The Promotion and Practice of Physical Activity in the United States

Li Changqing，Steven N.Blair，Xiong Kaiyu

1 Sport Science College，Beijing Sport University，Beijing 100084，China 2 Arnold School of Public Health，University of South Carolina，Columbia，SC，USA 29208 3 Teaching and Experimental Center，Beijing Sport University，Beijing 100084，China Corresponding Author：Xiong Kaiyu，Email：xiongkaiyu@vip.sina.com

The Promotion and Practice of Physical Activity in the United States

Li Changqing1，Steven N.Blair2，Xiong Kaiyu3

1 Sport Science College，Beijing Sport University，Beijing 100084，China 2 Arnold School of Public Health，University of South Carolina，Columbia，SC，USA 29208 3 Teaching and Experimental Center，Beijing Sport University，Beijing 100084，China Corresponding Author：Xiong Kaiyu，Email：xiongkaiyu@vip.sina.com

Regular physical activity（PA）is beneficial for improving health and quality of life for people of all ages. However，according to Healthy People 2020，only 18.8%of adults in the Unites States meet the recommendations for both aerobic PA and muscle-strengthening activity.Given the benefits of PA and the low participation rate，researchers and practitioners have made great efforts to promote PA at the population level in the United States.This review will introduce strategies for PA promotion in the United States，and briefly discuss the frameworks and behavioral change theories that support these PA interventions.

physical activity，sedentary behavior，active lifestyle

2010年，美国出台了《全民体力活动促进计划》（The National Physical Activity Plan，NPAP），该计划包含了政策推荐、实践经验及措施等一系列增加居民体力活动的策略，试图通过在全国范围内营造“活跃的生活方式”的文化氛围，促进更多人达到《2008美国人体力活动指南》中的体力活动推荐量。《全民体力活动促进计划》的内容涉及公共卫生、教育、城市规划、医疗保健、企业及行业、休闲娱乐及运动健身、非营利机构和大众传媒在内的8个领域，共有5个总策略、52个特定部门的策略及相对应的215个分策略，且部分策略制定了一年及五年目标。2011年，专家组对《全民体力活动促进计划》进行了过程评价，以监督计划的实施情况，并为计划的改进提供建议。过程评价采用定性及定量研究方法，对一年内开展的活动、目标完成情况、经验教训等进行总结。这一年内，《全民体力活动促进计划》的实施取得了可喜成绩，但仍存在诸多挑战，如缺乏长期的资金支持、各领域之间需加强沟通及合作、计划内容需及时更新以保证与体力活动及公共卫生领域的发展同步等。

人的体力活动是一种复杂的行为，按照不同行为改变理论，其影响因素亦不同。许多科学研究及实践已经采用行为改变理论为指导进行体力活动的干预，以保证干预效果。有些行为改变理论（如生态学模型）认为，支持性政策是促进行为改变的有效手段之一。在制定支持性政策的复杂过程中，政策分析框架将有助于政策的设计及对政策实施效果进行评估。本文简要介绍常用于促进体力活动增加的政策分析框架：社区行动模型（Community Action Model）、RE-AIM框架（RE-AIM Framework）和健康影响评估（Health Impact Assessment），以及常用于促进体力活动增加的行为改变理论：生态学模型（Ecological Model）、社会认知理论（Social Cognitive Theory）和跨理论模型（Transtheoretical Model）。

本文还通过3项研究实例，增加读者对生活方式干预研究的进一步认识。本文希望通过对当前美国有关体力活动促进的经验介绍，为制定或完善体力活动计划及体力活动干预方案提供参考。

