Physical activity is one of the most powerful tools for promoting health and wellbeing. Movement is not only medicine—effective at treating a range of physical and mental health conditions—but it is also preventive medicine, because movement reduces the risk for many conditions ranging from cancer and heart disease to depression and Alzheimer’s disease. But rates of physical inactivity and sedentary behavior have remained high in the U.S. and worldwide for decades.

Engagement in physical activity is impacted by myriad factors that can be viewed from a social ecological perspective. This model views health and health behavior within the context of a complex interplay between different levels of influence, including individual, interpersonal, institutional, community, and policy levels. When it comes to healthy behavior such as physical activity, sustainable change is considered most likely when these levels of influence are aligned to support change. Every level of influence on physical activity within a social-ecological framework is directly or indirectly affected by federal policy, suggesting physical activity policy has the potential to bring about substantial changes in the physical activity habits of Americans. 

FIGURE 1. Adapted from Heise, L., Elisberg, M., & Gottemoeller, M. (1999)

Why are federal physical activity policies needed?

Physical inactivity is recognized as a public health issue, having widespread impacts on health, longevity, and even the economy. Similar to other public health issues over past decades such as sanitation and tobacco use, federal policies may be the best way to coordinate large-scale changes involving cooperation between diverse sectors, including health care, transportation, environment, education, workplace, and urban planning. An active society requires the infrastructure, environment, and resources that promote physical activity. Federal policies can meet those needs by improving access, providing funding, establishing regulations, and developing programs to empower all Americans to move more. Policies also play an important role in removing barriers to physical activity, such as financial constraints and lack of safe spaces to move, that contribute to health disparities. With such a variety of factors impacting active lifestyles, physical activity policies must have inter-agency involvement to be effective.

What physical activity initiatives exist currently?

Analysis of publicly available information revealed that there are a variety of initiatives currently in place at the federal level, across several departments and agencies, aimed at increasing physical activity levels in the U.S. Information about each initiative was evaluated for their correspondence with levels of the social-ecological model, as summarized in the table. Note that it is possible the search that was conducted did not identify every relevant effort, thus there could be additional initiatives that are not included below.

Given the large number of groups with the shared goal of increasing physical activity in the nation, a memorandum of understanding (MOU) may help to promote coordination of goals and implementation strategies.

