Physical Activity Promotion: Prevention of

Chronic Disease Morbidity & Mortality

Antronette (Toni) Yancey, MD, MPH, FACPMAssociate Professor, Dept. of Health

Services,Co-Director, Ctr. to Eliminate Health

DisparitiesUCLA School of Public Health

www.ph.ucla.edu/cehdwww.toniyancey.com

Unhealthy eating and inactivity are leading causes of death in the U.S.

HHS estimates that unhealthy eating and inactivity contribute to 310,000 to 580,000 deaths each year. That’s 5 times more than are killed by guns, HIV, and drug use combined.1

The typical American diet is too high in saturated fat, cholesterol, salt, and refined sugar and too low in fruits, vegetables, whole grains, calcium, and fiber.

Such a diet contributes to four of the seven leading causes of death and increases the risk of numerous diseases, including:

heart disease diabetes cancer high blood pressure obesity osteoporosis stroke

60% of Americans are at risk for health problems related to lack of physical activity (ie: get less than 30 minutes of moderate activity 5 or more times per week). 2

1. Heart Disease 724,900

2. Cancer 541,400

3. Stroke 158,400

4. Chronic Obstructive Pulmonary Disease 112,700

5. Accidents 97,800

6. Pneumonia and Influenza 91,900

7. Diabetes 64,900

8. Suicide 30,500

9. Nephritis 26,200

10. Chronic Liver Disease/Cirrhosis 25,100

11. Septicemia 23,800

12. Alzheimer’s 22,700

13. Homicide and Capital Punishment 18,400

14. Atherosclerosis 15,400

15. High Blood Pressure 14,300

Diet and Physical Inactivity 310,000-580,000

Tobacco 260,000-470,000

Alcohol 70,000-110,000

Microbial Agents 90,000

Toxic Agents 60,000-110,000

Firearms 35,000

Sexual Behavior 30,000

Motor Vehicles 25,000

Drug Use 20,000

Leading Contributors to Premature Death1

Leading Causes of Death3

(Diet is a leading risk factor for causes of death shown in bold or green.)

The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin

All patients had impaired fasting blood sugars, but were not diabetic

Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week

They were followed over 2.8 years

DIABETES PREVENTION PROGRAMDIABETES PREVENTION PROGRAM

DPP Research Group. N Engl J Med. 2002;346:393-403.

Lifestyle intervention was much more effective than either placebo or metformin

DIABETES PREVENTION PROGRAMDIABETES PREVENTION PROGRAM

Fitness & Mortality

•Low fitness is bad for health

Walking & CVD •Walking as little as 5 mins. daily is beneficial for fitness

•30 mins. daily provides best health benefit (heart disease prevention)

•60 mins daily can cause reversal of heart disease

Physical Activity& Risk of Common

Cancers Colon: 30-40% decreased risk among active

men & women (Rectal—no association) Breast: substantial evidence for dec risk;

strength of assn--time period may be critical Prostate: findings inconclusive Possible mechanisms: 1. decreased GI transit time (dec carc expos) 2. enhanced immune function (moderate PA) 3. lowered levels of reproductive hormones

Population Attributable Fraction Cancer Mortality – Male Never Smokers

PopulationBMI Exposure* RR† PAR (%)

25.0-29.9 42% 1.1 4.0%

30.0-34.9 21% 1.4 6.8%

>35.0 13% 1.3 3.4%

14.2%

*NHANES 2000, men age 50-69

Population Attributable Fraction Cancer Mortality – Women Never Smokers

PopulationBMI Exposure* RR† PAR (%)

*NHANES 2000, women age 50-69

25.0-29.9 29% 1.1 3.3%

30.0-34.9 23% 1.3 6.1%

35.0-39.9 11% 1.4 3.5%

>40.0 8% 1.9 7.0%

19.8%

YEAR % Obese % No LTPA

1991 10% 23.3%

1995 14.4% 22.7%

1998 16.8% 25.5%

1999 19.6% no data

2000 19.2% 26.5%

20

15

10

5

30

25

20

15

1991 1995 1998 2000

BRFSS DATA

http://apps.nccd.cdc.gov/brfss/Trends/trendchart_c.asp?state_c=CA&state=US&qkey=10020&SUBMIT1=Go

% obese

%No

LTPA

Lesser Effectiveness of Key Environmental Interventions

in Underserved Groups: Example

Posting of Signs Promoting Stair Usage(suburban Baltimore mall)

Overall, stair use increased from 4.8% to 6.9%, 7.2%, depending upon which of 2 signs used

Among whites, increased from 5.1% to 7.5%, 7.8%

Among blacks, changed from 4.1% to 3.4%, 5.0% Among n’l wt, inc from 5.4% to 7.2%, 6.9% Among overwt, inc from 3.8% to 6.3%, 7.8%

Andersen, Franckowiak, Snyder et al., Ann Int Med, 1998;129:363-369.

