Fitness
MAHA Commission promotes fitness as a vital sign for children. What does that mean?
Nobody’s against fitness for children. But health secretary Robert F. Kennedy Jr.’s proposal to make physical activity a “vital sign” akin to blood pressure or growth is raising questions among physiology experts.
Physical fitness for all and children’s health are two tentpoles of Kennedy’s Make America Healthy Again mission, articulated in the MAHA Commission’s initial meeting in May, outlined in a draft Make Our Children Healthy Again report in August, and solidified in the full report Tuesday. The report promotes “physical activity as a vital sign,” a concept that usually defines a healthy level as 150 minutes of movement per week.
The commission, though, urges states to establish specific metrics of fitness, for example, a “predicted VO₂ Max” as a baseline for evaluating Medicaid managed care organizations on how much they were improving health. Other factors would include sleep, nutrition, and potentially “select high-quality supplements.”
And decades after President John F. Kennedy introduced it, the Presidential Fitness Test will return to gauge the speed and strength of America’s schoolchildren, the report says.
When the test was introduced in the 1960s, people worried that kids were spending too much time indoors, sitting around and watching television. To jump-start their fitness, physical activity at school was encouraged with routines from running to rope climbing, culminating in an annual test.
STAT has requested comment from the Department of Health and Human Services, which directed inquiries to the White House, asking about the basis for these ideas and what might come next.
What is VO₂ max, anyway?
Experts told STAT they were puzzled by the mention of VO₂ max as a metric. VO₂ max stands for the maximum volume of oxygen the body can take in and use in a single minute during intense physical activity. It’s determined by a standard exercise stress test that measures breathing with a mask to calculate oxygen consumption to define fitness.
As a measure of cardiorespiratory fitness, higher is better. It’s less clear whether it makes sense to apply an adult athlete’s numbers, aka VO₂ max, to children at play.
“It’s a really great test. It’s not really something you can do in someone under 9, 10 years old in a really good way,” Jared Hershenson, a pediatric cardiologist who directs cardiac exercise and rehabilitation at Children’s National Hospital, told STAT. “If you’re talking about trying to measure someone’s fitness who’s younger than that, there really is not any objective test that can do that, or quantitative test that can be done.”
VO₂ max is difficult to measure, even for adults, I-Min Lee, a professor of epidemiology at the Harvard T.H. Chan School of Public Health who studies the role of physical activity in preventing chronic diseases, also told STAT. You need lab equipment and you need participants to exercise to the point of exhaustion. Picture people on an exercise bike or a treadmill, going full out while wearing a mask to track their oxygen levels. Many people won’t or can’t do that, she said.
There are predictive equations that do not rely on lab tests, but instead use age, sex, body mass index, or other numbers. With varying degrees of accuracy, they are more feasible in large numbers of people to advance health.
Lee underscored that physical fitness and physical activity are related, but not identical constructs. Activity is something we do; fitness is a physiological construct.
There’s this catch: Fitness can be improved by regular activity, but it’s also partially genetically determined, she said. “I could exercise to death, but I will never be as fit as Lance Armstrong, since I don’t have his genes.”
Outside the lab, VO₂ max is familiar to weekend warriors who upload their runs, swims, rides, and hikes to sports/social media sites like Strava to track training and add up kudos from their friends. That less-than-lab-quality number is derived from heart rate and other data collected by the watches on their wrists, made by Garmin or Apple or Coros, among others in the burgeoning market for wearables.
In June, Kennedy predicted wearables for all in the next four years, but later pulled back, saying in a statement to Axios that “they are not for everyone because of concerns like cost and personal privacy.”
Eric Topol, a cardiologist and geneticist at Scripps Research Institute, scoffed at measuring VO₂ max in kids when for adults, studies have shown there are more practical ways to measure fitness that don’t involve lab testing or expensive wearables.
“To do that in children? Are you kidding me?” he said in an interview. “That is just absurd. But that’s just the anti-science movement that keeps spewing out things that are not substantiated or possible or likely.”
Topol himself gets his VO₂ max data on his iPhone, but acknowledges its limits compared to a physiology lab. For children, it would make more sense to give them a wristband with a pedometer to measure activity. “Let’s go with something simple and cheap like that, that everybody could have,” he said.
We’re not there yet for children’s wearables, Hershenson said, while acknowledging its potential if government and private sector entities work together. There are no reliable fitness data from wearables in pediatric patients, for the children Hershenson’s center sees who have significant challenges or for healthier kids. Companies on their own might have variations in how they measure fitness.