FIGURE 2. Agency roles

Department or Agency	Existing or Potential Role
Administration for Children and Families (ACF)	ACF’s strategic goals include taking a “preventative and proactive approach to ensuring child, youth, family, and individual well-being.” Physical activity is a powerful preventative and proactive approach.
Administration for Community Living (ACL)	ACL’s Health, Wellness, and Nutrition program addresses behavioral health, prevention of injuries and illness, and chronic disease self-management for aging and disability populations, all of which relate to physical activity, though physical activity is not directly addressed in the program’s goals.
Agency for Healthcare Research and Quality (AHRQ)	AHRQ moves scientific evidence into practice to help healthcare systems and professionals deliver care that is high quality, safe, accessible, equitable, and affordable, and works to ensure that the scientific evidence is understood and used. AHRQ provides support to the U.S. Preventive Services Task Force (USPSTF), which makes recommendations about clinical preventive services including physical activity.
Centers for Disease Control and Prevention (CDC)	The CDC conducts research and provides health information to tackle health problems causing death and disability for Americans, put science into action to prevent disease, and promote healthy and safe behaviors, communities and environment. The CDC has several programs focused on physical activity, partnering with other government agencies and departments as well as other organizations, including the Active People, Healthy Nation program and funding initiatives such as the State Physical Activity and Nutrition Program (SPAN 2023), which supports state-level programs to implement evidence-based strategies to address health disparities related to poor nutrition, physical inactivity, and/or obesity.
Centers for Medicare and Medicaid (CMS)	CMS’ Behavioral Health Strategy is aimed at increasing access to equitable and high-quality behavioral health services and improving outcomes for people covered by Medicare, Medicaid and private health insurance. CMS could play an important role in providing access to gym memberships and exercise prescriptions for both intervention and prevention. Currently, gym memberships or fitness programs may be included in the extra coverage offered by Medicare Advantage Plans depending on the person’s location. Less commonly, coverage is provided by Medicare Supplement (Medigap) plans. For Medicaid, some states cover gym memberships as part of weight loss initiatives or partner with YMCAs or other community organizations to run health programs.
Council on Environmental Quality (CEQ) and Environmental Protection Agency (EPA)	CEQ and EPA coordinate federal environmental activities and the development of environmental policy, which has a reciprocal beneficial relationship with physical activity. For example, to reduce emission and energy use, climate change policies have been introduced to encourage cycling, walking and other forms of sustainable, active transport. Parks and other green spaces that sequester carbon dioxide also provide space for people to be active. Policies that reduce air pollution help to reduce a barrier to exercising outside.
Department of Agriculture (USDA)	The USDA’s strategic priorities include addressing climate change via climate smart agriculture, forestry, and clean energy. Climate, clean air, and spaces for outdoor recreation and camping such as forests are all related to physical activity. The USDA works with the Bureau of Land Management, National Park Service, and others to increase physical activity on federal land (hiking, rafting, biking, etc.), and also provides funding for urban forestry, which promotes physical activity in urban areas.
Department of Education (DE)	The DE sets guidelines for physical education in schools and has provided funding for research on physical activity in schools, such as the Carol M. White Physical Education Program, which awarded grants from 2001-2015 to Local Education Agencies (LEAs) and community-based organizations (CBOs) to initiate, expand, or enhance physical education programs. The DE could also designate physical education as a core subject and ensure that physical activity is not assigned or withheld as punishment.
Department of Housing and Urban Development (HUD)	HUD has an important role in community building and infrastructure. The built environment can support physical activity (e.g., by providing safe spaces for movement). For example, HUD’s Office of Community Planning and Development develops communities by promoting decent housing, suitable living environments, and expanded economic opportunities for low- and moderate-income people. Research shows that receiving HUD housing assistance is associated with higher physical activity levels in low-income Americans. HUD is also involved in the climate action plan.
Department of the Interior (DOI)	The DOI manages public lands and minerals, national parks, and wildlife refuges. Within the DOI, the Bureau of Land Management and National Park Service maximize land use, including recreational activities that involve physical activity in outdoor spaces. The National Park Service promotes health and wellness through the Healthy Parks Healthy People initiative, which involves a collaboration with partners and interdisciplinary teams in the sectors of public health, medicine, conservation, and recreation to put a spotlight on the role of parks as social determinant of health.
Department of Transportation (DOT)	The DOT promotes physical activity in the public sector through building and maintaining sidewalks or trails, as well as connecting them; reducing car dependency; provide increased opportunities for walking and bicycling; encouraging the creation and implementation of policies to support alternate modes of transportation; providing direct investments to supportive infrastructure such as bicycle lanes, greenways, multi use paths, sidewalks and trails; reducing distances between key destinations and providing and improving bicycle and pedestrian facilities; and installing streetlights. For example, the Safe Routes to School Programs, which promotes safe ways for youth to walk or bike to and from school through the funding of infrastructure (e.g., sidewalks) and educational programs, grew out of these federal funding programs. The DOT and its partner agencies also work to address air and noise pollution and reduce greenhouse gas emissions, to improve opportunities for safe, active, multimodal transportation and reduce dependence on vehicles, such as the Clean Air Act and the Congestion Mitigation and Air Quality Improvement (CMAQ) Program.
Department of Veterans Affairs (VA)	The VA’s Veterans Health Administration is America’s largest integrated health care system. Their National Center for Health Promotion and Disease Prevention includes talking to one’s doctor about physical activity as one of their recommended preventive services. The integrated nature of medical care through the VA would promote the implementation of exercise prescriptions to a large and vulnerable population and could serve as a model for more widespread implementation.
Health Resources and Services Administration (HRSA)	HRSA offers programs to improve access to health care for people who are uninsured, isolated, or medically vulnerable, and funds grants and cooperative agreements related to its mission. Funding related to physical activity is directly related to its strategic goal to “Take actionable steps to achieve health equity and improve public health.”
National Institutes of Health (NIH)	As the federal government’s medical research agency, NIH supports physical activity related research in its intramural laboratories and through research funding to scientists at other organizations. Requests for applications (RFAs) and Notices of Special Interest (NOSIs) for exercise-focused research grants can promote continued research on the impacts of physical activity on health.
Office of Minority Health (OMH)	The OMH promotes the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate health disparities. Prevention through physical activity and nutrition is one of OMH’s focus areas, as are clinical conditions including diabetes and hypertension that can be prevented or treated with physical activity.
Office of Personnel Management (OPM)	One role of OPM, which oversees human resources for federal employees, is to help federal agencies integrate prevention strategies into their workplace through worksite health and wellness programs and organizational and employee benefits. Examples include encouraging employees to use flexible work schedules (non-duty time) to participate in health promotion activities, allowing employees to request annual leave, leave without pay, or sick leave (as appropriate) to participate in health promotion programs, and providing short periods of excused absence for health promotion programs and activities officially sponsored and administered by the agency.

