HEALTH & FITNESS A TO Z
Guidelines for Physical Activity and Health
in the United States: Evolution over
50 Years
by William L. Haskell, Ph.D., FACSM
CURRENT STATUS OF PHYSICAL ACTIVITY AND PUBLIC
HEALTH GUIDELINES
In November 2018, the U.S. Department of Health and Hu-
man Services (DHHS) issued the second edition of Physical Activ-
ity Guidelines for Americans (1). These guidelines are considered to
be the “official” guidelines for physical activity and public health
in the United States. The guidelines are official in that all mes-
saging and programs dealing with physical activity and health
published or supported by the U.S. Federal Government should
use, or at least be consistent with, these guidelines. The first edi-
tion of the guidelines was issued in 2008 by DHHS and provided
recommendations for youth, adults, and older adults (2). The
guidelines were developed from research published over the past
70 years, along with previous guidelines or recommendations
issued by professional organizations and government agencies
in the United States over the last half-century. A Physical Activity
Guidelines for Americans Midcourse Report that focuses on interventions
to increase physical activity in youth was published in 2012 (3).
The scientific basis for the 2008 DHHS guidelines was pre-
pared by a Physical Activity Guidelines Advisory Committee
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(PAGAC) composed of experts in the sciences of physical activity
and health who conducted an extensive literature review (4). In
2018, a new PAGAC accepted most of the recommendations,
but not all, made by the 2008 PAGAC and the DHHS guide-
lines writing committee. The 2018 report noted important ben-
efits of physical activity that are supported by strong scientific evidence
(see Box 1). These new indications are in addition to the many
benefits included in the 2008 DHHS guidelines, such as cardio-
vascular and metabolic-related health benefits, increased bone
and muscle health, and significant lowering of all-cause, cardio-
vascular, and cancer mortality.
Core recommendations in the 2018 guidelines, including to
sit less and move more, a weekly target of 150 minutes per week
of moderate-intensity or 75 minutes per week of vigorous-intensity
aerobic activity, and frequent muscle strengthening activities,
remained much the same. The major change in the activity rec-
ommendation in 2018 was to no longer require bouts of aerobic
activity be of at least 10 minutes in duration—activity bouts of
any duration now contribute toward the weekly goal. Although
there still is limited published research testing for health benefits
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HEALTH & FITNESS A TO Z
Figure 1. Association of hazard ratio for all-cause mortality with daily activity amount in quartiles when accumulated in
10-minute bouts or total moderate- to vigorous-intensity physical activity (not using bouts).
of exercise accumulated throughout the day in bouts lasting less
than 5 minutes each, data are beginning to emerge that show
the potential efficacy (see Figure 1) (5,6). However, understand-
ing the specific health benefits of very short bouts remains in
need of more research.
The major change in the activity
recommendation in 2018 was to no longer
require bouts of aerobic activity be of at least
10 minutes in duration — activity bouts of any
duration now contribute toward the weekly goal.
Although there still is limited published
research testing for health benefits of exercise
accumulated throughout the day in bouts
lasting less than 5 minutes each, data are
beginning to emerge that show the potential
efficacy (see Figure 1) (5,6).
To include a specific recommendation in the DHHS guide-
lines, the combined evidence from studies needs to be consid-
ered strong. For this reason, some currently popular activities,
such as high-intensity interval training, were not included in
the primary recommendations because of the lack of sufficient
data. Also, the increased health risks caused by too much sitting
were addressed with general recommendations to decrease sit-
ting time using almost any type of activity. However, data were
inadequate to support specific targets for daily sitting time. Re-
gardless, sitting less is associated with better health, especially
in low-fit and high-risk persons.
6 ACSM’s Health & Fitness Journal ®
Box 1
The 2018 Physical Activity Guidelines report noted
important benefits of physical activity that included strong
scientific evidence for reduced risk of dementia; improved
cognitive function; reduced cancer of the bladder,
endometrium, esophagus, kidney, lung, and stomach;
health benefits for children ages 3 to 5 years; and reduced
risk for adults developing a new chronic condition or risk of
progression of a condition they already have (secondary
prevention).