“In any of the technology, as far as I know, nothing’s been correlated with exercise tests. You’d have to have some sort of standard testing to compare it to,” he said. “I think it’s going to have to be some sort of surrogate,” maybe heart rate recovery, which tracks how fast the heart rate returns to its normal resting state after exercise.
Presidential Fitness Test, redux
Then there’s the metric President Trump wants to bring back to life: The Presidential Fitness Test. Started in the 1960s by President Kennedy and modified decades later by President Obama, it sent schoolchildren racing the mile and doing situps, pushups, pullups, and rope climbs. The new report says HHS and the Department of Education will partner with the President’s Council on Sports, Fitness, and Nutrition to help states and schools reintroduce it.
Hershenson isn’t sure measuring how many pullups a child can do is going to help gauge fitness, strength, or flexibility as they pertain to future health.
“I think it’s useful to have some sort of baseline. But you need to know what to do with that,” he said. “We’re not just gonna throw a ball around. Let’s find ways that we can improve this person’s strength and this person’s fitness by doing stuff that’s fun.”
That also means thinking about barriers to exercise.
“To me the best approach is always treating each person individually to figure out how I can help them be the best version of themselves,” Hershenson said. “That’s extraordinarily difficult when you’re making massive public policy for however many millions of people, but I think it’s going to be different for everybody.”
“Is it a questionnaire? Is it measuring heart rate recovery? Is it measuring how many steps you take?” he asked. “It’s probably not going to be perfect.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
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In addition to the psychological impact, there are physical risks associated with following online fitness trends.
The experts cautioned that some activities may not be suitable for all individuals, and may even result in over-exertion or injury for some people.
This is often due to their high intensity and specificity in the muscle groups trained.
Ms Nur Amelina Azlan, a physiotherapist at Heal360 Physioclinic, said: “For example, pilates is very postural, very focused on the core muscles, whereas something like your spin class is more cardiovascular.
“But what we need is both elements together, not just one over the other.”
MAKING FITNESS “FIT” YOU
So, if what works for other people may not be the best for different people with different needs, how does one find what works for oneself?
Mr Martin John, clinical director at Orchard Health Clinic, which offers physiotherapy among other services, said that the first step is to be honest about your starting point.
“How is your energy? How is your sleep? How stressed are you? How much do you sit? How well do you move?
“Those are important questions because exercise should match the person, not the trend.”
Most people wouldn’t mind being a little bit fitter. But the fittest? That seems unreachable. However, many argue that all-conquering CrossFit athlete Tia-Clair Toomey is, by objective measures, the fittest woman in history.
Toomey, who is an ambassador for the fitness app Pliability, has won the CrossFit Games – an annual competition to find the fittest man and woman on earth – an unrivalled six times on the trot. In 2023, she paused to have her first child, then returned in 2024 and won the competition two more times.
In the midst of her winning streak, the 32-year-old also represented Australia in weightlifting at the 2016 Rio Olympics, won gold in the same event at the 2018 Commonwealth Games, qualified for the 2022 Winter Olympics in the two-woman bobsled and completed a Hyrox doubles race in a lightning-fast 54 minutes 24 seconds.
In short: Toomey is incredibly fit. The average person might not be able to emulate her superior fitness levels, and most don’t want to – they simply want to be fit and healthy enough to thrive in everyday life. You can, however, benefit from her insights about how to approach exercise.
Read more: Do these three things each week to be fitter than most Brits
1. Don’t let perfect be the enemy of good
“You can’t be perfect at everything all the time,” says Toomey. “Trying to juggle too many things at once is where many people come unstuck, because you’re stretching yourself too thin. So it’s important to find balance.”
The aim is not to do everything immaculately, but to identify the things that are truly valuable to you – these might be your workouts, work or supporting your family – and take pride in throwing the (cluttered) kitchen sink at them.
“Even if it’s just a simple workout, you can feel really fulfilled at the end of the day knowing you gave it your best,” Toomey says. “I think a workout is a perfect place to demonstrate this.”
Read more: Walking experts reveal the number of daily steps you need to boost health – and it’s not 10,000
2. Small changes make a big difference
Most people set themselves lofty fitness (and life) goals, then fall short of them. Just look at how many New Year’s resolutions have been discarded by the time February rolls around. Toomey suggests a more manageable approach.
“If you can get 1 per cent better every day, you can’t ask for any more than that,” she says. “It’s when you create excuses, stop challenging yourself and give up on pursuing your chosen goal that you stop progressing and plateau.”
She recommends making small tweaks to improve how you feel each day, rather than obsessing over a daunting target.
For example, you could head to bed 15 minutes earlier and keep your phone out of the bedroom, drink an extra glass of water, go for a walk after dinner or eat an extra portion of fruits and vegetables. Small changes soon accumulate to make a big difference over time.
