Physical Activity and the Health of a Nation: A National Challenge and Collective Response

Increasing Physical Activity Among Youth During School Days

The military is comprised largely of young people. Nearly 90% of applicants are aged 17 to 24 years at enlistment, ⁹ meaning that most 2030 candidates are currently in middle and high school, while most 2035 candidates are in elementary school. To our dismay, however, many of these children and adolescents are not enrolled in physical education courses. Currently just six states require physical education at every grade level, from kindergarten through high school, and only Oregon and the District of Columbia meet national guidelines for total weekly physical education time. ¹⁰ In addition to increasing opportunities for physical activity during the school day, we advocate for policies to promote active commuting to and from school (e.g., Safe Routes to Schools), classroom-based physical-activity breaks, intramural and organized sports, and physically active clubs. ¹¹ As U.S. Surgeon General Vivek Murthy ¹² recently wrote, physical activity—and particularly organized sports—is an incredibly powerful tool to improve academic performance, build resilience and social-emotional skills, and reduce mental health issues in youth.

Incorporating Technology

Wearable technology has the potential to help service members monitor health behaviors, such as sleep quantity and quality, and provide motivation to meet device- or user-defined goals, such as steps per day. The U.S. Space Force, for example, is experimenting with a “Continuous Fitness Assessment” as an alternative to the periodic fitness assessment practiced historically across the armed services. Currently in the data collection phase, this initiative allows Guardians to track their physical activity with wearable fitness devices. The premise, which is intuitive but still empirically unverified, is that continuous data monitoring more effectively promotes a perennial culture of physical fitness than an annual or biannual fitness assessment. Rather than serving as a measure, the fitness assessment becomes the target—a classic example of Goodhart’s Law (i.e., when a measure becomes the target, it also becomes ineffective as a measure). Although geo-positioning and other data privacy challenges associated with these devices are real, the Space Force initiative has already demonstrated that cybersecurity compliance is possible. ¹³

Addressing Sleep, Nutrition, and Stress

Acknowledging that physical activity is synergistically related to the other Lifestyle Medicine pillars, we also discussed the importance of sleep, nutrition, stress management, social connections, and substance avoidance, with an emphasis on the first three behaviors. Perhaps due to an undervaluation in the military tradition, sleep may be the most neglected Lifestyle Medicine pillar among current service members. Two-thirds of active component U.S. Army personnel in a recent survey reported fewer than 7 hours of sleep nightly, and 14% had a diagnosed sleep disorder. ¹⁴ Inadequate sleep has been associated with less physical activity and greater prevalence of tobacco use among soldiers, demonstrating synergy between the Lifestyle Medicine pillars. ¹⁵ Improving sleep health for service members may require a multi-pronged approach, including improved education on mission ramifications of sleep deprivation, novel strategies to maximize sleep opportunities for shift workers, increased access to cognitive-behavioral and other therapies for insomnia, and development of a leadership milieu that values sleep. To the lattermost point, we were encouraged when the National Guard Bureau recently issued a sleep challenge. ¹⁶

The military food landscape is complex. Food outlets on military installations include both Congressionally-appropriated sources (e.g., commissaries and mess halls) and non-appropriated fund outlets (e.g., clubs and franchise restaurants); food is also frequently served at unit events, such as ceremonies and potlucks. ¹⁷ A dietary pattern that minimizes processed foods and added sugars and emphasizes a whole-food, plant-predominant approach is vital for the health of service members—including reduction of cardiometabolic disease and musculoskeletal injury and enhanced mental clarity and cognitive ability. Improving the nutritional environment in military units may include adjusting the choice architecture (i.e., making the healthier food choice more affordable and accessible), inspiring leaders to provide healthier foods at military events, and educating personnel on the health and performance ramifications of their diet, both in-garrison and while deployed. ¹⁸

Service members frequently operate in high stress environments. Some who enter the armed forces have a history of adverse childhood experiences or other traumatic backgrounds—the scars of which can be exacerbated by service-related stressors. To protect the mental, emotional, and spiritual health of service members, we endorse several strategies: embed mental health experts within operational units to remove barriers to care and to build trust through frequent face-to-face interactions; normalize the experience of stress and emphasize the value of early intervention; involve family members in behavioral care; reimagine physical training sessions to incorporate physical activities that also foster mindfulness and psychosocial resiliency; and offer mental health strategies in packages that are acceptable to service members. As one of us quipped, a simple marketing technique is to append a martial adjective to the health behavior, such as tactical breathing, warrior yoga, or strategic napping.

Aligning with Current Military and Veterans Programs

Current frameworks employed by the Departments of Defense and Veterans Affairs, such as Total Force Fitness and the Whole Health Program, ¹⁹ acknowledge that health and performance should be approached holistically. When introducing Lifestyle Medicine strategies for service members and Veterans, we advise mapping initiatives onto these extant frameworks while considering four factors. First, understand that military readiness is not necessarily synonymous with general good health, but rather reflects the ability of a unit or individual to accomplish a specific mission set. Second, recognize that the military population encompasses tremendous heterogeneity, with its myriad career fields encountering different mental, physical, nutritional, and environmental stressors. Third, grasp the complexity of the health landscape, which includes differences between in-garrison and deployed locations and differences between the active and reserve components. Finally, realize that change in military and Veteran health care often transpires slowly—“glacially,” as one of us described it—requiring unwavering persistence and commitment.

Recruiting Lifestyle Medicine Professionals

Wearing the military uniform is not the only way to serve. Lifestyle Medicine professionals can serve their nation invaluably by promoting a healthy civilian population that is physically and mentally prepared to confront any adversary. As we concluded our panel and as we conclude here, we wish to speak directly to you, the Lifestyle Medicine professional. In the spirit of the epochal Uncle Sam recruiting poster from World War I, we want you! Here are just a few ways to serve.

1. Model healthy behaviors. Although it may sound trite, you are a role model for your patients, colleagues, and family members. Studies have consistently demonstrated that physically active health care providers are more likely to provide physical-activity counseling and to influence the behavior of their patients. ²⁰ If you are not doing so already, we encourage you to meet national recommendations by getting at least 150 weekly minutes of moderate-intensity equivalent aerobic activity and conducting at least 2 weekly episodes of muscle-strengthening activity. ²¹