BRIEF HISTORY OF THE EVOLUTION OF PHYSICAL
ACTIVITY AND HEALTH GUIDELINES
In 1953, the first studies were published that hypothesized
moderate/vigorous-intensity physical activity performed on
multiple days of the week provided some protection against cor-
onary heart disease clinical events (7). Morris and colleagues re-
ported that more active conductors on double-deck buses in
London who walked up and down stairs during much of each
shift had lower rates of coronary heart disease events compared
with drivers of the same buses. Also, they reported that London
postmen who walked routes carrying their mail bags had sig-
nificantly fewer coronary heart disease events compared with
switchboard operators who sat at work all day. Over the next
two decades, other investigators who had access to data col-
lected on large employee populations generally reported similar
outcomes. Also, several early studies that included brief physical
activity questionnaires found that more active men had lower
rates of heart disease than their less active counterparts during
longitudinal follow-up (8). During this time, several exercise
physiology laboratories began reporting the results of exercise
training studies on health-related biological markers such as
plasma cholesterol and triglycerides, blood glucose, blood
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Figure 2. Leisure-time physical activity (MET-hours per week) and hazard ratio for all-cause mortality.
pressure (BP), adiposity, and cardiorespiratory fitness. The re-
sults of these and an increasing number of similar studies be-
came the early scientific basis for physical activity and health
recommendations or guidelines starting in the early 1970s by
the American Heart Association (AHA) and the American College
of Sports Medicine (ACSM). Between 1972 and 1996, ACSM,
AHA, various units within the DHHS, and other organizations
published a large number of recommendation or guideline doc-
uments for exercise/health professionals or the general public.
A list of these recommendations between 1965 and 1996 is
available in Physical Activity and Health, A Report to the Surgeon General (9).
Most of the data supporting physical activity recommenda-
tions have been derived from two study designs: (a) prospective ob-
servational studies with all-cause and cause-specific mortality being
the most common outcome and (b) exercise intervention (training)
studies where changes in disease biomarkers are key outcomes.
It is the combination of different types of results from the obser-
vational and interventional studies that lend strength to many of
the current physical activity guidelines. Increases in activity pro-
duce improvement of some biomarkers in the causal pathways
of various chronic diseases supporting the concept of “causality,”
Sidebar 1: METS
METS are used as an indicator of energy expenditure. One
MET is the rate of energy expended by a person sitting
quietly, and it is considered to be 3.5 ml of oxygen per
kilogram of body weight. Four METS means a person is
exercising at an intensity that requires four times the
energy they expend while sitting at rest. If a person
exercises for 30 minutes at 4 METS, they have expended
120 MET-minutes (30  4) or 2 MET-hours. If this exercise
is performed for 5 days, the total weekly expenditure
will be 10 MET-hours or 600 MET-minutes.
Volume 23 | Number 5
whereas observational studies provide clinical outcomes such as
mortality generally not obtainable in intervention studies because
of the need for a large sample size, a long-term follow-up, and a
large number of outcomes.
The earliest guidelines had a major focus on exercise pro-
grams to improve cardiovascular and muscular fitness and help
decrease the risk of exercise-induced cardiovascular or musculo-
skeletal injury in adults. For example, in the first AHA recom-
mendations published in 1972 (10), the following precautionary
statement was made: “Exercise is a therapeutic agent designed
to promote a beneficial clinical effect and, as such, has specific in-
dications and contraindications and possible toxic or adverse re-
actions” (page 24). Public health guidelines since the 1990s have
focused more or the extensive health and performance benefits
provided by being appropriately active than on the risks associ-
ated with recommended exercise. Especially important were the
guidelines by the CDC and ACSM published in 1995 because of
their strong public health orientation (11). Also, the “>10-minute
bout requirement” was introduced in these guidelines.
The ACSM guidelines provided in their position stands expe-
rienced relatively minor changes in the 33 years between 1978
and 2011. In 1978, the key recommendations focused on endur-
ance activity of 15 to 60 minutes per session, 3 to 5 sessions per
week of moderate/vigorous intensity (60% to 90% of HRmax re-
•
serve or 50% to 80% VO2max). Activities that help maintain
muscle and bone strength, flexibility, and balance were recom-
mended (12). In 2011, key recommendations from ACSM
stated that most adults should engage in moderate-intensity car-
diorespiratory exercise training for ≥30 minutes per day on
≥5 days per week for a total of ≥150 minutes per week or
vigorous-intensity cardiorespiratory exercise training for ≥20 min-
utes per day on ≥3 days per week (≥75 minutes per week), or a
combination of moderate- and vigorous-intensity exercise to
achieve a total EE of ≥500–1000 MET-minutes per week. On
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HEALTH & FITNESS A TO Z
2 to 3 days per week, adults were advised to perform resistance
exercises for each of the major muscle groups, neuromotor exer-
cise involving balance and agility, and various flexibility and
coordination activities (12).
