C3a Review of Physical Activity and Health v 2 a 20121011

7/30/2019 C3a Review of Physical Activity and Health v 2 a 20121011

1/39

Review

Thebenefitsofphysicalactivityforhealthandwellbeing

2ndedition

C3CollaboratingforHealth*

October2012


2/39

2 Review:Thebenefitsofphysicalactivityonhealthandwellbeing(2nd

edition) www.c3health.org

Contents

Overview 3

PartI: Evidencesupportingthebenefitsofphysicalactivityonhealthandwellbeing 4

1.Theimpactofphysicalactivityonhealth 4

2.Literaturereviewoftheevidence 6

PartII: Evidencesupportinginterventionstoencouragephysicalactivity 12

1.Thescaleoftheproblem 12

2.Anactiveenvironment? 12

3.Behaviourchange 13

4.Selectedinterventions 14

PartIII:Casestudies 17

1.Introduction 17

2.Whatmakesforbestpractice? 17

3.Casestudies 18

Appendix1:Selectedliteratureonthehealthbenefitsofphysicalactivity 24

Appendix2:Physicalactivityinterventions 28

Appendix3:Levelsofevidence 32

Endnotes 33

Director:ChristineHancock

FirstFloor,

28

Margaret

Street,

London

W1W

8RZ,

United

Kingdom;

Tel

+44

(0)

20

7637

4330;

Fax

+44

(0)

20

7637

4336

C3CollaboratingforHealthisaregisteredcharity(no.1135930)

andacompanylimitedbyguarantee(no.6941278),registeredinEnglandandWales.


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Overview

Thepurposeofthisreviewistoprovideasnapshotofthescientificevidenceofthebenefitsofphysical

activityonhealthandwellbeing,focusingparticularlyonthepreventionofnoncommunicablediseases

(NCDsalsooftenreferredtoaschronicdiseases),andtopresentcasestudiesofwhatworksindifferent

settingsandcontexts.Thissecondedition(October2012)updatestheevidenceandcasestudies.

PartIprovidestheevidencesupportingthebenefitsofphysicalactivityonhealthandwellbeingand,

togetherwithdetailedtablesinAppendix1,formsaliteraturereviewfocusingonevidencebasedstudies

thataddressthebenefitsofphysicalactivityonreducingtheimpactofnoncommunicablediseases(NCDs)

suchascancer,heartdisease,strokeandtype2diabetes.Thisisanextremelywelldocumentedarea,and

thisreviewselectskeytextscoveringresearcharticlesandreviewsthatarewidelycited.

PartIIandAppendix2togetherprovideashortreviewoftheevidenceonphysicalactivityinterventions,

includingthebenefitsofcreatingamorehealthpromotingenvironment.

PartIIIpresentsaseriesofcasestudiesthatmayserveasaguidelineforindividualsand/ororganisations

thatareconsideringincorporatingstrategiestotackletheburdenofNCDsintheirlocalcommunity.In

additionto

examples

that

are

grounded

in

scientific

evidence,

aselect

group

of

case

studies

are

presented

thatdonotincludedetaileddata,butcanbeseenasinnovativeandpromising.

Evidenceandexamplesofoneofthecheapestandsimplestofallphysicalactivitieswalkingare

presentedthroughoutthereview(eachinstanceisindicatedbythefootprinticon).Walkingisalsothe

subjectofaseparatereviewbyC3,Thebenefitsofregularwalkingforhealth,wellbeingandthe

environment(September2012).

AlmosteverycommunityaroundtheworldisfacedwiththechallengeofcombatingNCDs,andwehope

thatthisreviewandcasestudieswillprovideinformationthatprovidestherationaleforactionandideas

fortacklingphysicalinactivityinmanydifferentsetting.


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PartI:

Evidencesupportingthebenefitsofphysicalactivityon

healthandwellbeing

1.Theimpactofphysicalactivityonhealth

i)Thebenefitsofphysicalactivity

Beingphysicallyactiveplaysanessentialroleinensuringhealthandwellbeing,andthereisalargebodyof

researchinvestigatingthebenefitsofexercise.iPhysicalactivitybenefitsmanypartsofthebodythe

heart,skeletalmuscles,bones,blood(forexample,cholesterollevels),theimmunesystemandthenervous

system1andcanreducemanyoftheriskfactorsfornoncommunicablediseases(NCDs).Theserisk

factorsinclude:

reducingblood

pressure;

improvingbloodcholesterollevels;

loweringbodymassindex(BMI).

Therolephysicalactivityplaysin

manydiseases,suchastype2

diabetes,heartdiseaseandmany

cancers,meansthattheWorld

HealthOrganization(WHO)

estimatesthat:

physicalinactivity

is

the

fourth

leadingriskfactorforglobal

mortality2(seeFigure1);and

physicalinactivityisresponsible

for6%ofdeathsglobally

around3.2milliondeathsper

year,including2.6millionin

low andmiddleincome

countries,and670,000ofthese

deathsarepremature.3

In2012,TheLancetpublishedaseriesofarticlesonphysicalactivity,suggestingthattheimpactofphysical

inactivityonmortalitycouldbeevengreateruptoaround5.3milliondeathsayearrivallingeven

tobaccouseasacauseofdeath.4

However,inactivityasedentarylifestyleiscommonplace:around31%oftheworldspopulationisnot

meetingtheminimumrecommendationsforphysicalactivity,andglobalprevalenceofinactivityis

estimatedasbeingaround17%.5Increasingphysicalactivityhasbeenshowntohaveapositivedose

responseinotherwords,thatthebenefitsofphysicalactivityincreaseastheamountandintensityofthe

activityincreases.Reachingtherecommendedminimumlevelofphysicalactivitycomparedwithnoactivity

wasfoundtoleadtoareductioninallcausemortalityof19%andthisrisesto24%ifanhouradayis

spentinphysicalactivity.6Inaddition,thereisa31%lowerriskforallcausemortalityinactiveindividuals.7

iForwhatconstitutessufficientphysicalactivity,seePartI,section2(iv)below.

Figure1:Deathsattributedto19leadingfactors,by

countryincomelevel(2004)


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ii)Internationalactiononhealthandphysicalactivity

In2011,theUnitedNationsheldaHighlevelMeeting(attendedbyover30headsofstate,andwith

statementspresentedbyover130memberstates)toaddresstheepidemicofnoncommunicablediseases.

Physicalactivityasariskfactorwasrepeatedlyhighlightedanddiscussionisnowunderwaytosettargets

toreducetheriskfactorsforNCDs,includingphysicalinactivity.

InMay

2012,

the

World

Health

Assembly

set

atarget

to

reduce

deaths

from

non

communicable

diseases

by

25%by2025.Thistargetisunlikelytobereachedwithouttacklingthepandemicofphysicalactivity,8

throughplanning,policy,advocacy,training,monitoringandwideranginginterventions.Therearealso

callsforphysicalactivitytobeincludedinthesuccessorstotheMillenniumDevelopmentGoals(whichare

duetoexpirein2015)ahealthypopulationisessentialforsustainable,longtermdevelopment,andthe

growthofNCDs(andriskfactors)isthreateningtoundermineachievementstodate:theWorldEconomic

ForumandHarvardSchoolofPublicHealthestimatethattheanticipatedeconomicburden(cumulative

outputloss)ofthemajorNCDsbetween2011and2030tobearound$30trillion.9

Therearealsointernationalorganisationscampaigningonphysicalactivity,highlightingthehealthbenefits

forexample,the2010TorontoCharterforPhysicalActivity,whichisacalltoallcountriestohelpmake

physicalactivityapriorityforall,providingaframeworkforactionandpartnershipsacrossmultiple

sectorsandwithcommunitiestobuildhealthier,active,environmentallysustainablecommunities.10

Anexample:Walking

Walkingisoneofthebestformsofphysicalactivityitislowimpact(sodoesnotputstresson

thejoints),weightbearing(soitcanimprovebonedensity)anda60kgindividualwalking

brisklywillburnabout300kcalanhour,soitcanassistwithweightloss.Additionalbenefits

includestressreductionandimprovedsleep.Itischeap,easyandcanbeundertaken

throughoutthelifespan

Andthelongtermhealthbenefitsofwalkingarestartling.Alargestudyofnurses11

foundthatregular

walkinggreatlyreducedtheriskofdevelopingtype2diabetesasimilarlevelofprotectiontothatfound

fromundertakingtheequivalentenergyexpenditureonavigorousactivity.

Formoreonthehealthbenefitsofwalking,seeC3sreviewofThebenefitsofregularwalkingforhealth,

wellbeingandtheenvironment(August2012).12


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2.Literaturereviewoftheevidence

Theevidenceisresoundingthatphysicalactivityimproveshealth,andthestudiesreferredtointhisreport

coveravarietyofdifferentpopulations,researchmethodologiesandphysicalactivities.iiThetablesin

Appendix1coverresearchstudiesand/orreportsthatillustratethebenefitsofphysicalactivityon:

overweight

and

obesity

(Table

1a)

this

is

a

major

risk

factor

for

NCDs;

type2diabetes(Table1b);

cardiovasculardisease(Table2);

coronaryarterydisease(Table3);and

cancer(Table4).

Inaddition,Table5setsoutevidenceonthebenefitofphysicalactivityonmentalhealth,including

reducingstressandalleviatingdepression.

Theimprovementsinphysicalactivityareespeciallypronouncedforhighriskindividuals,forexamplethose

whoareobeseorhavehighbloodpressure(hypertensive).13

Researchhasalsoshownthatbeingphysicallyactivedailywillreducethechancesofmortalityassociatedwithcardiovasculardisease:30minutesof

moderateintensityexerciseonmostdaysoftheweek,equivalentto4.2MJ(1000kcal)aweek,was

enoughtoreducecardiovascularrelatedmortality.14

i)Majorchronicdiseases

ThefourmajorNCDs15cardiovasculardisease,type2diabetes,cancersandchroniclungdisease

betweenthemaccountfor59%ofthe57milliondeathsannuallyand46%oftheglobalburdenofdisease

doublethenumberofdeathsfromallinfectiousdiseases(includingHIV/AIDS,TBandmalaria),maternal

andperinatalconditions,andnutritionaldeficienciescombined.16Theyalsokillatayoungerageinless

developedcountries:inlow andmiddleincomecountries,29%ofNCDdeathsoccuramongpeopleunder

theageof60,comparedto13%inhighincomecountries.17

AccordingtotheWorldHealthOrganization,physicalinactivityistheprincipalcauseofapproximately:

27%oftype2diabetes;18

30%ofischemicheartdisease.19

Aslifestyleschangebecomingmoresedentary,aswellasrapidlychangingdietsthesediseasesare

becomingmorecommon,andarestrikingatayoungerage.Forexample,diabetesprevalenceisrisingfast

comparativeratesamongthoseaged2079areasfollows20:

China:4.2%currentlyhavediabetes,withprojectionsof5.0%for2030;

India:7.8%currentlyhavediabetes,withprojectionsof9.3%for2030;

Mexico:10.8%currentlyhavediabetes,withprojectionsof12.9%for2030;

SaudiArabia:13.6%currentlyhavediabetes,withprojectionsof18.9%for2030.

