Abstract: “Health first” is the guiding ideology or the core idea of school physical education (and other fields) in China. On the one hand, this guiding ideology is the echo of national macro-policy, on the other hand, it also exposes many theoretical and practical problems. Its theoretical foothold faces the following challenges: 1) “Health first” is too prominent in school physical education, but its school education background is ignored to some extent, the practice of “health first” lacks an examination of the evolution of health connotation; 2) The understanding of “health first” has the misreading of the order of “primary and secondary”; 3) The improper positioning of the relationship between physical education and health leads to the violation of school physical education to health. Therefore, we should point out that: 1) As the guiding ideology of school physical education, “Health first” has the orientation of derivation, homogeneity, top-down derivation and magnification. It is necessary to make a clear distinction with the guiding ideology of “Health first” in school education. 2) After the founding of the People's Republic of China, “Health first” has gone through different periods, and the meanings of health were respectively dominated by medical health and physical quality. At present, there is a tendency to stress physiological load in practice. The implementation of “health first” in school physical education in the new period needs to seek new external support and internal theoretical foundation. 3) President Mao Zedong put forward the background of “health first” as “reducing the burden”. Its important enlightenment lies in revealing the basis and fundamental significance of health. Based on the above, the key point of implementing “health first” in school physical education should be as follows: When health conflicts with those factors that affect health, health is the most important factor, not the first one in the ranking of the values and functions of sports. 4) Examining the “health first” in school physical education should be from the perspective of macro-health concept, rather than the limited health function of sports, as well as the regulation of the amount and intensity of exercise. 5) The implementation of “health first” in school physical education should be the same as the value of school education and multi-dimensional education.