The work of several agencies and departments within the federal government relates to physical activity promotion. Current initiatives are in place, but there are also opportunities for additional efforts that could further the goal of creating a more active nation.

FIGURE 3. Agency interactions

Department, Agency, or Division	Individual	Interpersonal	Organizational	Community	Policy
Administration for Children and Families (ACF)		X			X
Administration for Community Living (ACL)				X	X
Agency for Healthcare Research and Quality (AHRQ)	X		X		X
Centers for Disease Control and Prevention (CDC)	X		X
Centers for Medicare and Medicaid (CMS)			X		X
Council on Environmental Quality (CEQ)				X	X
Department of Agriculture (USDA)				X	X
Department of Education (DE)			X		X
Department of Housing and Urban Development (HUD)				X	X
Department of the Interior (DOI)				X	X
Department of Transportation (DOT)				X	X
Department of Veterans Affairs (VA)			X
Environmental Protection Agency (EPA)				X	X
Health Resources and Services Administration (HRSA)	X		X
National Institutes of Health (NIH)	X		X
Office of Minority Health (OMH)	X		X		X
Office of Personnel Management (OPM)			X		X

These and other federal departments and agencies can coordinate action with state and local partners, for example in healthcare, business and industry, education, mass media, and faith-based settings, to implement physical activity policies. 

The CDC’s Active People, Healthy Nation initiative provides an example of this approach. This campaign, launched in 2020, has the goal of helping 27 million Americans become more physically active by 2027. By taking action steps focused on program delivery, partnership engagement, communication, training, and continuous monitoring and evaluation, the campaign seeks to help communities implement evidence-based strategies across sectors and settings to provide equitable and inclusive access to safe spaces for physical activity. According to our analysis, the strategies of the Active People, Healthy Nation initiative are aligned with the social-ecological model. The Physical Activity Policy Research and Evaluation Network, a research partner of the Active People, Healthy Nation initiative, provides an example of coordinating with partners in other sectors to promote physical activity. Through collaboration across sectors, the network brings together diverse partners to put into practice research on environments that maximize physical activity. The network includes work groups focused on equity and inclusion, parks and green space, rural active living, school wellness, transportation policy and planning, and business/industry.

The Biden-Harris Administration National Strategy on Hunger, Nutrition, and Health, announced in September 2022, also includes strategies that are consistent with a social-ecological model. The strategy outlines steps toward the goal of ending hunger and increasing healthy eating and physical activity by 2030 so that fewer Americans will experience diet-related diseases. Pillar 4 of the strategy is to “make it easier for people to be more physically active—in part by ensuring that everyone has access to safe places to be active—increase awareness of the benefits of physical activity, and conduct research on and measure physical activity.” The strategy specifies goals such as building environments that promote physical activity (e.g., connecting people to parks; promoting active transportation and land use policies to support physical activity) and includes a call to action for a whole-of-society response involving the private sector, state, local, and territory governments, schools, and workplaces.