UK:3.6%currentlyhavediabetes,withprojectionsof4.3%for2030.

iiReadersareadvisedtorefertotheindividualreportsforspecifics.


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ButreversingthetideofphysicalinactivitycanhavestrikingimpactsonmanyofthemajorNCDsdiabetes,

manycancersandheartdisease.Specificbenefitsinclude:

ariskreductionforbreastcancerofapproximately2040%forthosewhodovigorousphysicalactivity

for3060minutesonfivedayseachweek;21

themostactivepeopleareat30%lowerriskofcoloncancerthantheleastfit;22

a2530%

reduction

in

stroke

among

active

individuals;23

physicallyinactivepeoplecanhaveasmuchastwicetheriskofcoronaryheartdisease.24

AstudyinTheLancetin2012foundthatremovingphysicalinactivityhasthelargesteffectoncoloncancer

around10%couldbepreventedifeveryoneweretobeactive,althoughthisvariesfromregiontoregion

withsmallereffectsoncoronaryheartdisease(around6%)andtype2diabetes(around7%).However,

theincidenceofcoronaryheartdiseaseismuchhigherthancoloncancer,sotheeffectwouldbegreatest

hereforexample,15,000deathsfromCHDcouldhavebeenavertedinAfricabyeradicatingphysical

inactivity,andaround1,000deathsfromcolorectalcancer.25

Inaddition,physicalactivitycanbenefitthosewhoalreadyhave,orarerecoveringfrom,anNCD.For

example,studies

both

of

people

currently

with

cancer26

and

cancer

survivors27

have

found

that

physical

activityisassociatedwithhealthrelatedqualityoflife,includingphysicalfunctioning,fatigueand

depression.28Physicalactivitycanalsohelptoreducetheriskofcancerrecurrenceandmortalityforbreast

cancer(uptoabout40%riskreduction),coloncancer(50%)andprostatecancer(30%).29

Despitethese

benefits,arecentsurveyintheUKshowedthat37%ofthosesurveyedwerenotphysicallyactiveatall,the

majorityhadnotbeenspokentobytheirGP(82%)oroncologist(77%)orclinicalnursespecialist(79%)

aboutthebenefitsofphysicalactivity.30

ii)Mentalhealth

Inadditiontothebenefitsofphysicalactivityonimprovinghealthandreducingriskfactorsforchronic

disease,it

has

been

shown

to

be

effective

in

improving

mental

health,

which

is

also

amajor

cause

of

disabilityworldwide.EstimatesmadebytheWorldHealthOrganizationarethat154millionpeopleglobally

sufferfromdepression,andmentalillnessesaffectandareaffectedbychronicconditionssuchascancer,

heartandothercardiovasculardiseases,diabetesandHIV/AIDS.31

Theevidenceonthementalhealthbenefitsofphysicalactivityislesswelldocumentedthanforthe

physicaleffectsastheeditorsofthejournalMentalHealthandPhysicalActivityputit,inthejournals

inauguraleditorial:Somanyresearchquestionscometomindinthisfieldthathavebarelybeen

considered.32However,thebodyofevidenceisgrowingfast,withmanystudiesandclinicaltrialshaving

shownspecificbenefitsincluding:improvedmood,reducingsymptomsofstress,anger,depressionandjob

burnout,33alleviatinganxiety34 andslowingcognitivedecline.Ithasbeensuggestedthatphysicalactivity

mayhave

effects

on

treating

depression

comparable

to

Prozac

or

behavioural

therapy.

35

Table5(seeAppendix1)presentsselectexamplesofthebenefitsandresearchstudiesthatsupporteach

benefit.

Muchresearchhasfocusedonadults,butthereisevidencethatamongadolescentsincreasedleisuretime

physicalactivity(i.e.outsidestructuredschoolprogrammes)issignificantlyassociatedwithfewer

depressivesymptomsoveratwoyearperiod.36Somestudiesalsoshowthatphysicalactivityaccelerates

learningbyincreasingcognitiveprocesses(e.g.memoryfunctioning).37

Amongolderpeople,physicalactivitycanbeofbenefittomaintainingmentalhealth,withonestudyof

womenaged7081showingthatthoseinthehighestphysicalactivityquintiletohavea20%lowerriskof

cognitivedecline

(including

tests

of

general

cognition,

verbal

memory

and

attention).38


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TheWorldAlzheimerReport2009estimatedthatthereare35.6millionpeoplelivingwithdementia

worldwide,withthisfiguresettoincreaseto65.7millionpeopleby2030and115.4millionby2050.39

ThereisalsosomeevidencethatphysicalactivitymayhelptoslowtheprogressionofAlzheimers40

and

reduceitsriskthroughanumberofmechanismssuchaspromotingvascularhealthbyloweringblood

pressureandreducingotherriskfactorsthatleadtothedisease.41Researchsofarinthisareaisshowing

promisingresults42forexample,onestudyhasfoundthatpeoplewhoexercisedthreetimesaweekhada

riskofAlzheimers32%lowerthanthosewhoexercisedlessfrequently43butfurtherstudiesneedtobe

done.

EpidemiologicalstudiessuggestthatexercisereducestheriskofParkinsonsdisease,andregularphysical

activityisshowntoimprovethequalityoflifeinParkinsonsdiseasepatientsandreducetheirneurological

symptoms.However,thereislimitedevidenceontheexactcognitiveprocessesand,again,furtherstudies

needtobedone.44

PhysicalactivityinitiativessuchasthosedescribedintheCaseStudiesbelowcanhavesignificantimpacton

mentalhealthandthesebenefitsmaybeevengreaterifthephysicalactivitytakesplaceoutdoors,in

greenspace.Forexample,UKmentalhealthcharityMINDranasmallstudyofgreenexercise(physical

activityoutdoors),questioningpeopleinvolvedinwalking,gardening,conservationandcycling.90%of

those

surveyed

said

that

they

feel

that

green

exercise

benefits

their

physical

health

but

an

even

higher

proportion,94%,feltthatitimprovedtheirmentalhealth.45

iii)Wholelifebenefitsofphysicalactivity

Thebenefitsofphysicalactivityhavebeenshowntobeeffectiveacrossthelifespan,amongyoungandold

alike,andTable6inAppendix1presentsaselectsamplingofstudiesthatillustratethebenefitofphysical

activityacrossthelifespan.

Physicalactivityhasbeenshowntoimproveeducationalattainmentinchildrenaswellaspreventobesity.

However,girlsmayfaceparticularchallengestomaintaininglevelsofphysicalactivity,andwomenandgirls

oftenhavelowerlevelsofphysicalactivity.InEngland,forexample,theaveragetotalnumberofhours

spentdoingphysicalactivityinaweekisgreaterforboys(10hours)thanforgirls(8.7hours),andthereisa

cleardecreasewithageamonggirls(theproportionofwhommeetingtherecommendationsrangesfrom

35%amonggirlsaged2tojust12%among14yearolds).46

Genderstereotypesandsafetyissuesmayalsoplayaroleforexample,inasmallstudybythePan

AmericanHealthOrganizationamong1317yearoldsinManagua,Nicaragua,only13%ofgirlstookpartin

physicalactivityintheirneighbourhood(comparedtooverhalfofboys),girlscitedmoresafetyconcerns,

andgirlsreceivedlesssupportfortheirfamiliestoparticipateinsport.47

Arecentstudyhasshowedthathigherfitnessinmiddleagewassignificantlyassociatedwithlowerriskof

developingchronicdiseasesinlaterlife.Theveryfitwerenotfoundtolivesignificantlylonger,butdidlive

longerin

good

health

an

example

of

compression

of

morbidity.

Those

with

the

highest

levels

of

mid

life

fitnessspent34%moretimethantheleastfit

withoneornochronicdisease.48

Amongolderadults,engagementinroutine

exerciseonaregularbasisleadstoimproved

functionalabilitiessuchasmobility49and

reducedriskoffalls,andisrelatedto

increasedlongevityandtoreduced

inflammation(inflammationisthoughtto

contributetolossofstrengthandmuscle

power,

cardiovascular

disease

and

depression).50Itmayalsohavebenefitsfor

cognitivefunction.51

TaichiinLondon


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Inmanypartsoftheworld,physicalactivitydeclinessubstantiallyasweage(seeFigure2,below,forthe

UnitedKingdom52).However,thisisnotalwaysthecaseinChinaandsomeeastAsiannations,physical

activityincreaseswhenpeopleretire.53

Animportant,andoftenunderserved,grouparepeoplewithdisabilities,whonumberoverabillion

worldwideand

who

may

face

substantial

barriers

to

participating

in

physical

activity.

In

the

United

States,

forexample,adultswithadisabilityaretwiceaslikelytobeinactiveasthosewithnodisabilityleaving

thematevengreaterriskofthehealthproblemsattendantonsedentarylifestyles.54

iv)Recommendedlevelsofphysicalactivity

Therecommendedguidelinesfortheamountofphysicalactivitythatindividualsshouldengageinona

routinebasisinordertoobtainand/ormaintainhealthandwellnesshasbeendevelopedbyleading

national/internationalbodiesand,althoughtheymayvaryonspecifics,thegeneralfeaturesareallsimilar.

Theexamplepresentedbelow(p.10)istakenfromtheAmericanCollegeofSportsMedicineandthe

AmericanHeartAssociationguidelinesandiswidelyused.55Theadditionalinformationforolderadultsis

alsofromtheACSMandAHAandtheinformationforchildrenfromtheUSCDC.56

Evensmallamountsofphysicalactivity15minutesadaycanhaveasignificanthealthimpacts,increasinglifeexpectancyby

threeyearscomparedtoaninactivegroup.57

Inaddition,thereisnowevidencethatsittingforlongperiodsregardlessofphysicalactivitylevelstherest

ofthetimeisalsoariskfactorforallcausemortality:theriskofdeathwithinthreeyearsis15%greater

amongthosewhositforbetween8and11hoursadaycomparedtothosewhositforfewerthanfour

hours,and40%greateramongthosewhositforover11hoursaday.58

Aneasyruleofthumb(usingwordingfromtheUSCDC)isthetalktest:ifyou'redoingmoderateintensity

activityyoucantalk,butnotsing,duringtheactivity.Ifyou'redoingvigorousintensityactivity,youwillnot

beable

to

say

more

than

afew

words

without

pausing

for

abreath.

iii

iiihttp://www.cdc.gov/physicalactivity/everyone/measuring/index.html

Anexample:Walking

Forgoodhealth,10,000stepsadayisrecommendedthisisabout5miles(8km),dependingon

stridelength,andistheequivalentofwalkingbrisklyforabout90minutes.Thiscanbespreadthroughout

theday.Briskwalkingisanexampleofmoderateintensityactivity;racewalkingbecomesvigorousactivity.

