Understanding barriers to physical activity is a first step in removing them.

Preventing or delaying onset of the major causes of death and disability in the United States could save this nation billions of dollars annually in direct healthcare costs. Tremendous successes in fundamental public health strategies such as vaccines, workplace protection, family planning, tobacco control, childbirth safety, nutrition, and sanitation in the 20th century alone contributed 25 of the additional 30 years of life expectancy gained over the past century. Although heart disease was a major killer of men and women a century ago, mortality rates for both genders have declined precipitously. Today, public health and medical interventions against heart disease contribute to gains in life expectancy: reduced smoking rates (most markedly among men), improved emergency care, and development of a variety of drugs that can prevent a first heart attack, treat the immediate effects of one, or control risk of subsequent heart attacks. Yet to paraphrase Mark Twain, reports of the demise of heart disease may be premature. Two bad actors began to emerge over the past decade, a duet posing increased risk for numerous other diseases and conditions, most notably heart disease, and there is no sign of substantive progress in silencing their show. Obesity and diabetes, alone and together, threaten the longterm health of this nation, with each estimated to contribute directly and indirectly to over $100 billion in annual costs. Physical activity is protective against both conditions and associated heart disease, with the greatest benefit accruing to those who are least active. Gender differences in physical activity emerge in the teen years, and women continue to lag behind men in achieving recommended levels of physical activity. Racial and ethnic minority women report lower levels of physical activity than do white women, yet as the accompanying works in this volume show, these women show higher levels of lifestyle than leisure-time physical activity. Rates of obesity among white, African-American, and Mexican-American females are staggering, reaching 31%, 51%, and 40%, respectively and affecting an increasing percentage of children and adolescents. Not surprisingly, diabetes rates in these populations also exceed the overall U.S. averages. The articles in this supplement to the American Journal of Preventive Medicine add significant insight to factors important to women’s levels of physical activity. In particular, the information provided from large population survey samples of racial and ethnic minority women can be useful to public health programs and policymakers as they seek to remove barriers and provide incentives to help women become more active. The survey was unique in using an ecologic approach to explore respondents’ perspectives on exercise and physical activity. Because of the multiple sites involved in the project, it also included urban and rural subpopulations of women. More importantly, the respondents themselves represented women aged 20–50, a key window during which women tend to be in systems of care (primarily around their reproductive health needs) and before their risk of cardiovascular disease, diabetes, and other conditions might be predicted to rise. Although the survey design did not query for issues already well supported in the literature, this approach nonetheless may have missed three key barriers to women’s capacity to become more active. The survey did provide an option for respondents to list a “health condition” as a barrier; respondents may interpret this language to mean something they have either been diagnosed with, or a condition brought to the attention of a healthcare provider. Urinary incontinence disproportionately affects women. It may not be diagnosed even among women with regular access to care, and it represents an area that needs further exploration to help balance the information gained from the ecologic surveys reported here. One survey of 41,000 middle-aged women in Australia found that urine leakage may reduce their inclination to exercise. Women may consider urine leakage a normal part of aging, particularly after the birth of one or more children, and they may be too embarrassed to discuss it with their provider. Thus, women may not consider urine leakage a “health condition” unless specifically asked by a health professional. Furthermore, obesity can exacerbate urine leakage, presenting a stigmatizing barrier to the very people From the Office on Women’s Health, U.S. Department of Health and Human Services, Washington DC Address correspondence and reprint requests to: Wanda K. Jones, DrPH, 200 Independence Avenue, SW, Room 712E, Washington DC 20201. E-mail: wjones@osophs.dhhs.gov.