1 Background

Physical inactivity is considered to be the biggest public health problem of the 21st century[1].Global statistics estimate that physical inactivity causes 6%of coronary heart disease，7%of type 2 diabetes，10%of breast cancer，and colon cancer and 9%of premature mortality；in 2008，5.3 million of the 57 million deaths that occurred worldwide were attributed to physical inactivity[2]. Over the last 50 years in the United States，occupationrelated moderate physical activity（PA）has decreased progressively，and the corresponding energy expenditure has been reduced by over 100 calories per day[3].Less time required for household management has reduced energy expenditure in women，and both women and men spend more time in sedentary activities[4].According to the 2003-2004 National Health and Nutrition Examination Survey，individuals age six years and older in the U.S.spent 7.7 hours per day，or about 55%of their waking time，in sedentary behaviors such as watching TV，playing video games or searching the internet[5].These data demonstrate the importance of promoting popul ationhealthvia increasing levels of PA.This paper will briefly introduce the promotion and practice of PA in the United States.

2 Strategies of Physical Activity Promotion in the USA：National Physical Activity Plan

The release of the 2008 Physical Activity Guidelines for Americans was a landmark event in the history of PA promotion in the field of public health.The Guidelines provided detailed recommendations on the types and amounts of PA that people should perform to ensure health benefits[6].However，the Guidelines alone were insufficient to change people’s sedentary behavior and help them become more physically active.Although physicalactivityisanindividualbehavior，itis influenced by social，policy，cultural，and environmental factors that must be addressed in order to increase population levels of PA[7].Therefore，a plan was needed to help all Ameri-cans achieve the levels of PA recommended in the Guidelines.

The N ationalPhysicalActivityPlan（NPAP）of the U.S.was launched in 2010（available online：http：//www.physicalactivityplan.org/theplan.php）.It isacomprehensivesetofstrategies，including recommended policies，practices，and initiatives，that aim to build a national culture that supports physically active lifestyles[8].The NPAP focuses on 8 societal sectors：Public health；Education；Transportation，land use，and community design；Healthcare；Businessandindustry；Parks，recreation，fitness，and sport；Volunteer and non-profit organizations；and Mass media.It includes 5 primary strategies and 52 sector-specific strategies，with 215 correspondingtactics，alldesignedtopromotePA nationally.Some of the strategies include one year and five year goals.

Characteristics of the NPAP include the following[7，8].First，the NPAP was developed by a private-public collaborative partnership，which allowed the NPAP to go forward with efficiency and effectiveness.Second，the NPAP focused on multiple sectors of society in order to reach all members of the population.Third，the NPAP Coordinating Committee invited experts to summarize practical evidences on policy，systems，and environmental changes as recommendations for the Plan to ensure the widespread adoption of the NPAP.Fourth，development andimplementationoftheNPAPinvolvedbroad participation of diverse organizationsandgroupsto ensure its relevance for all population groups.Fifth，the NPAP is updated regularly in order to ensure that it continues to meetthePAneedsoftheAmerican population.

Process evaluation of the NPAP was performed during 2011，and the results were used tomonitor objectives and provide feedback for further improvement. Activities in each sector were reported quarterly via an internet-based reporting system.Qualitative interviews were conducted by telephone at the end of 2011 to reflect on the accomplishments and lessons learned during the year.The evaluation team also collected notes from meetings as supplemental information.Some sector leaderssaidthatthisprocessevaluationnotonly summarizedtheaccomplishments，butalsoprovided motivation for their ongoing activities[9].Example strategies，goals，and accomplishments of the 6 sectors that were evaluated，based on the 2011 Evaluation Report on Sector Activities for the U.S.NPAP（Available online：http：//www.physicalactivityplan.org/evaluation.php），are listedinTable1.Thevolunteerandnon-profit organizations and mass media sectors were not included，

asthosesectorsdidnotdefinestrategiesinthe implementation plan[10].

Table 1 Example Strategies，Goals，and Activities for the 6 NPAP Sectors

Dr.Russell R.Pate，the president of the National Physical Activity Plan Alliance，which oversees implementation and evaluation of the NPAP，says that the NPAP hasachievedsomeimportantsuccessesandhas benefitted from several decisions made by the NPAP's founding leadership team.These include the decision to develop the NPAP base on a private-public collaborative partnership，to build a coalition of national nonprofit organization，to ensure collaboration between academics andprofessionals，andtokeepaprimaryfocuson activities that are directly connected to the NPAP itself.

