Ben Levine, MD

These guidelines not a large change from what the guidelines were previously, with a few notable exceptions. Perhaps the most important change was to emphasize the personal and public health benefits of making the transition from a sedentary to an active lifestyle. One strategy that was taken was to remove any specific time ranges on specific exercise bouts and rather emphasize that any activity is better than no activity.

Although I am somewhat skeptical about the adverse physiological consequences of sitting by itself, and am not convinced that there are biological benefits of brief periods of standing or walking short distances, I am very much in favor of people who are previously very sedentary becoming active. I agree completely with that focus of the guidelines (to do anything that gets you moving) as the place to start because the key to adopting an active lifestyle is making it part of your personal hygiene.

Perhaps the most important next policy step I’d like to see adopted by HHS to advance these guidelines is to ensure adequate reimbursement for the time and effort required to implement these guidelines in a practice setting. For example, I was pleased to see Adm. Giroir emphasize the Physical Activity Vital sign, which was developed at Kaiser Permanente by Robert E. Sallis, MD, and which we are implementing here in north Texas at Southwestern Health Resources. It asks two simple questions as part of the patient intake in the electronic medical records (along with BP, pulse, body weight, etc.) to determine whether patients are meeting physical activity guidelines; if not, an alert is provided.

The next step though is to ensure that practices are reimbursed for spending time with patients providing advice about how to increase physical activity. A new ICD-10 code was just released last month to allow exercise counseling, and I’d like to see this promoted as part of the effort to advance the guidelines. Perhaps more importantly though, I’d like to see exercise professionals be compensated like physical therapists for working with patients to improve their fitness, not just in cardiac rehab or after an injury, but for overall health promotion.

Editor's Note: This perspective was updated on Nov. 14, 2018 with major changes from Dr. Levine.

John P. Higgins, MD, MBA, MPhil, FACC, FAHA, FACP, FACSM, FASNC, FAGC

I would sum these guidelines up with the phrase, “Just move it.” It looks like the main message is any physical activity is essentially better than none, and I agree with that. For example, someone doing a little bit of gardening or sweeping around the house for 10 minutes in the morning, walking up and down some stairs or doing a lap at work at lunch time for 15 minutes.

The idea is that everything, no matter how minimal, is a good thing that counts. The idea is to have someone start off small. For example, they recommend that walking is the easiest exercise — and I agree with that for most individuals — and build on what they’re doing. These mini-wins of activity will add up to maxi-wins down the line.

This is a great way for people to try to maintain their weight. They also discuss diet and other aspects that are important.

The main take home is if you can think about being active, have that on your mind and try to do something active through the day, that’s going to accrue your benefits.

Also, I like the fact that they talked about how the AHA is going to support the guidelines and that there are a lot of other areas like business and industry, community, recreation, fitness and parks, education settings, faith-based settings, wherever people spend their time.

Work is a big portion of people’s time. It’s typically 40 to 100 hours a week, so anything that businesses can do to try to increase activity will help. That means everything from standing/exercise desks to having some exercise program, yoga program or stretching program at work, which a lot of people are doing now, and also having competitions with activity trackers and rewarding the team at work that gets the most steps for the week, having a small gym or supporting gym memberships at work, inviting in health and wellness motivators/speakers and having an annual wellness day at work.

In the community, it would be great to have more places where people can walk and exercise, some more outdoor exercise areas and parks, better foot paths and making exercise mandatory at schools. Two-thirds of Americans don't have a park/playground within walking distance of their homes, and we need to fix this. We still don’t have that and that’s an important thing that we can do. We make immunization mandatory in a lot of schools and exercise is medicine, so this is just as important as that.

I like the ranges provided in the guidelines. A lot of people could do 150 minutes of moderate exercise or 75 minutes of vigorous or high intensity exercise. I like the fact that they’re saying if the minimum should be that, but you should be targeting for adults 150 to 300 minutes of moderate exercise or 75 to 150 minutes of vigorous exercise. That’s also stepping it up a bit compared to some of the other guidelines that are out there.

They also mention the importance of resistance or muscle building for the health of the muscles and bones and for older people and the importance of the balance and flexibility for everyone, but certainly for the older people.

