Leisure-Time Physical Activity by Rural-Urban Status and Region — United States, 2020

In brief. Physical activity promotes health and prevents disease, and adults in rural areas and in some regions have long been less likely to meet the activity guidelines. In 2020 only a small share of U.S. adults met the leisure-time guidelines for aerobic activity, muscle strengthening or both. People in larger metropolitan areas and in the West were more likely to meet them than those in smaller urban areas, rural areas or other regions. Rural residents might be helped by investment in the structures, policies, systems and environments that make leisure-time activity possible.

The guidelines

The 2018 physical activity guidelines for adults call for:

• Aerobic activity — at least 150 minutes a week of moderate-intensity activity, or at least 75 minutes of vigorous activity, or an equivalent mix.
• Muscle strengthening — at least 2 days a week of moderate or harder activity working all the major muscle groups.

Meeting both counts as meeting the combined guideline.

The share of adults meeting them in their leisure time rose from 1998 to 2018 in nearly every demographic and regional group, but gaps by rurality and by Census region (Northeast, Midwest, South, West) persist. Earlier studies could only split counties into nonmetropolitan and metropolitan; in 2020 the National Health Interview Survey (NHIS) public data added a four-level rural-urban classification.

How the study was done

NHIS is a nationally representative household survey of noninstitutionalised U.S. adults, run each year by CDC. Changes to the questionnaire meant 2020 could not be combined with earlier years. Its sample of 31,568 adults was made up of 21,153 interviewed for 2020 (response rate 48.9%) and 10,415 from the 2019 sample interviewed again (29.6%); after dropping 1,161 with missing answers, 30,407 were analysed.

Respondents reported how often and how long they did moderate and vigorous leisure-time activity (vigorous minutes counted double) and how often they did muscle-strengthening activity. Logistic regression compared each group with a reference group — large central metropolitan counties, and the West — adjusting for sex, age, race and ethnicity, education and income relative to the poverty line.

Results

• Rural-urban. Adults in nonmetropolitan counties were significantly less likely than those in each of the three more urban categories to meet every guideline (adjusted odds ratios 0.68–0.89). Adults in medium and small metro counties were less likely than those in the two largest categories to meet them (0.85–0.89), including less likely than large fringe metro residents to meet the aerobic (0.88) and combined (0.86) guidelines.
• Region. Adults in the Northeast, Midwest and South were less likely than those in the West to meet every guideline (0.75–0.82), and did not differ from one another (0.99–1.07).
• Everywhere. Whatever the county type or region, no more than 52% met the aerobic guideline, 35% the muscle-strengthening one and 28% both.

What it means

Programmes such as CDC's Active People, Healthy Nation and Healthy People 2030 need detailed tracking of where people fall short. Next steps include breaking results down by age, race and ethnicity, sex and income; collecting data for counties and cities to guide local work; and measuring the full range of activity — from sitting to vigorous — at leisure, at work, in getting around and at home.

The authors point to a 2001 framework for measuring public health system performance: results depend on the system's structural capacity — its human, information, organisational, physical and financial resources. For rural areas and small towns they suggest:

• learning from new partners already running activity programmes there — public librarians, barbers and hair stylists, community health workers — and sharing their practices with similar places;
• training established partners, such as health departments and Cooperative Extension, in current evidence-based practice;
• bringing more organisations into multisector physical-activity planning;
• improving the built environment through community health programmes, cleanup of abandoned mine land and brownfields, and rural economic development;
• public, private and philanthropic investment to support all of these.

Backing research and practice networks focused on the least active rural areas could help reach Active People, Healthy Nation's goal of helping 27 million more Americans become physically active by 2027.

Limitations

• The survey was taken during the COVID-19 pandemic, which affected behaviours such as physical activity.
• Self-reported activity is prone to recall errors and overestimates.
• Activity at work, in travel and at home was not measured, so total activity could not be assessed.

Sources

• Abildso CG, Daily SM, Umstattd Meyer MR, Perry CK, Eyler A. Prevalence of Meeting Aerobic, Muscle-Strengthening, and Combined Physical Activity Guidelines During Leisure Time Among Adults, by Rural-Urban Classification and Region — United States, 2020. MMWR Morbidity and Mortality Weekly Report, CDC.