Also according to Dr.Pate，important challenges remain.A sustainable business model is needed for longterm financial support of the NPAP.Partnerships with organizations must be built to implement the strategies of the NPAP，and the NPAP needs to be updated regularly to keep pace with current developments in PA and public health.The process of reviewing，revising，and refining the NPAP is underway，and the updated Plan，which is anticipated to be released in 2015，will add faith-based settings as a sector and remove the volunteer and nonprofit organizations sector[11].The evaluation will move from process evaluation towards short-term impacts and long-term outcomes of the NPAP[9].The lessons learned to date from the implementation of the NPAP may be helpful to those who are developing evaluations for national PA plans or other national-level plans in the field of public health[7].

3 HowtoIncreasePhysicalActivityor Reduce Sedentary Behavior in Practice

Most people realize that PA has beneficial effects on their health，but not enough people are meeting the current PA recommendations[6].In order to increase the potential to improve the health of populations，the application of theoretical models to develop comprehensive PA interventions is increasing.According to the ecologic model，policy is one of the determinants of human behavior and may favorably or unfavorably impact PA[12]. PA professionals intend to design PA interventions with policy changes combined with other strategies to maximize and sustain their impact in large populations.In this section，wewillintroducesomepolicyanalysis frameworks and theoretical behavior change foundations that can be applied to PA interventions and illustrate 3 PA intervention studies from the U.S as examples.

3.1 Policy Analysis Frameworks that Target PA

Enacting policy changes to promote PA can be a complicatedprocessandrequiresapolicyanalysis framework to help design and evaluate health policies. This section will emphasize three frameworks that are commonly applied to PA policy change efforts：The Community Action Model，the Reach Effectiveness Adoption Implementation Maintenance（RE-AIM）framework，and the Health Impact Assessment（HIA）.The choice of framework depends on the specific context and the target policy.

3.1.1 Community Action Model

The Community Action Model is an ecologic framework with 5 strategies（5Ps）to promote PA via policy and environmental changes combined with traditional behavioral interventions[13].The 5Ps include preparation，promotions，programs，physical projects，and policy.Preparation is the process of preparing and reinforcing action that includes developing and maintaining partnerships，collecting information，identifying funding and resources fortheprogram，andprovidingappropriatetraining. Promotions include the development of information and advertisements via media，which are the main way to educate people.Programs are organized activities that directly or indirectly engage individuals in PA.Projects provide opportunities or remove barriers to PA through environmental changes.Policies in the public health area include laws，regulations，formal and informal rules，and agreements that are designed to improve populationbased health[14].The Community Action Model has been shown to be useful for building environments that support active living in communities[13]and active transportation to school initiative in elementary schools[15].The applications of community action models suggest intervention efforts are maximized when interventions use multiple strategies，rather than focusing only on policy change[13，15].

3.1.2 RE-AIM framework

RE-AIM is typically used to conceptualize and evaluate the public health impact of health promotion interventions[14].As a policy analysis framework，RE-AIM helps to consider how a policy change will spread among different groups of people and to identify the population（s）that will benefit the most[16].The framework includes[14]：

Reach（the number，percentage，and characteristic of persons who receive or are affected by the initiative，intervention，or program），Effectiveness（the consequences of intervention effects，including potential positive and negative effects，quality of life，and economic outcomes），Adoption（the number，percentage，and typical settings that adopt the target policy or program），Implementation（thefidelityofintervention，suchasthedelivery consistency，time，andthecostofintervention），and Maintenance（the extent to which a program or policy becomes institutionalized or part of the routine organizational practices and policies at organization level，or long-term（6 or more months）effects of a program or policy at individual level）.For example，the RE-AIM framework has been used to identify the most effective and generalizable policies and environmental strategies for promoting healthy eating and active living to prevent childhood obesity，and to provide evidence for policy makers to use when designing policies[17].