The Congressional Physical Activity Caucus has been active in introducing legislation that can help realize the goals of the current physical activity initiatives. For example, in February 2023, Sen. Sherrod Brown (D-OH), co-chair of the Caucus, introduced the Promoting Physical Activity for Americans Act, a bill that would require the Department of Health and Human Services to continue issuing evidence-based physical-activity guidelines and detailed reports at least every 10 years, including recommendations for population subgroups (e.g., children or individuals with disabilities). In addition, members of the Caucus, along with other members of congress, reintroduced the bipartisan, bicameral Personal Health Investment Today (PHIT) Act in March 2023. This legislation seeks to encourage physical activity by allowing Americans to use a portion of the money saved in their pre-tax health savings account (HSA) and flexible spending account (FSA) toward qualified sports and fitness purchases, such as gym memberships, fitness equipment, physical exercise or activity programs and youth sports league fees. The bill would also allow a medical care tax deduction for up to $1,000 ($2,000 for a joint return or a head of household) of qualified sports and fitness expenses per year.

What progress has been made?

There are signs that some of the national campaigns are leading to changes at other levels of society. For example, 46 cities, towns, and states have passed an Active People, Healthy Nation Proclamation as of September 2023. According to the State Routes Partnership, which develops “report cards” for states based on their policies supporting walking, bicycling, and active kids and communities, many states have shown movement in their policies between 2020 and 2022, such as implementing new policies to support walking and biking and increasing state funding for active transportation. However, more time is needed to determine the extent to which recent initiatives are helping to create a more active country, since most were initiated in the past two or three years. Predating the current initiatives, the overall physical activity level of Americans increased from 2008 to 2018, but there has been little change since that time, and only about one-quarter of adults meet the physical activity guidelines established by the CDC.

Clearly, there is a critical need for concerted effort to implement the strategies outlined in current physical activity initiatives so that national policies have the intended impacts on communities and on individuals. Leveraging provisions in existing legislation related to the social-ecological model of physical activity promotion will also help with implementation. For example, title III-D of the Older Americans Act supports healthy lifestyles and promotes healthy behaviors amongst older adults (age 60 and older), providing funding for evidence-based programs that have been proven to improve health and well-being and reduce disease and injury. Physical activity programs are prime candidates for such funding. In addition, programs under the 2021 Bipartisan Infrastructure Law and the 2022 Inflation Reduction Act are helping to change the current car-dependent transportation network, providing healthier and more sustainable transportation options, including walking, biking, and using public transportation, and are providing investments in environmental programs to improve public health and reduce pollution. For example, states can use funds from the Highway Safety Improvement Program for bicycle and pedestrian highway safety improvement projects, and funding is available through the Carbon Reduction Program for programs that help reduce dependence on single-occupancy vehicles, such as public transportation projects and the construction, planning, and design of facilities for pedestrians, bicyclists, and other non-motorized forms of transportation.

Partnering with non-governmental groups working towards common goals, such as the Physical Activity Alliance, can also help with implementation. The Alliance’s National Physical Activity Plan is based on the socio-ecological model and includes recommendations for evidence-based actions for 10 societal sectors at the national, state, local and institutional levels, with a focus on making change at the community level. The plan shares many priorities with those of the Active People, Healthy Nation initiative, while also introducing new goals, such as establishing a CDC Office of Physical Activity and Health. 

With coordinated action based on established public health models, such as the social-ecological framework, federal policies can be successfully implemented to make the systemic changes that are needed to create a more active nation.

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The work for this blog was undertaken before Dr. Dotson joined the Agency for Healthcare Research and Quality (AHRQ). Dr. Dotson is solely responsible for this blog post’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement as an official position of AHRQ or of the U.S. Department of Health and Human Services.