“It takes a lot of pressure off people when they break their goals down like that,” Toomey says.
Read more: Study reveals the small changes to your diet, sleep and exercise that can add years to your life
3. Be open-minded
A lot of people use the phrase “exercise isn’t for me”. This is likely linked to a less-than-pleasant experience at some point in their past.
But exercise is a very broad umbrella, and Toomey urges people to remain open-minded when approaching it. This is something she learned firsthand.
“I enjoyed my first CrossFit session, but I didn’t really enjoy the coach, so I opted not to go back for two months,” she says. “Who knows where I would be now if I never went back because of that one interaction.”
Toomey ended up trying a different gym and finding a coach who was more passionate and encouraging. “Then I was hooked and fully committed,” she says.
For the everyday exerciser, this could mean changing the variables to make your workouts more fun. For example, if you don’t like how running feels, you could swap to a lower-impact activity like swimming or cycling. Or if you find solo strength training sessions boring, you might join an exercise class.
There is no need to suffer through a certain type of exercise just because someone told you it’s the best. Take a playful approach to your workouts and continue to experiment until you find something you enjoy. Because if your exercise plans are fun, you are far more likely to stick to them.
Read more: The easiest way to strengthen your entire body, according to this expert coach
4. Put your ego aside
If you have ever watched Toomey compete, it’s hard to imagine her struggling with anything exercise-related. But, she says, when she first started CrossFit training she found it difficult to hold a barbell overhead in a stable position.
This was exposed in a CrossFit workout named “Nancy” – five rounds of a 400-metre run and 15 overhead squats (squatting while holding a 30kg barbell overhead).
“I was a runner prior to CrossFit, so I would race ahead during the 400m runs, but then the overhead squats were very challenging for me,” Toomey says.
To learn the correct technique, she started by scaling back the overhead squats, using an empty barbell rather than one loaded up with weight. Then, as she improved, she gradually increased the load on the bar.
“It’s all about building confidence,” Toomey says. “Everyone wants to go from zero to 100, but you need to put your ego aside, take your time and put the work in to actually learn a movement. That is how people evolve.”
If Toomey is willing to scale back exercises to learn them properly, the rest of us should be too. That might mean starting with goblet squats rather than barbell squats, wall press-ups rather than full press-ups, or walking rather than running.
There are exercise options to suit all fitness levels – you just have to find the appropriate ones for you and gradually progress them over time.
Read more: Sitting all day wreaks havoc on your hips and spine – here’s how to stop that from happening
5. Variety is the spice of life
What is the one exercise Toomey wishes more people would do? She struggles to pick just one before prescribing variety.
“I just love seeing people active,” she says. “But constantly doing one thing will have a lot of impact on the body. I think it’s really important to have a variety of exercises. That way you’re constantly working different muscles, building broad fitness and stimulating the mind in different ways.”
This is good advice for any exerciser. The body works on a rough use-it-or-lose-it basis, so if you don’t use a joint or muscle to its full potential, it can weaken and tighten over time. Greasing the groove on a wide range of movement patterns is the best way to prevent this and stay mobile for decades to come.
Read more: After 50 you need to train smarter – the eight rules for strength training in midlife, according to experts
6. Commit to a plan
A one-off workout cannot transform your fitness, but a progressive exercise plan can. This is why Toomey recommends finding a structured programme to follow over a longer time period than just a single session.
“That is going to help you stay motivated, particularly if it’s linked to some sort of sports or fitness goal like your first 10K, triathlon or pull-up,” she says.
“It gives you something to aim for. Otherwise people think, ‘Oh, I’m just going to keep doing this forever,’ and it can feel quite overwhelming. Following a programme helps you build healthy habits that you integrate into your daily routine and actually stick to.”
Read more: I specialise in coaching people aged 40-plus – do these six things for immediate results
7. Look after yourself
Muscle isn’t built in the gym. What you do during your workouts triggers myriad positive physiological changes, but the actual adaptations happen while you are recovering.
For this reason, Toomey places a great emphasis on sleep and nutrition, prioritising quality fuel and recovery between her training sessions.
As part of this, she regularly uses a sauna, breathwork and completes a stretching and mobility protocol via the Pliability stretching app shortly after waking each day.
“I tend to wake up feeling a bit stiff and sore from the previous day,” she says. “But I want to walk into the gym feeling strong and confident. That stretching session acts as a form of meditation as well, helping with both mobility and mental clarity.”
Read more: Swap the gym for this trainer’s six-move kettlebell workout to build full-body strength at home
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