CaseStudy5inPartIIIfocusesparticularlyonwalkingandmoreexamplesofwalkinginitiativesare

includedinC3sreviewoftheevidenceonwalking.59

Figure2:LevelsofphysicalactivityamongadultsinEngland(selfreported)

Men Women


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Physicalactivityguidelines

Topromoteandmaintaingoodhealth,adultsaged1865yearsshouldmaintainaphysically

activelifestyle.

Theyshouldperformmoderateintensityaerobic(endurance)physicalactivityforaminimum

of30minutesonfivedayseachweekorvigorousintensityaerobicactivityforaminimumof

20minutesonthreedayseachweek.

Combinationsofmoderate andvigorousintensityactivitycanbeperformedtomeetthis

recommendation.Forexample,apersoncanmeettherecommendationbywalkingbrisklyfor

30minutestwiceduringtheweekandthenjoggingfor20minutesontwootherdays.

Thesemoderate orvigorousintensityactivitiesareinadditiontothelightintensityactivities

frequentlyperformedduringdailylife(e.g.selfcare,washingdishes,usinglighttoolsatadesk)

oractivitiesofveryshortduration(e.g.takingouttrash,walkingtoparkinglotatstoreor

office).

Moderateintensityaerobicactivity,whichisgenerallyequivalenttoabriskwalkand

noticeablyacceleratestheheartrate,canbeaccumulatedtowardthe30minutesminimumby

performingboutseachlasting10ormoreminutes.

Vigorousintensityactivityisexemplifiedbyjogging,andcausesrapidbreathinganda

substantialincreaseinheartrate.

Inaddition,atleasttwiceeachweekadultswillbenefitbyperformingactivitiesusingthe

majormusclesofthebodythatmaintainorincreasemuscularstrengthandendurance.

Becauseofthedoseresponserelationbetweenphysicalactivityandhealth,personswhowish

tofurtherimprovetheirpersonalfitness,reducetheirriskforchronicdiseasesanddisabilities,

orpreventunhealthyweightgainwilllikelybenefitbyexceedingtheminimumrecommended

amount.

Forolderadults(over65s,orthoseaged5064withchronicconditionssuchasarthritis),the

recommendationisthesame,withbalanceexercisesalsorecommended.Itisalsothecasethat

goalsbelowthisthresholdmaybenecessaryforolderadultswhohavephysicalimpairmentsor

functionallimitations.

Children(aged617)shoulddoatleastanhourofphysicalactivityeveryday.Thiscaninclude

eithermoderateintensityaerobicactivityorvigorousintensityactivity(althoughthelattershould

beincluded

on

at

least

three

days

each

week).

Muscle

strengthening

activities

(such

as

gymnastics)andbonestrengtheningactivities(suchasrunningorskippingrope)arealso

recommendedonatleastthreedaysaweek.

Despitetheclearbenefitsofphysicalactivityforhealth,globallyaroundoneinthreeofthepopulationis

notreachingtherecommendedlevelofphysicalactivity60andsignificantlymoreinsomecountries.Inthe

UnitedStatesonly19%ofadultsmeetguidelinesforbothaerobicandmusclestrengtheningphysical

activity,61andintheUnitedKingdom39%ofmenand29%ofwomenmeettherecommendations.62


11/39



v)Socioeconomicdisparities

ThereisarelationshipbetweensocioeconomicandphysicalactivityintheUnitedKingdom,showninFigure

3.63Formen,thereislittlevariationinthetopfourquintiles,withmeninthelowestincomequintile(i.e.

theleastwelloff)leastlikelytomeetthetargets.Forwomen,theproportionmeetingthetargetishighest

inthetopquintile,withlittlevariationinthelowestfour.Inaddition,theproportionofpeoplegettingthe

lowest

amount

of

activity

increases

as

income

falls

23%

of

men

in

the

highest

quintile

achieve

only

low

levelsofphysicalactivity,comparedwith46%inthelowestquintile,andtheequivalentforwomenis28%

(highestquintile)and45%(lowestquintile).

Therehavebeensomestudiesintowhypatternsofphysicalactivityvarybetweendifferentsocioeconomic

groupsandtherearecertainlyintuitivereasonswhythismaybeso,evenwherestrongempirical

evidenceislacking.Forexample,thestreetsinpoorerneighbourhoodsareoftenlesssafeforwalkingor

cyclingbecauseoftrafficandaperceivedfearofcrime.Theinfrastructureforactivelivingmayalsonotbe

inplaceinsuchareas:onestudyintheUnitedStatesfoundthatmovingfromacommunitywitha1%

povertyratetoa10%povertyrateisassociatedwithadecreasedprevalenceofbikepathsfrom57%to9%

respectively64astheareagotpoorer,theavailabilityofbikepathsfelldramatically.Inaddition,access

bothtoattractive,safegreenspaceandtocommercialresourcesforstructuredphysicalactivitysuchas

gyms65maybemorelimitedinsomemoredeprivedareas.

Itisanunfortunatefactthathealthpromotionmessagesareoftenadoptedfirstbythemoresocially

advantaged,with

evidence

indicating

that

health

campaigns

tend

to

have

the

dual

impact

of

improving

healthonaverageacrossthepopulation,butalsowideninghealthinequalities.66Thismakescreating

opportunitiesforactivelivingmakingiteasytobephysicallyactiveparticularlyimportantinmore

deprivedareas:campaignstoencourageexercisewilldolittletoincreaseactivitylevelsamongtheleast

welloffunlesstheyhavethemeanstomakethechange.

Figure3:ProportionofpeopleinEnglandmeetingthephysicalactivityrecommendationsby

equivalisedhouseholdincomeandsex


12/39



PartII:

Evidencesupportinginterventionstoencouragephysical

activity

1.The

scale

of

the

problem

Despitethelargebodyofevidencethatsupportthebenefitsofbeingphysicallyactive,indeveloped

countriesthemajorityofadultsdonotmeettherecommendedlevel.Comparingphysicalactivitylevels

betweencountriesischallenging,becausetherearenocommontoolsbywhichitismeasured:the

internationaltoolssuchastheInternationalPhysicalActivityQuestionnaireandtheWHOsGlobalPhysical

ActivityQuestionnaireareoftennotpartofnationalsurveys.However,itisclearthatindeveloped

countriesonlyaminorityofadultsachievetherecommendedlevelsofphysicalactivity.InEngland,for

example(asFigure2shows,above),only39%ofadultmenand29%ofadultwomenmeetthe

recommendations.

However,

this

lack

of

clear

data

should

not

stop

efforts

to

increase

physical

activity,

as

the

health

benefits

areevident(seePartI).

2.Anactiveenvironment?

AstheratesofNCDscontinuetorise,recentlygreatereffortsandresourcesarebeinginvestedinhowto

bestencouragepeopletoliveahealthierlifestyle,includingmakingbetterphysicalactivitychoices.

Researchoverthepastfewdecadeshasprovidedagreaterunderstandingofthefactorsinfluencing

whetherornotanindividualorcommunityisphysicallyactive,andFigure4depictsaconceptualmodelof

themultiplefactorsandinfluencesinvolvedinlivingahealthyphysicallyactivelifestyle.Interventionsthat

takeintoconsiderationthesemultiplelayersofinfluencearemorelikelytobeeffectivethansingle

interventionstargeting

aparticular

factor.

Tackling

these

multiple

factors

is

to

encourage

active

living.

Figure4:Layersofinfluenceaffectingengagementinphysicalactivity67

Inrecentyearstherehasbeenshiftawayfromencouragingindividualbehaviourchangetoanapproach

thataddresseswider,populationlevelfactors.Individualisedbehaviourchangeisoftennotsustainableor

effective6869unlessitbecomeshabitforming.Changingtheoverallenvironmentmakesbehaviourchange

moresustainableashashappenedwithsmokingincountriessuchastheUK:initiallytheburdenof

responsibilitywasputsolelyonindividuals.Oncethatviewexpandedtoincluderecognitionofsocietal

responsibilityaswell,populationlevelactionandchangesinsmokingprevalencefollowed.Physicalactivity

hasto

learn

from

these

examples.

70


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Therearedifferentleversthatcanbeusedatthepopulationleveltochangeboththesocialenvironment

andthebuiltenvironment,whichtogetherinfluencethehealthchoicesmadebyindividuals.

Factorsinthesocialenvironmentsknowntoinfluenceparticipationinphysicalactivityare

socioeconomicstatus,culturalbeliefs,andopportunitiestoimprovesocialcohesioninthe

neighbourhood,cityandregions.Factorsinthebuiltenvironmentthatinfluenceparticipationin

physicalactivityareurbandesign,transport(traffic),availabilityofgreenspace,andlanduse

patterns.Newinfrastructuresuchasbikepathsorfitnessequipmentinparksandincreasedaccessto

facilities(such

as

expanded

hours

of

operation

of

fitness

areas,

or

increased

lighting

to

improve

perceptions

ofsafety)canbeeffectiveinencouragingphysicalactivity.71

Anexampleofcreatinganactiveenvironment:walkingandcycling

Encouragingwalkingandcyclingisagoodwayofincreasingphysicalactivity,andsuccessful

interventionstopromotewalkingorcyclingcouldaddressfactorseitherinthebuiltenvironment

orsocialenvironment.

Changingthe

built

environment

through

improvements

in

the

roads

and

pavements

may

be

afeasible

optionforcitiesthatareprioritisingthealleviationoftrafficcongestionandreductionofthecitys

carbonfootprint.InLondon,forexample,cyclinghasbeenastatedpriorityforthemayor,and

improvementstocyclinginfrastructurehaveresultedinanincreaseof123%incycletripsbetween

2001and2009(seeCaseStudy2).

However,iftheresourcesorpoliticalwillisnotyetinlinetomakemajorenvironmentalchanges,

anotherstrategyistoaddressthesocialfactorstopromotewalkingorcycling.Creatingcommunity

walkingorbikinggroupsaresimplewaystoencouragepeopletowalkandbike.