For over 10 years, physical inactivity has been recognized as a global pandemic with widespread health, economic, and social impacts. Despite the wealth of research support for movement as medicine, financial and environmental barriers limit the implementation of physical activity intervention and prevention efforts. The need to translate research findings into policies that promote physical activity has never been higher, as the aging population in the U.S. and worldwide is expected to increase the prevalence of chronic medical conditions, many of which can be prevented or treated with physical activity. Action at the federal and local level is needed to promote health across the lifespan through movement.

Research Clearly Shows the Benefits of Movement for Health

Movement is one of the most important keys to health. Exercise benefits heart health and physical functioning, such as muscle strength, flexibility, and balance. But many people are unaware that physical activity is closely tied to the health conditions they fear most. Of the top five health conditions that people reported being afraid of in a recent survey conducted by the Centers for Disease Control and Prevention (CDC), the risk for four—cancer, Alzheimer’s disease, heart disease, and stroke—is increased by physical inactivity. It’s not only physical health that is impacted by movement, but also mental health and other aspects of brain health. Research shows exercise is effective in treating and preventing mental health conditions such as depression and anxiety, rates of which have skyrocketed in recent years, now impacting nearly one-third of adults in the U.S. Physical fitness also directly impacts the brain itself, for example, by boosting its ability to regenerate after injury and improving memory and cognitive functioning. The scientific evidence is clear: Movement, whether through structured exercise or general physical activity in everyday life, has a major impact on the health of individuals and as a result, on the health of societies.

Movement Is Not Just about Weight, It’s about Overall Lifelong Health

There is increasing recognition that movement is important for more than weight loss, which was the primary focus in the past. Overall health and stress relief are often cited as motivations for exercise, in addition to weight loss and physical appearance. This shift in perspective reflects the growing scientific evidence that physical activity is essential for overall physical and mental health. Research also shows that physical activity is not only an important component of physical and mental health treatment, but it can also help prevent disease, injury, and disability and lower the risk for premature death. The focus on prevention is particularly important for conditions such as Alzheimer’s disease and other types of dementia that have no known cure. A prevention mindset requires a lifespan perspective, as physical activity and other healthy lifestyle behaviors such as good nutrition earlier in life impact health later in life.

Despite the Research, Americans Are Not Moving Enough

Even with so much data linking movement to better health outcomes, the U.S. is part of what has been described as a global pandemic of physical inactivity. Results of a national survey by the CDC published in 2022 found that 25.3% of Americans reported that outside of their regular job, they had not participated in any physical activity in the previous month, such as walking, golfing, or gardening. Rates of physical inactivity were even higher in Black and Hispanic adults, at 30% and 32%, respectively. Another survey highlighted rural-urban differences in the number of Americans who meet CDC physical activity guidelines that recommend ≥ 150 minutes per week of moderate-intensity aerobic exercise and ≥ 2 days per week of muscle-strengthening exercise. Respondents in large metropolitan areas were most active, yet only 27.8% met both aerobic and muscle strengthening guidelines. Even fewer people (16.1%) in non-metropolitan areas met the guidelines.

Why are so many Americans sedentary? The COVID-19 pandemic certainly exacerbated the problem; however, data from 2010 showed similar rates of physical inactivity, suggesting long-standing patterns of sedentary behavior in the country. Some of the barriers to physical activity are internal to the individual, such as lack of time, motivation, or energy. But other barriers are societal, at both the community and federal level. At the community level, barriers include transportation, affordability, lack of available programs, and limited access to high-quality facilities. Many of these barriers disproportionately impact communities of color and people with low income, who are more likely to live in environments that limit physical activity due to factors such as accessibility of parks, sidewalks, and recreation facilities; traffic; crime; and pollution. Action at the state and federal government level could address many of these environmental barriers, as well as financial barriers that limit access to exercise facilities and programs.

