brisk walk each day. Only half of US adults meet the aerobic physical activity guideline so we know there is much room for improvement.⁶ We also know population-level change is possible because we have observed small improvements in adults meeting the aerobic physical activity guideline from 2008 (44%) to 2015 (50%).⁶ The CDC, together with other federal agencies, states, and communities, can build on these improvements by launching a comprehensive and thoughtful response, as was done for smoking, to improve physical activity levels in the United States through Active People, Healthy Nation^SM.

Active People, Healthy Nation^SM

Active People, Healthy Nation^SM includes 5 action steps to improve physical activity in the United States, centered around core public health functions of program delivery, partnership engagement, communication, training, and continuous monitoring and evaluation (Table 1). In this commentary, we describe the vision for Active People, Healthy Nation^SM, how it builds on previous public health models, and how implementation by the CDC and partners can improve the physical activity levels of Americans.

Table 1.

Action Steps, Goals, and Potential Activities for Active People, Healthy Nation^SM

Action step	Goal	Potential activities
(1) Deliver physical activity programs that work	Use proven programs to promote physical activity at national, state, and community levels	Support the priorities of the National Physical Activity Plan: data collection systems, state and community activities, and policy development Provide technical assistance to states and communities as they put strategies in place to increase physical activity
(2) Mobilize partners	Support partners to create and sustain national, state, and community efforts to increase physical activity	Support physical activity initiatives through national, state, and community networks Develop leadership coalitions at the community level to improve physical activity Coordinate national efforts to increase physical activity across different settings
(3) Create and disseminate messages that promote active lifestyles	Connect and communicate the benefits of adopting an active lifestyle	Develop and communicate branded messages to connect a larger audience with the benefits of active lifestyles, using multiple channels Launch a robust national media campaign to promote active lifestyles
(4) Train leaders for action	Prepare community and state leaders to promote and support physical activity	Train state and community leaders about effective strategies that support active lifestyles Support successful training model to equip community leaders with the skills to improve conditions for active lifestyles
(5) Develop technologies, tools, and data that matter	Address gaps in monitoring and evaluating physical activity, walking, and walkable communities	Enhance national, state, and local data collection systems on physical activity Evaluate walking and walkability interventions at state and local levels Explore using data from alternative sources, such as mobile and wearable devices, to gauge levels of activity

Note: Adapted from Active People, Healthy Nation^SM: The Role of Public Health fact sheet. https://www.cdc.gov/physicalactivity/downloads/APHN-Role-of-Public-Health.pdf.

The features of Active People, Healthy Nation^SM are not revolutionary, but they are evolutionary. Decades of research and evaluation identified evidence-based strategies to improve physical activity, and there is strong consensus for moving this evidence into action. Strategies to improve physical activity are recommended by the US Community Preventive Services Task Force,¹⁰ the Department of Health and Human Services,¹¹ the Institute of Medicine,¹² and through systematic evidence reviews and case studies.^13–15 Several documents identify key strategies to promote and monitor physical activity to include Healthy People 2020,⁶ 2008 Physical Activity Guidelines for Americans,³ and STEP IT UP! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities.¹⁶ The US National Physical Activity Plan identifies cross-sector and sector-specific strategies and tactics for promoting physical activity nationwide. Reducing health disparities and promoting health equity are important, cross-cutting goals in these documents, which is an overarching theme of Active People, Healthy Nation^SM.

Five Action Steps of Active People, Healthy Nation^SM

To accelerate progress, Active People, Healthy Nation^SM will enhance current CDC activities through a comprehensive public health model.¹⁷

Active People, Healthy Nation^SM includes 5 action steps:

1. Deliver programs widely that work in communities;

2. Mobilize partners across sectors to promote physical activity;

3. Create and disseminate effective messages that support physical activity;

4. Train leaders, across sectors, in state-of-the-art approaches to promote physical activity; and

5. Develop technologies and tools that provide useful and local-level data for stakeholders.

The CDC has already started working with states and communities to advance Active People, Healthy Nation^SM. Through funding and technical assistance, the CDC works with states and community-based partners to help them to implement policy, systems, and environmental approaches to improve physical activity based on guidance from the Community Preventive Services Task Force.¹⁰ The task force recommends implementing new or improved pedestrian, bicycle, or transit transportation systems (ie, activity-friendly routes) that are combined with implementing new or improved land use or environmental design (ie, connecting everyday destinations).