Anexampleofasuccessfulactiveenvironmentistheciclovas72whichtranslatesasbikepaths

initiatives(originatinginBogot)totransformbusystreets,ononedayoftheweek,bybanningall

formsof

motorised

transport,

leaving

them

open

for

walkers,

runners

and

cyclists.

73

In

addition,

free

yogaandotherexerciseclasses(knownastherecreova)areheldinlocalparks.74Thepublichealth

benefitsaresignificant:costbenefitratiosareestimatedat3.234.26forBogot.75

3.Behaviourchange

IntheUnitedKingdom,atleast,thegreatmajorityofthepopulationalmost95%acceptandknow

aboutthelinkbetweenphysicalactivityandhealth.However,themajorityofusdonotdonotachievethe

recommendedamountsofactivity(seeFigure2),apatternseenacrossthedevelopedworldand,

increasingly,amongurbandwellersinlowerincomecountries.76

Fosteringlongtermbehaviourchange

requiresovercoming

anumber

of

perceived

barriers

that

need

to

be

overcome

in

order

to

take

regular

exercise,includingalackofmotivationandashortageoftimeoverathirdclaimthatworkcommitments

preventthemfromtakingphysicalactivity,andaquarterusefamilycommitmentsasanexcuse.77Finding

waystoovercomethesebarriersisessential,throughaddressingindividualdeterminantsandthesocial

environmentforexample,promotingactiveliving,ratherthanexercisinginagym,canhelppeopleto

buildexerciseintotheworkingday,asfitnessgoalscanbeachievedthrough10minuteboutsofmoderate

physicalactivity.

Thesocialaspectsofphysicalactivity(see,forexample,CaseStudies5and6)canalsoactasapowerful

incentive,andthereisevidencethatinterventionsthatprovidesocialsupportareeffectiveindriving

behaviourchange,eitherthroughsocialnetworkingorthroughpeertopeerinteractions.78

Carefullytargeted

interventions

that

are

tailored

to

specific

groups

and

individuals

for

example,

suggestingsmall,manageable,appropriatechanges,orsettingpersonalgoalscanhelptoencourage

sustainablebehaviourchange.Prompts(suchasbyphone,textoremail)canalsohelppeopletosustain


14/39



theirphysicalactivityhabits,79andtherearealsoarangeofonlinetoolsavailableforindividualstotrack

theirphysicalactivity(forexample,mapmyrun.com)andshareideas,routesandchallengeswithothers

throughsocialmedia(forexample,dailymile.com).

WidercampaignssuchastheUKsChange4Life80focusedonimprovingdietandphysicalactivity,and

usingmassmediacanalsohavesomeeffect,andspearheadedawalkingcampaign,

Walk4Life.Creatingacultureinwhichphysicalactivityisasocialnorm,oreven

fashionable,could

be

an

effective

way

to

increase

physical

activity

81

:atipping

point

for

behaviourchange.

Motivationalinterviewingisoneofthemostcommontherapeuticstrategiesusedtoinitiatebehaviour

changeitgaugesapersonsreadinesstochangetheirbehaviour,andisusedtohelptoprimepeoplefor

thechange.Itiscommonlyusedonpeoplewithaddictivebehaviours(suchastobaccouseandalcohol),

andistypicallyusedintherapyenvironmentsalthoughphysicalactivitycouldalsomakeuseofsomeof

thesamebasicprinciples.

Prescribingphysicalactivity

EncouragingGPs

to

prescribe

walking

and

other

physical

activity

(also

known

as

exercise

referral)

can

also

beaneffectivebehaviourchangeintervention.82InSweden,forexample,asystemofPhysicalActivityon

Prescription(Fysiskaktivitetprecept:FaR)isregularlyusedtheprescriptionistailoredtothehealth

needsoftheindividualpatient,andcanbeassimpleasawrittensuggestionofanactivityoramuchmore

comprehensivesolution,supportedbyanactivityorganisersuchasvolunteerorsportsorganisations.83

IntheUnitedKingdom,patientsarereferredtoaqualityassuredsystemsuchasaleisurecentreor

walkinggroup,withtheirGPretainingclinicalcontrol.NaturalEnglandscampaignforOurNatural

HealthServiceaimedtohighlightthelinkbetweenoutdooractivityingreenspaceandhealth.It

aimstoincreasethenumberofhouseholdswithinafiveminutewalkofgreenspaceofatleasttwo

hectares,andtoenableGPsandcommunitynursestosignpostpatientstoanapprovedhealthwalk

oroutdooractivityprogramme.Unfortunately,however,manyhealthprofessionalsareunawareofthe

benefitsofphysicalactivity,andarecentsurveyfoundthatthereisalackofappropriatefocusonteaching

thebenefitstomedicalstudents:almosthalf(44%)ofmedicalschoolsintheUK,forexample,donoteven

teachtheguidelinesonphysicalactivity.84ThegoaloftheMove.Eat.Treatcampaign85intheUKistoensure

bettereducationforhealthprofessionalsinhowtodeliverlifestyleadvice,includingonphysicalactivity.

Theevidenceontheeffectofexercisereferralisnotclearcut.Ithasbeensuggestedthatitmaybecost

effective,86butthemedium andlongtermeffectsofprescribingexerciseareoftennottracked,andthere

havebeenrelativelyfewrandomisedcontrolledtrialsthathaveassessedtheimpactofprescribing

exercise.87

4.Selected

interventions

Table7inAppendix2providesaselectlistofinterventionsthathavebeenidentifiedbytheUSCentersfor

DiseaseControlasbeingeffectiveinpromotingphysicalactivity.Thetableincludestheintervention

components,outcomesandeffectsize(ifavailable),andkeyimplementationfactorsthatarelinkedtothe

contextandareimportanttoconsiderinseekingtoreplicatethefindings.Thecomprehensivereviewon

whichthetableisbasedidentified94studiesthatmetitseligibilitycriteriaforinclusion,andthreemain

typesofinterventionsforincreasingphysicalactivity:

informationbased;

behaviouralandsocial;and

environmentalandpolicyinterventions.


15/39


16/39



Increasingphysicalactivity

Leisuretimeactivitiesareactivitiesdoneinperiodsoftimeoutsideofworkandessentialdomestic

activities.Thestrategyistoencouragesportparticipationordifferentsocialgroupswhichengagein

physicalactivity(e.g.walkinggroups,cyclinggroups,dancingorcommunitygardening).

Activetransportreferstowalkingorbikingasameansoftransportationandnotpurelyasaformof

recreation.Encouraging

walking

or

biking

to

work

or

school,

or

going

about

daily

activities

such

as

shoppingaregreatwaystomaintaininganactivelifestyle.

Activelivingisawayoflifeinwhichexerciseisfullyintegratedintodailyactivities.Thegoalisto

accumulate30minutesofphysicalactivityadayin10minutestints.Thiscanbedoneinvariousways:

throughleisuretimeactivity,activetransport,householdchores,takingthestairs,walkingadog,etc.

Waystopromotesimpleexerciseinitiatives:walking

Promotingwalkingasaformofactivetransportorasaleisuretimeactivityisasimplewayto

encouragephysicalactivity.Asidefromimprovingthebuiltenvironmenttoencouragewalking

thereareotherstrategies,whichhavebeenshowntobeeffectiveinpromotingwalking.Theyinclude:

brieftelephoneprompts;95

prescribingwalking(byhealthcareproviders);96

usingpedometers;97

massmediacampaigncoupledwithmediatedinterventions(facetofaceortelephoneprompt

interventions);98

socialinteraction.

99


17/39



PartIII:Casestudies

1.Introduction

Thepurposeofthesecasestudiesistoprovideinformationonthevarioustypesofactivities/programmes

thatare

currently

under

way

and

to

spark

ideas

that

can

be

further

explored

in

local

communities.

This

samplingofcasestudieswaschosentoreflectgeographicandculturaldiversityaswellasacombinationof

thedifferenttypesofphysicalactivities/programmespossible(e.g.leisuretimeactivitiesandactive

transport).Onesizedoesnotfitallanyinitiativemustbeadaptedtosuitthecircumstancesinwhichitis

beingestablishedandthepopulationatwhichitisaimed.

Whilehealthbenefitsoftheinitiativesinthecasestudieshavebeenincludedwhereknown(andthe

majorityhaveevaluatedatleastsomeofthementalorphysicalhealthbenefits),pleasenotethatmanyare

notsubjecttorigorousscientificstudy(seeAppendix3).However,evenifnotformallyassessedaspartofa

researchstudy,thespecificactivitiesthemselvesmaybeevidencebased:forexample,buildingonthe

evidenceofthebenefitsofpeersupportinpromotingphysicalactivity,thebenefitsofwalkingandofthe

use

of

pedometers.

There

is

ample

evidence

regarding

the

value

of

physical

activity

in

maintaining

and/or

improvinghealth.

Lackofevaluationwhile,ofcourse,innowaydiminishingtheeffectsoftheinitiativeonthosetakingpart

maymakethevalueoftheprojectlessobvioustoothers,andmakeitlesslikelytobereplicated

elsewhere.Tobeabestpracticecasestudy,anynewinitiativesshouldconsiderevaluatingitsparticipation

ratesandmental/physicalhealthimpacts.

2.Whatmakesforbestpractice?

Anadditionalreferencetoconsiderforthereviewofbestpractices/casestudiesmaybefoundinareport,

published

by

the

World

Health

Organization,

Review

of

Best

Practices

in

Interventions

to

Promote

Physical

ActivityinDevelopingCountries(2008),whichisalsohighlyrelevanttodevelopedcountries.

TheWHOnotedthatthefollowingfeaturesofaninterventionshouldbeinplaceifitistobeseenasan

exampleofbestpractice:

reachalargeproportionofthepopulation,orofadefinedpopulationgroup;

havemid tolongtermexperience/sustainability(atleast13years);

aretargetedtothewholepopulationaswellasspecificpopulationgroups(e.g.adults,children,senior

citizens,employees,disabledpeople,women);

defineclearobjectives(e.g.raisingawarenessontheimportance/healthbenefitsofphysicalactivity,

increasingpopulation

levels

of

physical

activity);

havepoliticalcommitmentoraguidingpolicy;

haveacoordinatingteam(e.g.programmecoordination,delivery,administration,research/evaluation,

dissemination);

receivesupportfromstakeholders(e.g.ministries,privatesectororganisations,NGOs,sports

associations,schools,employers,parents,localcommunitygroups);

provideaclearidentity(e.g.name,logo,mascot,branding);

areimplementedwithinthelocalreality(sources,infrastructure,culturalgroups);

distributedthe

intervention

components

using

various

channels

(e.g.

print

media,

electronic

media,

events,powerfulindividuals,advocates);

includesomeclearevaluationoftheprogrammeoritselements.