Physical Inactivity Takes a Toll on the Healthcare System and the Economy

Aside from a moral responsibility to promote the health of its citizens, the government has a financial stake in promoting movement in American society. According to recent analyses, inactive lifestyles cost the U.S. economy an estimated $28 billion each year due to medical expenses and lost productivity. Physical inactivity is directly related to the non-communicable diseases that place the highest burden on the economy, such as hypertension, heart disease, and obesity. In 2016, these types of modifiable risk factors comprised 27% of total healthcare spending. These costs are mostly driven by older adults, which highlights the increasing urgency to address physical inactivity as the population ages. Physical activity is also related to healthcare costs at an individual level, with savings ranging from 9-26.6% for physically active people, even after accounting for increased costs due to longevity and injuries related to physical activity. Analysis of 2012 data from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey (MEPS) found that each year, people who met World Health Organization aerobic exercise guidelines, which correspond with CDC guidelines, paid on average $2,500 less in healthcare expenses related to heart disease alone compared to people who did not meet the recommended activity levels. Changes are needed at the federal, state, and local level to promote movement as medicine. If changes are not made in physical activity patterns by 2030, it is estimated that an additional $301.8 billion of direct healthcare costs will be incurred.

Government Agencies Can Play a Role in Better Promoting Physical Activity Programs

Promoting physical activity in the community requires education, resources, and removal of barriers in order for programs to have a broad reach to all citizens, including communities that are disproportionately impacted by the pandemic of physical inactivity. Integrated efforts from multiple agencies within the federal government is essential. 

Past initiatives have met with varying levels of success. For example, Let’s Move!, a campaign initiated by First Lady Michelle Obama in 2010, sought to address the problem of childhood obesity by increasing physical activity and healthy eating, among other strategies. The Food and Drug Administration, Department of Agriculture, Department of Health and Human Services including the Centers for Disease Control and Prevention, and Department of Interior were among the federal agencies that collaborated with state and local government, schools, advocacy groups, community-based organizations, and private sector companies. The program helped improve the healthy food landscape, increased opportunities for children to be more physically active, and supported healthier lifestyles at the community level. However, overall rates of childhood obesity remained constant or even increased in some age brackets since the program started, and there is no evidence of an overall increase in physical activity level in children and adolescents since that time.

More recently, the U.S. Office of Disease Prevention and Health Promotion’s Healthy People 2030 campaign established data-driven national objectives to improve the health and well-being of Americans. The campaign was led by the Federal Interagency Workgroup, which includes representatives across several federal agencies including the U.S. Department of Health and Human Services, the U.S. Department of Agriculture, and the U.S. Department of Education. One of the campaign’s leading health indicators—a small subset of high-priority objectives—is increasing the number of adults who meet current minimum guidelines for aerobic physical activity and muscle-strengthening activity from 25.2% in 2020 to 29.7% by 2030. There are also movement-related objectives focused on children and adolescents as well as older adults, for example:

• Reducing the proportion of proportion of adults who do no physical activity in their free time
• Increasing the proportion of children, adolescents, and adults who do enough aerobic physical activity, muscle-strengthening activity, or both
• Increasing the proportion of child care centers where children aged 3 to 5 years do at least 60 minutes of physical activity a day
• Increasing the proportion of adolescents and adults who walk or bike to get places
• Increasing the proportion of children and adolescents who play sports
• Increasing the proportion of older adults with physical or cognitive health problems who get physical activity
• Increasing the proportion of worksites that offer an employee physical activity program

Unfortunately, there is currently no evidence of improvement in any of these objectives. All of the objectives related to physical activity with available follow-up data either show little or no detectable change, or they are getting worse.

To make progress towards the physical activity goals established by the Healthy People 2030 campaign, it will be important to identify where breakdowns in communication and implementation may have occurred, whether it be between federal agencies, between federal and local organizations, or between local organizations and citizens. Challenges brought on by the COVID-19 pandemic (e.g., less movement outside of the house for people who now work from home) will also need to be addressed, with the recognition that many of these challenges will likely persist for years to come. Critically, financial barriers should be reduced in a variety of ways, including more expansive coverage by the Centers for Medicare & Medicaid Services for exercise interventions as well as exercise for prevention. Policies that reflect a recognition of movement as medicine have the potential to improve the physical and mental health of Americans and address health inequities, all while boosting the health of the economy.