The 1990 ACSM Position Stand noted that in the 1978
Position Stand, an important distinction was made between
physical activity as it relates to health versus fitness. It indicated
that the quantity and quality of exercise needed by physically in-
active individuals to attain some health-related benefits may dif-
fer from activities recommended for fitness benefits. It is now
clear that lower levels of physical activity than those recom-
mended by the ACSM Position Stands may reduce the risk of
certain chronic degenerative diseases in low-fit and inactive per-
sons and yet may not be of sufficient quantity or quality (primar-
• Chronic Disease Prevention and Health Promotion; 1996.
ily intensity) to significantly improve VO2max. Data from large
prospective observational studies or meta-analysis of such stud-
ies have shown that lower mortality rates are associated with
small differences in reported moderate- and vigorous-intensity
activity, especially in the least active participants — the least ac-
tive benefit the most from an increase in activity (Figure 2).
FUTURE DIRECTIONS
As physical activity and health research moves forward, it needs
to focus on a number of unanswered questions that will inform
the development of new guidelines, including the effect of
light-intensity exercise on health risks or benefits, the best pat-
tern of activity over the 24-hour day (how best to balance time
spent during sleep, sedentary behavior, and activities of different
types, intensities, durations, and frequency), and the efficacy and
safety of short-duration HIIT in those with various chronic con-
ditions. This research should greatly benefit from the continued
development and innovative application of wearable measure-
ment devices and related software.
1. 2018 Department of Health and Human Services Physical Activity Guidelines for
Americans. [cited 2019 April 23]. Available from: https://health.gov/
paguidelines/.
2. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. [cited
2019 April 23]. Available from: https://health.gov/policy/accessibility.asp.
3. 2012 Department of Health and Human Services Physical Activity Guidelines
8 ACSM’s Health & Fitness Journal ®
Midcourse Correction. [cited 2019 April 23]. Available from: https://health.gov/
paguidelines/2008/midcourse/pag-mid-course-report-final.pdf.
4. 2008 Physical Activity Guidelines Advisory Committee Scientific Report. [cited
2019 April 23]. Available from: https://health.gov/paguidelines/2008/report/.
5. Saint-Maurice PF, Troiano RP, Matthews CE, Kraus WE. Moderate-to-vigorous
physical activity and all-cause mortality: do bouts matter? J Am Heart Assoc.
2018;7(6):e007678.
6. Diaz KM, Duran AT, Colabianchi N, Judd SE, Howard VJ, Hooker SP. Potential
effects of replacing sedentary time with short bouts of physical activity on mortality:
a national cohort study. Am J Epidemiology. 2019;188(3):537–44.
7. Morris JN, Heady JA, Raffle PA, Roberts CG, Parks JW. Coronary heart-disease and
physical activity of work. Lancet. 1953;262(6796):1111–20.
8. Fox SM, Haskell WL. Population studies in an international symposium on physical
activity and cardiovascular health. Can Med Assoc J. 1967;96:806–11.
9. U.S. Department of Health and Human Services. Physical Activity and Health:
A Report to the Surgeon General. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Center for
10. American Heart Association Committee on Exercise. Exercise Testing and Training
of Apparently Healthy Individuals: A Handbook for Physicians. Dallas (TX) and
New York (NY): American Heart Association; 1972.
11. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation
from the Centers for Disease Control and Prevention and the American College
of Sports Medicine. JAMA. 1995;273(5):402–7.
12. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine
Position Stand: quantity and quality of exercise for developing and maintaining
cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy
adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):
1334–59.
William L. Haskell, Ph.D., FACSM, is a
professor of medicine (active emeritus) at the
Stanford Prevention Research Center and
the Division of Cardiovascular Medicine at
Stanford University School of Medicine. His
doctoral training was in exercise physiology
with postdoctoral training in chronic disease
epidemiology. He has been a member of the
Stanford Medical School faculty for the past 40 years, with pri-
mary interests in applied and clinical research in preventive car-
diology, cardiac rehabilitation, and the role of physical activity
in chronic disease prevention and successful aging. Of particular
interest has been the role of habitual physical activity and related
health behaviors in metabolic and hemodynamic factors contrib-
uting to the development of atherothrombotic vascular disease
and diabetes mellitus.
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