18/39



3.Casestudies

Casestudy1:BrazilAgita

AgitaSoPauloisanongoing,communitywideandverysuccessfulinterventiontopromotephysical

activity.ItwasoriginallyimplementedinSoPaulo,Brazil,astatewith34millioninhabitants,andwas

launched

in

1996

by

the

Centre

for

Laboratory

Studies

on

Physical

Fitness

of

So

Caetano

do

Sul

(CELAFISCS).Whatstartedasagrassrootsinitiative,withvolunteerparticipationofexercisescientistsand

physicians,hasspreadandbecomeamodelforsimilarprogrammesacrossthecountryandintheAmericas

morewidely,includingArgentina,Colombia,andMexico.AworldwideNGO(AgitaMundo)initially

developedtheannualMoveforHealthinitiative,launchedbytheWHOonWorldHealthDay2002.(See

alsowww.agitasp.org.)

Agitaaimstoincreaseknowledgeandawarenessofthebenefitsofanactivelifestyle,andenhancephysical

activityparticipation,particularlythroughencouraging30minutesofphysicalactivity.Theoriginalmascot

ofthecampaign,thehalfhourman,hasnowbeensupplementedwith

othermascotssuchasthehalfhourwomanandhalfhourcowboyand

others,toadapttogenderandregionalculturesinanappealingway.The

focusis

more

on

active

living

and

physical

activity

for

health

than

on

sportandfitness,soeveryday,lifelongphysicalactivities(suchas

walking,gardening,homechoresandactivetransport)arethemost

recommendedactivitiesand,asBrazilianslovetodance,the

recommendationsforleisureactivitylargelyfocusondancing.

Thewholepopulationistargeted,withaparticularemphasisonchildrenandstudents,workersandolder

adults,andthecampaigntakesaholisticapproach,focusingnotonlyontheindividual,butalsoontheir

environment(family,teachers,peergroups,communityvaluesandmedia).

Healthimpacts

ThereareclearpositiveimpactsoftheAgitaprogramme.Awarenessoftheprogrammeanditsmessagesis

high(80%ofchildreninstateschoolsintheareaknowtherecommendationsonphysicalactivity,for

example),andinhabitantsare54%lesslikelytobesedentaryiftheyhaveheardoftheprogramme.

Physicalactivityhasincreasedforexample,intheover50s,thosewhoareirregularlyactivefell60per

centbetween1999and2004,whilethosewhoareactiverose61%.Overall,theproportionofpeople

doinglessthan150minutesaweekofphysicalactivityinthestateofSoPaulofellbyover71%between

2002and2008.

Thebenefitsoftheincreaseinphysicalactivityarealsohavingan

impact

on

physical

health.

In

Sorocaba,

the

mayor

and

local

administrationsawthevalueoftheprogramme,and

implementedchangesininfrastructure(suchasbetter

pavements),andthehealthimpactwasstriking:hospitalisation

fromdiabetesfellby57%between2000and2004,and

hospitalisationforstrokefellby50%.TheWorldBankhas

estimatedthatAgitarepresentsacostsavingtothehealthsystem

ofUS$310millioneachyear.100


19/39



Casestudy2:EnglandEncouragingcycling

InEngland,theneedforactivetraveltobeincludedinstrategiestotackleobesityandNCDsisexplicitly

recognisedbythegovernment:the2010WhitePaperonpublichealthstatesthatactivetraveland

physicalactivityneedtobecomethenormincommunities.101Andopportunitiesforcyclingaremultiplying

intheUK,throughtheworkoforganisationssuchasSustrans,anNGOwhichhasinvested500million

since

its

establishment

in

1977,

and

which

co

ordinates

partnerships

with

local

transport

authorities

and

publichealthteams,NGOsandover3,000regularvolunteers.

SustransNationalCycleNetworkconsistsofover20,000kmofdedicatedbikepathsandtrafficcalmed

roads,andaimstoincreasetheproportionofjourneysunderfivemilesthatarecycledfromitscurrent

levelofaround2%to20%.SustransBikeItinitiativeencouragesmoreschoolchildrentocycletoschool,

andinBikeItschoolstripsbybikehavemorethantrebledtoaround10%.

Inparticular,therebeensignificantincreasesincyclinginLondon:thenumberofpeopleenteringcentral

Londonbybicycleduringtheweekdaymorningpeakgrewby123%between2001and2009andby15%

in200809alone.Despitethisrise,bytheendof2009fatalitiesandseriousinjuriestocyclistshadfallen

24%fromtheratein199498andby3%in2009.102Thisincreaseisduetoavarietyoffactors,including

theintroduction

of

aCongestion

Charge

for

motor

vehicles,

improvements

to

cycling

infrastructure

and

the

recentestablishmentbyTransportforLondonandBarclaysBankofafleetof5,000hirebicycles(3million

journeysweremadeonthebikesinthefirsteightmonthsofoperation).

Healthbenefits

Since2000,Sustranshasbeenevaluatingthebenefits

ofitsprojects103:407millionjourneysweremadeon

theNationalCycleNetworkin2009(6%upon2008),

withanestimatedhealthbenefitfromcyclingof288

million.Thiscostbenefitofimprovingcycling

infrastructureis

estimated

as

being

nearly

4:1

over

just

10years,mainlyderivedfromimprovedhealthdueto

theincreaseinphysicalactivity.104Theenvironmental

impact,too,issignificant:theuseoftheNationalCycle

NetworkisalreadyestimatedtoreduceCO2emissions

byover600,000tonnesayear,comparedtoeach

journeyinsteadbeingtakenbycar.


20/39



Casestudy3:GlobalTheGlobalCorporateChallenge

TheGlobalCorporateChallengeisanannual,threemonthwalkingchallengeforemployees,which

wassetupin2004inAustraliaandisnowin55countries,withover100,000participantsin2011.

Workplacesenterteamsofsevenpeople,eachofwhomareissuedwithastarterpack(includinga

pedometer),withtheaimofachievingatleast10,000stepseachday.Thehopeisthatphysicalactivity

levels

will

increase

for

the

period

of

the

Challenge,

but

that

the

length

of

time

for

which

the

Challenge

runs

willmeanthatitishabitforming,i.e.thatparticipantswillcontinuetodogreateramountsofphysical

activityfollowingtheendofthefourmonths.

Eachparticipantaddstheirdailystepcounttoawebsite,whichbothtrackstheprogressoftheindividual

andalsocalculatesthedistancetravelledbytheteamasawhole,plottingacoursearoundtheworld

showingtheteamsprogressonamap.Thewebsitealsocontainsnutritionalandhealthinformation.The

costin2011was49perheadintheUnitedKingdom.In2010theaveragenumberofstepstakenper

participantintheGCCwas12,693(thisequatestowalkingatotalofover8kmperdayandburnsoffover

500kcal).From2010,eachcompanyssupportoftheGCChasalsosponsoredateamofchildrenaged812

yearstoenterafree50dayGlobalChildrensChallenge,105encouragingchildrenbothtobephysically

activeandtousephysicalactivitytolearnabouthealthand(throughthewebsite)geographyandsocial

science:in

its

first

year,

over

90,000

children

took

part.

Healthbenefits

Theaverageofficeworkerisestimatedtowalkonly3,000

stepsperday,sothe12,000stepsadayaveragedin2010

isafourfoldincreasesignificantincreaseindailyphysical

activity.This,coupledwithadviceonbetternutrition,has

alastingimpactonthehealthandwellbeingofGCC

participants.IndependenthealthscreeningbyMonash

UniversityfortheFoundationforChronicDisease

Preventionhasverifiedsignificantreductionsinparticipantwaistmeasurementsaswellasbothsystolic

anddiastolicbloodpressure.106AsurveyofGCC

participantsfoundthat94%ofthosewhotookpartsaid

thattheywouldcontinuethesamehigherlevelofphysical

activityaftertheconclusionoftheChallenge:along

lastinglifestylechangewiththepotentialforsignificant

andlongtermhealthbenefits.


21/39



Casestudy4:UnitedStatesandMexicoLiftOff/PausaParaTuSalud(Breakforyourhealth)Alsoaimedatencouraginghealthintheworkplace,LiftOffisaLosAngelesbasedstudy107of449

employees,predominantlysedentary,overweight,middleagedwomenofcolour,whometover26

sessions.Theinterventionintegratedshort,10minuteboutsofexerciseintotheworkingday,involving

moderateintensity,lowimpactaerobicdanceandcalisthenicmovementstomusic.Morethan90%of

meeting

attendees

participated

in

the

exercises.

The

same

model

has

now

been

expanded

to

other

settings

suchascommunitybasedhealthandsocialserviceorganisationsservingAfricanAmericanand/orLatinos

inCaliforniaandSouthCarolina.

Inasimilarprogramme,PausaParaTuSalud(BreakforyourHealth)tookplaceintheMexicanMinistryof

HealthfromJanuary2003toJanuary2004.108Eachexercisebreak,orpausa,wasscheduledataspecific

time(1111:30am),andallofficeemployeeswereencouragedtotakepart.Thesessionsbeganas10

minutesoflightstretchinganddancemovements,andthenincreasedinintensityastheemployees

becamefitter.Musicselectionsweresuggestedbyemployees,andtheroutinesvariedtoincludestrength,

flexibilityandaerobicconditioning.Theprojectalsomadeuseofstairpromptsandwrittenmaterials,and

seniorstaffencouragedemployeestotakepartinphysicalactivityoutsidetheworkplace.

Healthbenefits

AmongcompletelysedentaryindividualsinLiftOff,

interventionparticipants'selfperceivedhealthstatusratings

weresignificantlylowerthanthoseofthecontrolgroup.

Amongthecompletelysedentary,controlparticipantsreported

significantlyhigherlevelsofenergythandidintervention

participants.

IntheMexicaninitiative,maleemployeeslostanaverageof

1.01kginweight(womendidnotseeasignificantweight

reduction),and

waist

circumference

for

both

sexes

decreased

significantly(by1.9cmformenand1.4cmforwomen).There

wasalsoasignificantdecreaseinwomensdiastolicblood

pressure.

DrToniYancey,leadingproponentof

theinterventionataLiftOffclass


22/39



Casestudy5:UgandafootballleagueinGulu

TheGumMaromKidsLeagueisafootball(soccer)leagueinGulu,NorthernUgandaaregionthathasonly

recentlyemergedfromover20yearsofcivilwar,duringwhichtimeoneinthreeofallboysandoneinsix

ofallgirlsarethoughttohavebeenabducted,manyofwhomwereforcedtoserveaschildsoldiers.109The

leaguewasestablishedtoengagethelocalcommunity,buildamorerobustpeace,andimprovethe

physical

and

mental

health

of

1014

year

olds.