Deliver Programs Widely That Work in Communities

Brownson et al¹⁸ classified public health evidence into 3 types. In early physical activity and public health models, the emphasis was on type 1 evidence (eg, characterizing health benefits of physical activity) and type 2 evidence (eg, identifying evidence-based interventions and programs) to promote physical activity. Type 3 evidence emphasizes how to implement and scale interventions to achieve population-wide impact. Building on this model, Active People, Healthy Nation^SM will aim to deliver, evaluate, implement, and disseminate interventions at scale.

Even with recommendations on evidence-based interventions for increasing physical activity,¹⁰ communities need flexibility to achieve their goals. In Active People, Healthy Nation^SM, we envision guiding intervention implementation through community priorities, attention to achieving health equity, and other local circumstances. For example, one community may improve parks in low-income neighborhoods. Another may promote physical activity by updating playgrounds or initiating agreements for organizations to share local facilities. Another may support the routine design and operation of streets and communities that are safe for everyone through features, such as sidewalks, protected bike lanes, and frequent crossing opportunities.¹⁶ Another may work with community members and officials to initiate small-scale projects through low-cost efforts (eg, building temporary, protected bike lanes). Another may link health plans with exercise programs to improve access for older adults. To ensure the effective delivery of physical activity interventions, including policy, systems, and environmental approaches, efforts will need to be organized and coordinated between states and communities.¹⁹

Mobilize Partners Across Sectors

In previous public health models, linkages and collaboration between sectors were encouraged, but not always well supported. New public health models emphasize that collaborations among partners need an efficient structure and support.¹⁷ To be successful, Active People, Healthy Nation^SM will promote more extensive coordination and engagement among stakeholders at national, state, and community levels representing a variety of sectors (eg, transportation, business, health care, public health) to maximize efficiency and leverage resources.

Consistent with a national public health approach, Active People, Healthy Nation^SM aspires to encourage national stake-holders to prioritize and coordinate physical activity and public health research and practice initiatives based upon the ongoing review of new evidence. Increased coordination around technical assistance and support for implementation plans for Active People, Healthy Nation^SM could be a valued addition to this process.

In addition to the ongoing work that states do to bring together key sector constituencies (eg, transportation, business, health care, public health) to increase opportunities for physical activity, increased coordination could form around implementation and evaluation of Active People, Healthy Nation^SM. With support from national and state partners, community partners can identify needs and priorities to implement the Active People, Healthy Nation^SM strategies through tailored, action-oriented plans. Cross-collaboration, shared vision, and information sharing (including technical assistance) between national, state, and community stakeholders are key elements to realize the goal of Active People, Healthy Nation^SM to increase physical activity levels of 2.5 million youth and 25 million adults.

Create and Disseminate Effective Messages

Active People, Healthy Nation^SM will employ a diverse, updated, and coordinated communications approach to achieve progress. While there is much to be learned from counteradvertising campaigns in tobacco control and the VERB campaign that targeted tweens to increase physical activity,²⁰ targeting changing social norms related to activity will help to achieve progress. Effective messages will need ongoing development and refinement through message testing with segmented audiences. The target audiences for messages, however, will involve more than just those individuals who can improve their physical activity, but those who can change the environment to promote access to physical activity. Messages may be disseminated through national, state, or community campaigns, including those that use newer social media platforms. To increase impact and efficiency, for instance, campaigns could share logos and tag lines. The result would move beyond campaigns implemented by individual stakeholders to coordinated campaigns at the community, state, and national levels.