The following questions should be answered when applying the RE-AIM framework to plan or evaluate policy[14]：Whose health is to be improved as a result of the policy?What organization or governing body has the responsibility to pass or adopt the policy?Who has the responsibility to adhere to or obey the policy?And what organization，institution，orgoverningbodyhasthe responsibility to enforce the policy?

3.1.3 Health Impact Assessment（HIA）

Health Impact Assessment（HIA）is a practical approach to identifying the potential health impacts of a current or proposed policy or project（http：//www.cdc.gov/ healthyplaces/hia.htm）.The essential premise of HIA is that all public decisions should consider their impact on public health[18]，and the HIA process can be used to consider and analyze the health effects of proposed policies. The major steps to carry out HIA include[18]：Screening（identify whether a HIA is useful to the projects or policies），Scoping（identify which health effects to consider），Assessment（identify the baseline condition of the target population and evaluate the health risks and benefits that may be affected），Recommendations（develop suggestions to improve the project，plan or policy and/or to minimize adverse health effects），Reporting（present the results to decision-makers），and Monitoring and evaluating（determine the effects of the HIA on the decision-making process，the decision，the implementation of the decision，and the impacts of the decision on health determinants）.The application of HIA can raise awareness of public health issues among decision makers in non-health-related sectors.For example，organizations in the transportation or land use sector may take bicycle pathsintoconsiderationinordertohelpresidents become physically active.HIA has been shown to be a useful tool to promote public health[19].

3.2 Theoretical Behavior Change Foundations

Behavioral change theories are broadly applied to provide a framework to understand and explain factors that promote or impede behavior change，and to improve the success of interventions.We will briefly introduce threetheoriesfrequentlyusedinPAintervention：Ecological Model，Social Cognitive Theory，and Transtheoretical Model.

3.2.1 Ecological Model

The Ecological Model（EM）for behavioral change focuses on both individual and social environmental levels that may influence human behavior.It emphasizes the importance of interventions that target interpersonal，institutional，community，andpublicpolicyfactorsfor healthybehaviorchanges.EMassumesthatproper changes in the social environment will yield beneficial changes in individuals；therefore，it is vital to implement environmental interventions to support positive behavior change for individuals[12].The determinants of the EM and examples are shown below.

Intrapersonal factors include characteristics of the individual，such as knowledge，attitudes，behavior，and skills.Education programs can be conducted to increase exercise knowledge and teach specific sport skills to motivate individuals to become physically active.Interpersonal factors include individuals'formal or informal social networks and social support，including family，colleagues，and friends.For example，having a physically active family member may encourage a person to exercise regularly.Institutional factors include the social and physical environment of institutions or organizations，such as workplaces and schools.Having gym facilities or physical activity classes available at the workplace，for example，could greatly increase employees’PA participation.Community factors refer to the social and physical environment of neighborhoods and cities，such as having safeandaccessibleparksintheneighborhoodto facilitate exercise.Public policy refers to legislation，

rules，and policies at all levels of government.For example，allowing community members to use school playgrounds before or after school can promote PA participation in the community[12，16].

3.2.2 Social Cognitive Theory

According to the social cognitive theory（SCT），severalcoredeterminantsinfluencebehavior.First，knowledge refers to understanding the health risks and benefitsofdifferenthealthpractices.WithPA，for instance，knowledgeofPAbeneficialtoindividuals' health is important for a sedentary person to become physically active.Second，perceived self-efficacy refers to the confidence that individuals can exert control over their behaviors.Self-efficacy is considered to be the primary determinant of SCT.The belief that individuals can create anticipated health benefits via regular exercise would motivate people to be physically active.Third，outcome expectations represent the expected effectiveness after behavior change.Outcome expectation is the second importantdeterminantofSCT.Forexample，the expectations of decreased blood pressure via aerobic PA will encourage people with hypertension to engage in regular exercise.Fourth，the health goals that individuals set for themselves help to facilitate behavioral change. Setting short term and long term goals are important for individualstomaintainregularPA.Last，people encounter perceived facilitators and social as well as structural barriers during their efforts to change their behavior[20].For example，lack of time is one of the most common barriers to exercise.Understanding perceived facilitators and barriers is essential to developing health habits.