In

its

first

season

(SeptemberNovember

2010),

32

teams

wereformed,reaching240localboysand160girls,with32adultstrainedasfootballcoachesandpeace

buildingeducators.LeagueandtournamentgamestookplaceeachSaturday,withtrainingafterschoolon

atleastoneeveningaweek.Peacebuildingactivitieswereorganisedaroundeachgameortrainingsession,

includingconflictmanagementandhealthawareness,presentedthrougharangeofgenresincluding

poetry,roleplayanddebate.Theprojectwaspromotedonlocalradioandinschools,andprovedso

popularthatitcouldnotaccommodateallthechildrenwhowantedtotakepart.

AtacostofUSh25,000,000(US$10,400)forthefirstseason,itisapartnershipbetweenthelocal

communitybasedYouthCoalitionforPeaceandwithfundingfromCanadabasedNGOOAProjects110and

somesupportfromTheKidsLeague,aKampalabasedNGO.Schoolsandlocalgovernmentwereinvolvedin

designingtheprojecttoensuremaximumlocalsupport.

Theprojectisdesignedtobesustainablelocalstaffareplanningtolaunchthenextseasonwithminimal

externalmanagementsupport,andOAProjects(whilecontinuingtofundtheprojectin2011)isworking

towardscompletelocalownership.

Healthbenefits

Evaluationofthementalandphysical

healthofthechildren,andtheimpact

ofthepeacebuildingandgender

equityaspects,wasakeycomponentof

theproject.

The

evaluation

was

carried

outbyaresearchteamthatworked

withlocalschools.Mentalhealthwas

measuredusingalocallydeveloped

tool,andphysicalhealthusingabeep

test,standingjumpandBMIforage.

Preliminaryanalysisofbaselinedata

suggestsnormalgrowthpatterns,but

identifiedapopulationwidedeficitin

physicalfitnessandpersistentmental

healthchallenges.Finalresultsonthe

impactof

the

intervention

will

be

postedontheOAProjectswebsite.


23/39



Casestudy6:UKGreenGymatHerewardGPPractice,Bourne

ThisisanexampleofphysicalactivitythatisprescribedbyGPs,anddeliveredthroughaGreenGyma

schemeinwhichparticipantsaregiventheopportunitytotacklephysicaljobsintheoutdoors,improving

strength,practicalskillsandconfidence,andbenefitingthelocalnaturalenvironment.BourneGreen

Gym111waslaunchedinmid2009itnowhasover50members.ItistheonlyGreenGyminthecountryto

be

funded

by

the

NHS

and

run

from

a

GP

surgery,

and

is

also

supported

by

the

British

Trust

Conservation

Volunteers(BTCV).PatientsarereferredorencouragedtojoinbytheirGP,whogivesadviceonthecorrect

levelofexercise.Itispromotedwithpostersinthesurgeryswaitingroom.Projectstakeplacein

communitygardensandtherearealsosomeconservationeffortsinAbbeyLawns,TheWellheadand

BourneWoods.

Healthbenefits

Thelatestresults(assessedaftersixmonths)aredrawnfromaselfperceptionquestionnaireissuedto

members(80%ofwhomhadspecificheartproblems,suchasheartconditions,diabetesetc.).Therewere

clearphysical andmentalhealthbenefitsas,inadditiontothe

pleasurefelt

in

learning

new

skills

and

making

new

friends:

70%feltthattheirenergylevelshadimproved;

90%reportedimprovedemotionalwellbeing;

80%feltthattheirphysicalcapabilitieshadimproved;and

50%hadachievedweightloss(ofuptohalfastonearound

3kg).


24/39



Appendix1:Selectedliteratureonthehealthbenefitsof

physicalactivity

Tables14provideselectexamplesofkeyresearchstudiesand/orreportsthatsupporttheimpactof

physicalactivityonthepreventionandcontrolof,inparticular,threemajorNCDs:cardiovasculardisease,

type2diabetes

and

many

cancers.

Table

5provides

information

on

the

mental

health

benefits

of

physical

activity,andTable6theadvantagesconferredthroughoutlife.

Table1a:Preventionofoverweightandobesity

Haskell,W.L.,I.M.Lee,R.R.Pate,K.E.Powell,S.N.Blair,B.A.Franklin,C.A.Macera,G.W.Health,P.D.Thompsonand

A.Bauman,Physicalactivityandpublichealth:updatedrecommendationforadultsfromAmericanCollegeofSports

MedicineandtheAmericanHeartAssociation,MedSciSportsExerc(2007)39(8):142334:

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185649v1

Penedo,F.J.andJ.R.Dahn,Exerciseandwellbeing:areviewofmentalandphysicalhealthbenefitsassociatedwith

physicalactivity,

Cur

Opin

Psychiatry

(2005)

18:

18993:

http://www.ncbi.nlm.nih.gov/pubmed/16639173

USDepartmentofHealthandHumanServices,PhysicalActivityandHealth:AReportoftheSurgeonGeneral

(Atlanta,GA:CentersforDiseaseControlandPrevention,NationalCenterforChronicDiseasePreventionandHealth

Promotion,1996):http://www.fitness.gov/execsum/execsum.htm

Warburton,D.E.R.,S.Charlesworth,A.Ivey,L.NettlefoldandS.S.D.Bredin,Asystematicreviewoftheevidenceof

CanadasPhysicalActivityGuidelinesforAdults,IntJBehavNutrPhysAct(2010)7:39:


Table1b:

Prevention

of

type

2diabetes

Burchfiel,C.M.,D.S.Sharp,J.D.Curb,B.L.Rodriguez,L.J.Hwang,E.B.MarcusandK.Yano,Physicalactivityand

incidenceofdiabetes:theHonoluluHeartProgram,AmJEpidemiol(1995)41:3608:

http://aje.oxfordjournals.org/content/141/4/360.short

Dziura,J.,S.V.KaslandL.DiPietro,Physicalactivityreducestype2diabetesriskinagingindependentofbodyweight

change,JPhysActivityHealth(2004)1:1928:http://journals.humankinetics.com/jpahback

issues/jpahvolume1issue1january/physicalactivityreducestype2diabetesriskinagingindependentofbodyweightchange

Hu,F.B.,R.J.Sigal,J.W.RichEdwards,G.A.Colditz,C.G.Solomon,W.C.Willett,F.E.SpeizerandJ.E.Manson,Walking

comparedwithvigorousphysicalactivityandriskoftype2diabetesinwomen:aprospectivestudy,JAMA(1999)

282:14339:http://jama.amaassn.org/content/282/15/1433.abstract

Hu,F.B.,M.F.Leitzmann,M.J.Stampfer,G.A.Colditz,W.C.WillettandE.B.Rimm,Physicalactivityandtelevision

watchinginrelationtoriskfortype2diabetesmellitusinmen,ArchInternMed(2001)161:15428:


Rana,J.S.,T.Y.Li,J.E.MansonandF.B.Hu,Adipositycomparedwithphysicalinactivityandriskoftype2diabetesin

women,DiabetesCare(2007)30:538:http://www.ncbi.nlm.nih.gov/pubmed/17192333

Sawada,S.S.,I.M.Lee,T.Muto,K.MatuszakiandS.N.Blair,Cardiorespiratoryfitnessandtheincidenceoftype2

diabetes:prospectivestudyofJapanesemen,DiabetesCare(2003)26:291822:


Weinstein,

A.R.,

H.D.

Sesso,

I.M.

Lee,

N.R.

Cook,

J.E.

Manson,

J.E.

Buring

and

J.M.

Gaziano,

Relationship

of

physical

activityvsbodymassindexwithtype2diabetesinwomen,JAMA(2004)292:118894:



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Table2:Preventionofcardiovasculardisease

Alevizos,A.,J.Lentzas,S.Kokkoris,A.Mariolis andP.Korantzopoulos, Physicalactivityandstrokerisk,IntJClin

Pract(2005)59(8):92230:http://www.ncbi.nlm.nih.gov/pubmed/16033614

Blair,S.N.,H.W.KohlIII,C.E.Barlow,R.S.PaffenbargerJr,L.W.GibbonsandC.A.Macera,Changesinphysicalfitness

andallcausemortality:aprospectivestudyofhealthyandunhealthymen,JAMA(1995)273:10938:


Haskell,W.L.,I.M.Lee,R.R.Pate,K.E.Powell,S.N.Blair,B.A.Franklin,C.A.Macera,G.W.Health,P.D.Thompsonand

A.Bauman,Physicalactivityandpublichealth:updatedrecommendationforadultsfromAmericanCollegeofSports

MedicineandtheAmericanHeartAssociation,MedSciSportsExerc(2007)39(8):142334:


Myers,J.,A.Kaykha,S.George,J.Abella,N.Zaheer,S.Lear,T. YamazakiandV.FroelicherV:Fitnessversusphysical

activitypatternsinpredictingmortalityinmen,AmJMed(2004)117:91218:



physicalactivity,CurOpinPsychiatry(2005)18:18993:http://www.ncbi.nlm.nih.gov/pubmed/16639173

Paffenbarger,R.S.Jr,R.T.Hyde,A.L.WingandC.C.Hsieh,Physicalactivity,allcausemortality,andlongevityof

collegealumni,NEnglJMed(1986)314:60513:http://www.ncbi.nlm.nih.gov/pubmed/3945246

USDepartmentofHealthandHumanServices,PhysicalActivityandHealth:AReportoftheSurgeonGeneral

(Atlanta,GA:CentersforDiseaseControlandPrevention,NationalCenterforChronicDiseasePreventionandHealth

Promotion,1996):http://www.fitness.gov/execsum/execsum.htm




Table3:Preventionofcoronaryarterydisease

Specificbenefits:

Reductionsinsystolic

anddiastolicblood

pressure

Decreasesintotaland

lowdensitylipoprotein

(LDL)cholesterol

Increasesinhigh

densitylipoprotein

(HDL)cholesterol

Haskell,W.L.,I.M.Lee,R.R.Pate,K.E.Powell,S.N.Blair,B.A.Franklin,C.A.Macera,

G.W.Health,P.D.ThompsonandA.Bauman,Physicalactivityandpublichealth:

updatedrecommendationforadultsfromAmericanCollegeofSportsMedicineand

theAmericanHeartAssociation,MedSciSportsExerc(2007)39(8):142334:


Miller,T.D.,G.J.BaladyandG.F.Fletcher,Exerciseanditsroleintheprevention

andrehabilitationofcardiovasculardisease,AnnBehavMed(1997)19(3):2209:


Penedo,F.J.andJ.R.Dahn,Exerciseandwellbeing:areviewofmentalandphysical

healthbenefitsassociatedwithphysicalactivity,CurOpinPsychiatry(2005)18:

18993:http://www.ncbi.nlm.nih.gov/pubmed/16639173

USDepartmentofHealthandHumanServices,PhysicalActivityandHealth:A

ReportoftheSurgeonGeneral(Atlanta,GA:CentersforDiseaseControland

Prevention,NationalCenterforChronicDiseasePreventionandHealthPromotion,

1996):http://www.fitness.gov/execsum/execsum.htm

Warburton,D.E.R.,S.Charlesworth,A.Ivey,L.NettlefoldandS.S.D.Bredin,A

systematicreviewoftheevidenceofCanadasPhysicalActivityGuidelinesfor

Adults,IntJBehavNutrPhysAct(2010)7:39:



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Table4:Preventionofandrecoveryfromcancer

Fong,D.Y.T.etal.,Physicalactivityforcancersurvivors:metaanalysisofrandomisedcontrolledtrials,BMJResearch

(2012)344:370:http://www.bmj.com/content/344/bmj.e70

Mishra,S.I.etal.,Exerciseinterventionsonhealthrelatedqualityoflifeforcancersurvivors(Review),Cochrane

Library(2012)8:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007566.pub2/abstract

Mishra,S.I.etal.,Exerciseinterventionsonhealthrelatedqualityoflifeforpeoplewithcancerduringactive

treatment(Review),CochraneLibrary(2012)8:

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008465.pub2/abstract

Speck,R.M.etal.,Anupdateofcontrolledphysicalactivitytrialsincancersurvivors:asystematicreviewandmeta

analysis,JCancerSurviv(2010)4(2):87100:http://www.springerlink.com/content/p1500840qt11h157/




WorldCancerResearchFund/AmericanInstituteforCancerResearch,Food,Nutrition,PhysicalActivity,andthe

Preventionof

Cancer:

aGlobal

Perspective

(Washington

DC:

AICR,

2010):

http://www.dietandcancerreport.org/

Table5:Benefitsofphysicalactivityonmentalhealth

Larson,E.B.etal.,Exerciseisassociatedwithreducedriskforincidentdementiaamongpersons65yearsofageand

older,AnnInternMed(2006)144(2):7381:http://annals.org/article.aspx?volume=144&issue=2&page=73


physicalactivity,CurOpinPsychiatry(2005)18:18993:http://www.ncbi.nlm.nih.gov/pubmed/16639173

Taylor,B.,J.F.SallisandR.Needle,Therelationshipofphysicalactivityandexercisetomentalhealth,PubHealth

Rpts(1985)100(2):195201:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424736/




Table6:Benefitsofphysicalactivityacrossthelifespan

Children Improveeducational

attainment

Centersfor DiseaseControlandPrevention,TheAssociationbetween

SchoolbasedPhysicalActivity,includingPhysicalEducation,and

AcademicPerformance(Atlanta,GA:USDepartmentofHealthand

HumanServices,2010):

http://www.cdc.gov/healthyyouth/health_and_academics/pdf/pa

pe_paper.pdf

Preventobesity Janseen,I. andA.LeBlanc, Systematicreviewofthehealthbenefitsofphysicalactivityandfitnessinschoolagedchildrenandyouth,IntJ

BehavNutrPhysAct(2010)7:40:



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Midlife Improvehealthinoldage Willis,B.L. etal.,Midlifefitnessandthedevelopmentofchronicconditionsinlaterlife,ArchInternMed (2012)172(17):18:

http://archinte.jamanetwork.com/article.aspx?articleid=1352789

Elderly

adults

Increaseinfunctionalability Allison, M.andC.Keller, Physicalactivityintheelderly:benefitsandinterventionsstrategies,NursePract(1997)8:534:


Howe,T.E.,

L.

Rochester,

F.

Neil,

D.A.

Skelton

and

C.

Ballinger,

Exerciseforimprovingbalanceinolderpeople,CochraneDatabase

ofSystematicReviews:

http://summaries.cochrane.org/CD004963/exerciseforimproving

balanceinolderpeople

Stessman,J.,R.HammermanRozenberg,A.Cohen,E.EinMorand

J.M.Jacobs,Physicalactivity,functionandlongevityamongthevery

old,ArchInterMed(2009)169:147683:


Improvelongevity Stessman, J.,R.HammermanRozenberg,A.Cohen,E.EinMor and

J.M.Jacobs,

Physical

activity,

function

and

longevity

among

the

very

old,ArchInterMed(2009)169:147683:


Cognitivefunction Larson,E.B.etal.,Exercise isassociatedwithreducedriskforincidentdementiaamongpersons65yearsofageandolder,AnnInternMed

(2006)144(2):7381:

http://annals.org/article.aspx?volume=144&issue=2&page=73


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Appendix2:Physicalactivityinterventions

ThesystematicreviewpresentedinTable7isavailableonwww.thecommunityguide.org,andpartshavebeen

publishedintheAmericanJournalofPreventiveMedicine2002,22(4S):73107aswellasbytheUSDepartmentof

HumanServices,IncreasingPhysicalActivity:aReportontheRecommendationsoftheTaskForceonCommunity

PreventiveServices(2001).ThereviewfocusedonstudiesthatwereavailableforreviewinEnglish,wereeitherRCTs

ornon

RCTs

with

concurrent

control

group,

and

included

baseline

and

post

intervention

measures

of

outcomes.

Multipleelectronicdatabasescoveringresearchworldwidewereexaminedovera20yearperiod(19802000).

Table7:Physicalactivityinterventions

Intervention

type

Components Outcomes/effectsize Implementationfactors

Socialmarketing:

Communitywide

Campaigns

Mediacampaigns(print,

electronic,advertising,

press/publicity)

Communityparticipation

throughselfhelpgroups

Educationandcounselling

atworksites,schools,

communitygroups,

communityevents

Advocacyfor

environmentalchange

4.2%median

increaseinphysical

activity(range2.9

9.4%)

16.3%median

increaseinenergy

expenditure(range

7.621.4%)

Studiesincludedallsocio

economicgroups,urban

andrural,minoritiesin

theUSA

and

elsewhere

(Sweden,Denmark,

Scotland,Wales,

Australia)

Communityparticipation

ledtosocialcapitalbuild

upandgreatercohesion

Carefulplanning,

coordination,welltrained

staff,sufficientresources

required

Healtheducation

andskill

development

individually

adapted

behaviourchange

ingroupsetting

Programmestailoredto

individualsreadinessfor

change,specificinterests

andpreferences

Programmesincludegoal

settingandself

monitoring;social

support;reinforcement;

structuredproblem

solving;andrelapse

prevention

Deliveredingroupsettings

orbymail,telephoneor

directmedia

Increasesinphysical

activitymedian

35.4%(range16.7

83.3%)

Increasesinenergy

expenditure

median64.3%

(range3185.5%)

PrimarilyUSbased

studies

Volunteersampleslimit

generalisability

Community

participation

socialsupport

interventionsin

community

settings

Focusonbuilding,

strengtheningand

maintainingsocial

networksincluding

creatingnew

social

networksorbuildingon

existingnetworksoutside

Increasesintime

spentinphysical

activitymedian

44.4%(range19.9

45.6%)

Increasein


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ofthefamilysuchasthe

workplace.Examples

include:

Settingupbuddysystem

Contractingwithanother

persontomeetgoals

Establishingwalking

groups

Reinforcedbyphonecalls

anddiscussiongroups

frequencyof

physicalactivity

median19.6%

(range14.657.6%)

Decreasedadiposity

median7.3%

(range6.88.1%)

Policyand

environments:

activetransport

increasing

physicalactivity

asameans

of

transport

Telephonemarketing

Informationandaccess

maps

Travel

diaries

Workplacefacilitiesand

incentivesforactive

transport

Greentransport

promotioncampaignsand

events(e.g.ridetowork)

16%increasein

walkingtrips

10%decreasein

singlepersoncar

trips

27%increasein

publictransportuse

Primarilystudiedin

Australiawiththree

internationalstudies.

Evidenceislimitedbutis

promising.

Table8:

Intervention

framework

for

promotion

of

physical

activity

(CIH

programme)

Intervention Recommendedby

Communitycoalitionbuildingiv

Advocateforpolicyandstructuralchange

Collaboratewithrelevantstakeholders

Supportlinksbetweensettingsandcommunityprogrammesthat

supportphysicalactivitytoencourageindividualhealthbehaviour

change

Workwithinexistingnetworks

Rapidmonitoringandfeedbacktothecommunity,tokeepthe

communityinformedofdevelopmentsandmaintaintheirinterestin

specificinterventions

CIHEvaluationTeam

CDC

CDC/COMPASS

COMPASS

iv

For

more

information

about

the

effectiveness

of

Community

Coalitions,

please

see

A.

Hill

et

al.,

From

program

to

policy:expandingtheroleofcommunitycoalitionsandK.Hannietal.,Amethodologyforevaluatingorganizational

changeincommunitybasedchronicdiseaseinterventions,bothfromCDC:PreventingChronicDisease(2007)4(4).


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Structuralchanges

Create,supportandimplementpoliciesandpracticestoencouragephysicalactivity

Createandimplementtransportationpolicyandenvironmentaldesign:

Limitthe

role

of

automobilesv

Promotewalkingandbicycleridingvi

Designstreets/communitiestopromotephysicalactivity

Providephysicaleducation(60minutesormoreatleastfivetimesper

week)forschoolchildren

Createorenhanceaccesstoplacesforphysicalactivitycombinedwith

informationaloutreachactivities

Createstairwellsthataresafeandappealing

Usepointofdecisionprompts

Usenationalphysicalactivityguidelinesandencouragedevelopment

andupdateguidelinesifnecessary

CDC/COMPASS/DCP2/

DPAS

/

NICE

CDC/DCP2/DPAS/NICE

CDC/NICE

CDC/DPAS/NICE(together

withPODprompts)

CDC/NICE

CDC/DPAS

Institutionalisingtheencouragementofhealthylifestylebehaviour

Providesupportgroupsforincreasingphysicalactivity

Provideincentivestoencouragephysicalactivityinvarioussettingsvii

Institutionalisetheidentificationofunhealthyriskbehaviourandsupportbehaviourchange

Developprotocoltoaddressphysicalinactivity.