Train Leaders Across Sectors in State-of-the-Art Approaches

In previous public health models, training in physical activity emphasized short-term, on-site courses for small numbers of public health professionals. In Active People, Healthy Nation^SM, training would occur across sectors involving larger numbers of diverse leaders, with different formats including cross-sectoral team approaches. Training would build skills in practitioners, such as how to create and promote walkable communities and demonstrate how efforts across sectors can fit together to have impact. An example is the Walkability Action Institute (http://www.chronicdisease.org/page/WAI) that trains cross-disciplinary teams (eg, public health, transportation, planning, elected official) to develop an action plan for walkable communities through policy, systems, and environmental approaches. This can mean ensuring that sidewalks, paths, bicycle routes, or public transit are available, accessible, and connected with nearby destinations that people regularly use, such as schools, worksites, parks, or senior centers. In addition, workforce development trainings will empower state and community public health leaders to be chief health strategists capable of mobilizing community action to create activity-friendly communities for their constituents. Training is a companion activity to building partnerships, and will support a shared vision on how to achieve active, healthy, and economically strong communities.

Develop Technologies, Tools, and Data That Matter

Monitoring progress toward increasing physical activity is essential because it provides decision makers with information to evaluate the impact of programs. Active People, Healthy Nation^SM envisions a diverse and expanded approach to assessment and collection of data that matter. Data that matter emphasizes collection of timely, community-relevant data from a limited number of domains.¹⁷

Active People, Healthy Nation^SM will employ updated approaches to monitor and document impact. Lack of community-level data hampers the ability to develop and evaluate community initiatives. Where previous public health monitoring emphasized assessing physical activity of youth and adults at national and state levels, Active People, Healthy Nation^SM will also assess physical activity patterns and active design features that support physical activity (eg, sidewalks) at the community level. In 2015, the Surgeon General made a persuasive and evidence-based call for action to promote walking and walkable communities.¹⁶ However, a comprehensive set of metrics needs to be in place at the community level to determine what is working, for whom, and at what cost.

Many data gaps exist, and addressing some of these gaps may benefit from advancements in technology. Wearable devices may have a role to play in monitoring physical activity. For youth younger than high school age where reported assessments of activity are less accurate,²¹ using device-based technologies may be particularly suitable. Geographic information systems or mapping programs can help to examine features of community environments supportive of physical activity. For surveillance, experts recommend, as first steps, identifying and prioritizing the most relevant metrics to monitor and testing the feasibility of collecting data using alternative sources. Prioritizing metrics for youth, health care, schools, and communities is advancing through the National Academy of Sciences.²²

Working Together to Achieve Impact

Active People, Healthy Nation^SM emphasizes the efficient use of existing resources to maximize impact and achieve desired outcomes. For example, as communities maintain and improve their infrastructures, public health can encourage active design strategies to make bicycling and walking accessible and safe for everyone.

Public health cannot do this work alone. To achieve wide-scale impact, Active People, Healthy Nation^SM will need broad engagement from many sectors. Working together, the sectors can build partnerships to better coordinate activities. Built environment infrastructure improvements (eg, sidewalks) can increase physical activity by improving or creating walkable communities, although these communities may, in turn, experience unintended consequences such as gentrification. Working with business and real estate sectors, together, we can learn how to prevent or mitigate displacement of residents or businesses when communities undergo gentrification. Working with the technology sector, together, we can learn how to use the data from wearable devices to monitor physical activity levels communities while preserving confidentiality and personal choice. And by utilizing existing connections between local elected officials and community members, together, we can learn how to document the economic impacts of community revitalization.

Summary

By taking a comprehensive approach to promote physical activity through Active People, Healthy Nation^SM, we envision a population that is more active and much healthier. Active People, Healthy Nation^SM will advance cross-sector collaborations and coordinated actions between public and private partners and between organizations at federal, state, and community levels. Strategies to improve physical activity will emphasize policy, systems, programmatic, and environmental approaches and focus on community-level decisions and actions. Demonstrating how and to what extent Active People, Healthy Nation^SM is providing population benefit is paramount, and new technologies may be needed to monitor and evaluate impact.

Over the next decade, the Active People, Healthy Nation^SM initiative aims to achieve major, sustained improvements in aerobic physical activity levels of US youth and adults by improving physical activity in 2.5 million high school youth and 25 million adults. The potential benefits may extend beyond health: our children may perform better in school;¹⁶ our health care costs may be lower;⁸ our local economies may be stronger;¹⁶ our air may be less polluted;¹⁶ our communities may be more cohesive;¹⁶ our security may be enhanced by having a larger pool of physically fit adults for the military.²³ Through Active People, Healthy Nation^SM, the CDC is strengthening its approach to improve physical activity in the United States.