Meta-analysis evidence suggests that SCT is a worthwhile framework to explain PA behavior，and that self-efficacy and goals are the primary determinants related to PA in SCT.PA interventions may be more effective if researchers can design specific strategies that improve self-efficacy and emphasize goal setting and self-monitoring[21].

3.2.3 Transtheoretical Model

The Transtheoretical Model（TTM）is a stage-based model that focuses on the individual level and the psychological change that takes place in different stages[22].TTM conceptualizes behavior change as a five-stage process：precontemplation，contemplation，preparation，

action，and maintenance；movement through the stages is cyclical rather than linear and barriers in each stages are different.TTM proposes that interventions will be most effective when personalized to an individual's current stage of change.With exercise，for instance，the TTM classifies people as[22，23]：（1）Precontemplation.Individuals in the precontemplation stage do not exercise and do not plan to exercise within the next 6months.（2）Contemplation.Individuals in this stage do not exercise but are planningtostartwithin6months.（3）Preparation. Individuals in preparation are planning to start exercising within1 month and are already prepared for change.（4）Action.Individuals in action have engaged in exercise，but for less than 6 months.（5）Maintenance.Individuals in maintenance have been exercising for 6 months or more.Review studies have indicated that the effectiveness of TTM-based PA or exercise interventions were not clear，because the majority of interventions reported to be based on the TTM failed to accurately represent all dimensions of the model[22，24，25].Spencer et al[25].proposed some suggestions for policy makers and practitioners when applying TTM to exercise interventions.First，it is important to include the entire TTM，particularly the processesofchange，whendesigninginterventions. Second，due to the limited evidence，practitioners should carefullyapplyTTMtoadolescents，minorities，and underserved populations.Third，it is important to clearly define the term of"exercise"for the accurate staging of individuals.

3.3 Examples of Physical Activity Intervention Studies

3.3.1 The Lifestyle Intervention and Independence for Elders（LIFE）Study

As the number of older adults in the United States increases rapidly，it is vital for older Americans to maintain functional independence and improve their quality of life.The LIFE Study conducted a pilot study from 2004 to 2006 to determine the feasibility of using physical exercise to prevent mobility disability in older persons[26].The LIFE pilot study showed that a structured PAinterventionsignificantlyimprovedthephysical performance of these older adults[27].Based on the pilot data，the LIFE Study investigative team conducted a fullscale，multicenter，single-blinded，and randomized controlled trial during 2010 to 2013，to compare a long-term structured PA program with a successful aging health education program in reducing the risk of major mobility disability.The study included 1635 sedentary partic-

ipants from eight centers aged 70-89 who had physical limitations（but were able to walk 400meters）throughout the United States.They were randomized to a structured，moderate-intensity PA program conducted in a training center（twice/wk）and at home（3-4times/wk）that included aerobic，resistance，and flexibility activities or to a health education program that involved workshops related to elders as well as upper extremity stretching exercises.To maximize the effects of the intervention，the behavior change interventions were designed based on SCT and TTM，and combined with an approach of group-mediated cognitive-behavioral intervention[28].The primary outcome of this study was that the incidence of major mobility disability（described as the inability to walk 400 meters in 15 minutes）was 30.1%in the PA group and 35%in the health education group during an average 2.6 years of follow-up.Among participants in the PA group，14.7% experienced persistent mobility disability，compared to 19.8%in the health education group[29].The LIFE Study demonstrated that a structured，moderate-intensity PA program was beneficial for mobility and provided a strong evidence for both health care providers and community health systems to promote PA for vulnerable ambulatory older adults.