The bottom line is that we know that "exercise is medicine." It’s something that everyone agrees with, both providers and patients. We have anything that we can do to encourage activity across the population, both young and old. That is the goal, and these guidelines speak to that goal. They talk about children, adults and the elderly and all of the different things that are possible in how to do it.

We should try to get people whatever they like doing, as it is important. We need to monitor them with objective data.

A lot of people are using the activity trackers now, often through their smartphones. The next phase is we know what people should be doing, but can we get better at getting them to actually to do that? That’s where the monitoring and the rewards will come in to help people to achieve these new guidelines. Everything from benefits at work to reduction in insurance premiums are objectively improving healthy lifestyle in employees.

Importantly, we’re moving towards this now, this is going to be the future, that every patient encounter will have not only an exercise history, but they will leave with a prescription and down the line, particularly people that are not experienced in exercise, perhaps several sessions with an exercise specialist so they can teach them the correct form, function and how to actually do the exercise. They would go out with someone who’s an expert to make sure they’re on the right path and that they’re doing it right, so then we can cut them loose and check in with them periodically with monitoring. Someone once said, "Every journey begins with a simple step." I see these new guidelines as a first step in motivating all Americans in their journey towards improved health and wellness.

Michael S. Emery, MD, MS, FACC

Quite frankly, not a whole lot has changed with these guidelines. The core of the guidelines didn’t change. There’s a big emphasis on move more, sit less, which I would agree with. They took out that minimum of 10 minutes at a time.

I read some article where one of the coauthors said this is the next best thing since sliced bread. We’re going to eliminate this 10-minute thing that has clearly been the problem. In over a decade, I’ve never had a patient tell me I don’t exercise because the guidelines say I have to do it for 10 minutes at a time and I can’t do that.

The whole document is about 118 pages, which basically can be summed up with “get off the couch.”

Science is great, but the key is figuring out a way to get people to move. We must find out actual ways to incentivize people or to get them to come to reality that this is how they’re going to improve their health, longevity and their life. Writing it down on a piece of paper is not going to do that.

I’m worried about conflicts of interest in these authors. I can’t specifically point to it. There’s an article from CrossFit, Inc. (https://keepfitnesslegal.crossfit.com/2017/03/31/crossfits-attempted-comment-on-the-national-physical-activity-guidelines/), who did a really good job of exposing a lot of soda and beverage industry conflicts in exercise science that it is actually appalling to that extent. They are some conflicts in this document as well.

In essence, the document is OK. Health isn’t about just getting off the couch. It’s nutrition as well, and you can’t out-walk whatever you do with your fork. They cannot be completely disengaged from each other in order to actually improve health.

Recently the Gallup surveys came out, showing that 37 states had a rise in obesity. Not a single state declined, and they’ve all gone up. That just proves that we need to do more. We also need to eat less sugar. “Off the carbs, off the couch” is what I preach to all my patients. Keep it simple.

I do not think the removal of the 10-minute minimum will have a significant impact. Most people didn’t know that was even in there, or the other suggestions about duration.

The guidelines are written towards agencies and health professionals, but we don’t incentivize physicians to even talk about it because they’re too busy talking about everything else and the medications. It’s unclear whether physicians really understand exercise and nutrition. In fact, it’s not unclear. It’s clear that we don’t understand it. It’s not taught in most medical schools. There’s a slow increase and a few uptakes of these about exercise and medicine, although that’s another topic of controversy because of the soda funding of that program at the American College of Sports Medicine. Culinary medicine, lifestyle medicine and functional medicine are where we have to start moving people towards as part of their routine health care. Exercise is a part of that, it’s a huge part of it, but so is nutrition. Nutrition may even be a bigger part of that, but you can’t ignore one for the other.

Writing “move more, sit less” on a piece of paper doesn’t mean that we’ve created programs that structure an infrastructure and incentive to do it. That’s where we have to take this next big step, is to create the infrastructure, the structure and the incentives for people to do it and truly understand how important this is to their health in addition to nutrition, not smoking and all these things that drive chronic disease.

Exercise may be the most powerful pill that we have for chronic disease, but you can’t swallow it. We’ve pushed so many people into taking pills for everything that we have start to reshaping our entire paradigm. We didn’t get this way overnight. It’s been this way for decades. Switching is going to take some time, but it takes some hard choices.