Healthyscreeningreviseintakeassessmentforms

Treatment

Care

Provideannualhealthscreeningthataddressphysicalactivity

CIHEvaluationTeam

CDC(fortobacco)/NICE

Healtheducation/media

Trainhealth

care

professionals

to

prescribe

exercise

Providecommunitysponsoredprogrammeaddressingphysicalactivity

Providehealthscreeningsthataddressphysicalactivityandsecondary

DCP2

CDC

vForexample,usinganautomobileistwiceascostlyinEuropeasintheUnitedStates(duetoparkingcosts,petrol

costs,congestionfeesinurbanareas,amongotherthings);partlyasaresultofthesecosts,Europeanswalkorbicycle

moreandusetheircarsapproximately50%lessthanAmericans:PrioritiesinHealth(WorldBank,2006),p.100.In

Curitiba,Brazil,cityplannersusedstrategiesthatreducedcarusewhileincreasinguseofpublictransportation,

virtuallyeliminatingtheneedforcars:DCP2,ch.44,p.839.

viInterventionsthatworkincludeciclovas(seep.13),AgitaSoPaulo(CaseStudy1)andSafeRoutestoSchool.

viiMaynotbesustainable.


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preventionforthosefoundatriskaspartofaheathcampaign.

Usehealtheducationmaterialswithclear,simplifiedmessages

(increasephysicalactivity)

UsemediaandcommunitywidecampaignsaimedatincreasingPA(in

conjunctionwithotherstructuralchanges)

COMPASS/DCP2/DPAS

CDC/COMPASS/DPAS

Definitionofabbreviations:

DPAS:theWHOGlobalStrategyonDietandPhysicalActivity

CDC:theUSCentersforDiseaseControlandPreventionsTheCommunityGuide

COMPASS:theProtocolfortheWHOStudyoftheEffectivenessofCommunityBasedProgrammesfor

NCDPreventionandControl

DCP2:theWorldBanksDiseaseControlPrioritiesforDevelopingCountries


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Appendix3:Levelsofevidence

Mindthe(evidence)gap!

Thereareverymanyareasoftheimpactofphysicalactivityonhealththatwouldbenefitfrommore

research.These

include:

the

links

with

mental

health

(such

as

dementia

and

depression),

which

is

afast

growingareaofinvestigation;theimpactonhealthofexercisereferralschemes;theimpactofnew

initiatives(suchastheuseofmobilephonesincludingindevelopingcountries,wheremobilephone

ownershipismuchmorewidespreadthaninternetaccess112).Fromapolicyperspective,moreevidenceon

theeconomicsandcostbenefitofimprovingphysicalactivitywouldbeavaluablespurtoaction.113

Inparticular,andasisstronglyemphasisedintherecentLancetseriesonphysicalactivity,thereisaglaring

mismatchbetweenwherethestudiesonphysicalactivityinterventionshavebeendoneandwherethe

potentialliesforpopulationleveleffectsthatcantrulyaffectglobalhealth.114Studiesofinterventionsin

middle andlowincomecountriesareessentialifwhatworksindifferentculturesistobeassessed,and

appropriateactiontaken.

Existingevidence

Despitetheextensivebodyofresearchlinkingphysicalactivityandhealthbenefits,thereisrelativelylittle

scientificevidenceonspecifictypesofactivities(seeBox,below).TherearefarfewerLevel1andLevel2

studies(whicharecostlyandtimeconsuming),comparedtoLevel3studies.However,thisdoesnotcast

doubtontheveracityoftheoverwhelmingevidenceonthebenefitsofphysicalactivity,whichiswhymajor

nationalandinternationalauthoritiesresponsibleforhealthandwellbeinghaveunanimouslyendorsed

thebenefitsofphysicalactivityinreducingriskfactorsassociatedwithNCDs.

Levelsofscientificevidence

Level1 Randomisedcontroltrialswithoutimportantlimitations

Level2 Randomisedcontroltrialswithimportantlimitations

Observationalstudies(nonrandomisedclinicaltrialsorcohort

studies)withoverwhelmingevidence

Level3 Otherobservationalstudies(prospectivecohortstudies,casecontrol

studies,caseseries)

Level4

Inadequateor

no

data

in

population

of

interest

Anecdotalevidenceorclinicalexperience

Source:Warburton,D.E.R.,S.Charlesworth,A.Ivey,L.NettlefoldandS.S.D.Bredin,Asystematicreviewofthe

evidenceofCanadasPhysicalActivityGuidelinesforAdults,IntJBehavNutrPhysAct(2010)7:39.

Casestudiesareparticularlyimportantwhenthebasicscience(i.e.onthebenefitsofphysicalactivity)is

know,buttherehavenotbeenRCTsonthespecificactivitiesonwhichacommunity,workplaceorschool

wishestoembark.Casestudiescanprovideideas,novelwaysofencouragingphysicalactivityand

anecdotalevidence,

even

though

data

on

specific

health

benefits

may

not

have

been

rigorously

gathered.


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Endnotes

*Acknowledgement:KatyCooperandChristineHancock(C3CollaboratingforHealth)wouldliketothankFionaWong

andDeniseStevensatMATRIXPublicHealthSolutionsInc.fortheirassistanceinwritingandcompilingthefirstedition

ofthis

report.

C3

also

thanks

Bupa

for

funding

an

earlier

version

of

this

review.

1Foracomprehensiveoverviewofthebenefitsofphysicalactivityonthebody,seeProfessionalAssociationsfor

PhysicalActivity,PhysicalActivityinthePreventionandTreatmentofDisease(2010,2nd

edition,SwedishNational

InstituteofPublicHealth):http://www.fhi.se/en/Publications/Allpublicationsinenglish/PhysicalActivityinthe

PreventionandTreatmentofDesease/,chapter1.

2Figure1isfromtheWorldHealthOrganizationslideset,GlobalHealthRisks:Selectedfiguresandtables:

www.who.int/entity/healthinfo/global_burden_disease/global_health_risks_report_figures.ppt

3WorldHealthOrganization,GlobalRecommendationsonPhysicalActivityforHealth(WHO,2011):

http://whqlibdoc.who.int/publications/2010/9789241599979_eng.pdf

4I.M.

Lee

et

al.,

Effect

of

physical

activity

on

major

non

communicable

diseases

worldwide:

an

analysis

of

burden

of

diseaseandlifeexpectancy,TheLancet(2012)380:219:http://press.thelancet.com/physicalactivity.pdf,p.227.

5H.W.Kohletal.,Thepandemicofphysicalinactivity:globalactionforpublichealth,TheLancet(2012)380:294

305:http://www.thelancet.com/journals/lancet/article/PIIS0140 6736%2812%29608988/abstract

6J.Woodcocketal.,Nonvigorousphysicalactivityandallcausemortality:systematicreviewandmetaanalysisof

cohortstudies,IntJEpidemiol(2011)40(1):12138:http://www.ncbi.nlm.nih.gov/pubmed/20630992

7D.E.R.Warburtonetal.,AsystematicreviewoftheevidenceofCanadasPhysicalActivityGuidelinesforAdults,IntJ

BehavNutrPhysAct(2010)7:39:http://www.biomedcentral.com/content/pdf/14795868739.pdf

8Kohletal.,Thepandemicofphysicalinactivity.

9WorldEconomicForum/HarvardSchoolofPublicHealth,TheGlobalEconomicBurdenofNonCommunicable

Diseases(2011):

http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf,p.

6.

10GlobalAdvocacyforPhysicalActivity,TorontoCharterforPhysicalActivity(2010):

http://www.globalpa.org.uk/charter/

11F.B.Huetal.,Walkingcomparedwithvigorousphysicalactivityandriskoftype2diabetesinwomen:aprospective

study,JAMA(1999)282:14339:http://jama.amaassn.org/content/282/15/1433.abstract

12C3CollaboratingforHealth,Thebenefitsofregularwalkingforhealth,wellbeingandtheenvironment

(September2012):

http://www.c3health.org/c3activities/documents/

13Warburtonetal.:Systematicreview.

14R.S.Paffenbargeretal.,Physicalactivity,allcausemortality,andlongevityofcollegealumni,NEnglJMed(1986)

314:60513:http://www.ncbi.nlm.nih.gov/pubmed/3945246;J.Myersetal.,Fitnessversusphysicalactivitypatterns

inpredictingmortalityinmen,AmJMed(2004)117:91218:http://www.ncbi.nlm.nih.gov/pubmed/15629729

15ThisfollowstheWorldHealthOrganizationcategorisation.

16WorldHealthOrganization,PreventingChronicDisease:AVitalInvestment(2005):

http://www.who.int/chp/chronic_disease_report/en/index.html,p.2.

17 WorldHealthOrganization,GlobalStatusReportonNoncommunicableDiseases2010(WHO,2011),Executive

Summary:http://www.who.int/nmh/publications/ncd_report_summary_en.pdf,

p.

1.


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18

WorldHealthOrganization:GlobalHealthRisks:MortalityandBurdenofDiseaseattributabletoSelectedMajor

Risks(Geneva,WorldHealthOrganization,2009):

http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf

19 WHO,GlobalHealthRisks,ibid.

20

International

Diabetes

Federation,

Diabetes

Atlas

(4

th

edition):

http://www.diabetesatlas.org/map

21I.M.Lee,Physicalactivityandcancerpreventiondatafromepidemiologicalstudies,MedSciSportsExerc(2003)

35:18237:http://www.ncbi.nlm.nih.gov/pubmed/14600545

22Warburtonetal.,Systematicreview.

23PhysicalActivityGuidelinesAdvisoryCommittee,PhysicalActivityGuidelinesAdvisoryCommitteeReport

(Washington,DC:USDepartmentofHealthandHumanServices,2008):

http://www.health.gov/PAGuidelines/committeereport.aspx,p.683.SeealsoJ.R.Sattelmairetal.,Physicalactivity

andriskofstrokeinwomen,Stroke:JournaloftheAmericanHeartAssociation(2010)41:1243:

http://stroke.ahajournals.org/cgi/content/short/STROKEAHA.110.584300v1

24V.Press,I.FreestoneandC.F.George,Physicalactivity:theevidenceofbenefitinthepreventionofcoronaryheart

disease,QJM

(2003)

96:4

24551:

http://qjmed.oxfordjournals.org/content/96/4/245.full.

This

study

states

that

in

menwithoutpreexistingCHDthoseparticipatinginmoderateormoderatelyvigorousactivitieshada50%reduction

inrisk,comparedtothosewhowereinactive.

25Leeetal.,Effectofphysicalinactivity,pp.2278.

26See,inparticular,S.I.Mishraetal.,Exerciseinterventionsonhealthrelatedqualityoflifeforpeoplewithcancer

duringactivetreatment(Review),CochraneLibrary(2012)8:

http://onlinelibrary.wiley.com/

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