3.3.2 The Active Living Every Day（ALED）Program

The ALED Program is a step-by-step behavior change program that is based on ALED courses in the book[30]and online resources（http：//www.activeliving.info/ index.cfm）designed to help individuals overcome barriers to becoming physically active.ALED is based on the principles and concepts of TTM and SCT and has been proven effective in clinical trials[31].The course text was updated in 2011 based on feedback from participants and providers，whichmadeALEDsuitabletoabroader population.ALEDemphasizeslifestylemanagement skills，stresses a gradual change in PA behavior，enables flexible options to deliver the program in groups，online，via phone or face-to-face coaching，or through individual self-learning.The program can be tailored to individuals' status and characteristics.It has proven effective in creating long-term behavior change used in a number of situations and with numerous groups[32-35].

3.3.3 The Lifestyle Education for Activity and Nutrition（LEAN）Study

According to the data from the U.S.Centers For Disease Control and Prevention，the percent of adults older than 20 who were overweight or obese was as high as 69%in 2011-2012[36].Maintaining weight loss is still challenging，even though weight loss programs are proven effective in short-term.The LEAN Study was a groupbased，electronic self-monitoring lifestyle weight loss program.The aim of the study was to examine whether a self-monitoring device，called the SenseWear armband，that provides real-time feedback on energy balance，could improve weight loss maintenance.197 sedentary overweight or obese adults aged 46.8±10.8 years were randomized into 1 of 4 groups，a self-directed weight loss program via an evidence-based weight loss manual（standard care），a group-based behavioral weight loss program（GWL），the armband alone（SWA），or the GWL plus the armband（GWL+SWA）.The GWL and the weight loss manual were adapted from two evidencebased behavior change programs，ALED and Healthy Eating Every Day（HEED）.The theoretical frameworks for both programs are SCT and the TTM.GWL offered 14 group sessions to learn the ALED and HEED curriculum in the first 4 months，followed by 6 one-on-one telephone counseling sessions in the remaining 5 months. The counseling used the TTM as a framework for participants to improve maintenance of behavior change[37].The primary outcomes showed that body weight was significantly reduced in all 3-intervention groups at 9 months，but only the GWL+SWA group was statistically different at 9 months when compared with the standard caregroup.Waistcircumferencewassignificantly reduced in all 4 groups at 9months，but the intervention groups were not significantly reduced when compared to the standard care group.Economic analysis showed that the technology-based approaches（SWA）were more cost effective than traditional approaches to promote weight loss in the LEAN cohort[38].The LEAN Study indicated that real-time feedback from self-monitoring technology combined with a group-based behavioral intervention might be useful to enhance lifestyle changes and yield optimal weight loss in sedentary overweight or obese adults[39].

4 Summary

It is essential to develop comprehensive plans to get more people to be physically active to decrease chronic disease morbidity and mortality.Developing translational interventions and taking advantage of modern technology

can help reach large populations at a low cost，but implementingtheseapproachesremainschallenging. Other countries can learn from the current practice of PA promotion in the United States when applying policy and theory-based strategies to increase PA levels of the nation.

Acknowledgement

We greatly appreciate Dr.Xuemei Sui for her guidance of outlining and drafting the review paper as wellasGayeChristmus，DanielAaronGraves，and Leonard John Myers for their editorial contributions to the manuscript.

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规律的体力活动有助于提高人的健康状况及生活质量。然而，美国《2020健康人群》中的数据显示，仅有18.8%的美国成年人达到了《2008美国人体力活动指南》（2008 Physical Activity Guidelines for Americans）中提出的有关有氧活动和强壮肌肉活动的推荐量。为此，美国在提高居民体力活动水平上做出了不懈的努力。本文简要介绍美国为促进全民体力活动采取的主要策略、有助于体力活动干预研究的政策分析框架、行为改变理论及3项研究实例。

体力活动；静坐少动行为；活跃的生活方式

2015.09.18

国家建设高水平大学公派研究生项目（201306520007）

熊开宇，Email：xiongkaiyu@vip.sina.com