Excess physical environmental risk in

underserved communities: Pervasive targeted commercial marketing Distance to private fitness facilities Few worksite fitness opportunities Few/poor neighborhood recreation facilities Lesser neighborhood safety Poorer public/less reliable private transportation Poorly equipped facilities Poorly maintained sidewalks, e.g., cracks, litter, overgr.

foliage Fewer traffic calming devices, e.g., speed bumps Ample car “accommodation,” e.g., parking, high-

speed/multi-lane roads=“Move insecurity”1, 2

1Jahns & Jones, AJPM 2004;26:186 2Yancey, AJPM 2003;25(3Si)Adapted from Kumanyika S. Obesity in Minority Populations. In Fairburn G & Brownell K, Eating Disorders and Obesity. A Comprehensive

Handbook, 2002.

Marketing Expenditures, CMR, 2005(in millions)

$123.4

$22.8

$0.0

$35.7

$17.5$10.5

$43.9

Coca Cola Diet Coke Odwalla Minute Maid Dasani Powerade Sprite

Which billboard(s) is (are) about physical activity?

Media Project: five-city outdoor advertising content analysis

Funded by CA DHS, UT, Penn & RWJFCities: LA, Philadelphia, Austin, Sacramento,

FresnoComparing high & low SES predominantly

black, Latino, & white neighborhoods (all 6 categories not available in all cities, e.g., high SES black in Sacramento and Fresno)

Utilizing secondary data from CHIS, LACHS, grocery store scanner (MOU with major supermarket chain) purchase data for correlational analyses

Preliminary findings

Absence of billboards and near-absence of other outdoor advertising in affluent white neighborhoods—existing ads unrel. to weight

Essentially no outdoor advertising of PA-promoting goods & services in any community, but large amount sedentary entertainment & transportation ads in low-inc. communities

Pervasiveness of advertising in low-inc. white & Latino communities, but more fast food, sugar-sweetened and alcoholic beverages in latter

City of LA has moratorium on new billboards, but in low-inc. Latino comm., large # of new side of building ads similarly framed

Findings must be interpreted in light of historical covenants, fewer ads trad. In unincorp. areas

Excess sociocultural environmental risk in

underserved communities: Cultural attitudes about work, activity, rest Fears about safety Prevalent obesity/norms Female roles Cultural reverence for cars Hairstyle-related concerns about sweating Increased screen time, e.g., TV viewing, movie-

going

LA’s ESPN Radio 710 AM Ad

“We’re the prime rib on a dial full of tofu”

--March 2006

Cultural reverence for SUVs?

Hunter-gatherersHunter-gatherers 5000 cal 5000 cal

Agriculture Agriculture 6000 cal 6000 cal

Laborers Laborers 3000 cal 3000 cal

Office WorkersOffice Workers 1800 cal 1800 cal

1 million 1 million yrs agoyrs ago

10,000 10,000 yrs agoyrs ago

19151915

NOWNOW

AVERAGE ENERGY AVERAGE ENERGY EXPENDITUREEXPENDITURE ESTIMATESESTIMATES

Physical Activity Levels, %L.A. County Adults, 1999

District Sedentary (<10 min/wk)

County 41 +1Compton 45 +6

South 50 +9

Inglewood 46 +6

Long Beach 37 +5

West 31 +3

Physical Inactivity Levels: TV viewing/computer use, %

L.A. County Adults, 1999Ethnic Group TV/Computer Use

>3 hrs/d (95% CI)

County total 21.7 20.6-22.9African Americans 36.5% 32.4-40.5

American Indian

34.2% 16.1-52.3

Asian/Pacific Isl.

21.1% 17.6-24.6

Latino 15.8% 14.3-17.3

White 24.3% 22.4-26.2

Self-Perceived Overweight by Ethnicity & Gender,

% LA County Adults

Female Male

AA Overwt 67 29

AA Nml wt 20 --

API Overwt 86 46

API Nml wt 28 10

Lat Overwt 80 41

Lat Nml wt 26 9

W Overwt 84 46

W Nml wt 21 4

Influence of Self-Perceived Weight Status on PA,

% LA County Adults Overall, regardless of BMI, those perceiving themselves

as overweight more sedentary than those with average wt. self-perception (45% vs. 30%)

Influence most pronounced for males and normal weight individuals

Overwt. self-perception not assoc. with sedentariness among white women, the only one of the 6 ethnic-gender groups included in which BMI<25 normative

In multivariate analysis, self-perceived overweight, not BMI, predicts sedentary behavior (OR=1.40, CI 1.19, 1.64)Yancey, Simon et al., Obes (Res) 2006;14:980-8. Yancey, Wold et al., Am J Prev Med, 2004;27:146-52.

Current Population Status

Little change in leisure time physical activity (PA) during past several decades of obesity increases (1 in 5), but marked increases in sedentary entertainment, transportation, and other ADLs (Sturm, 2004)

PA levels within increasingly sedentary, deconditioned, overweight population are unlikely to increase primarily through individual motivation and volition—relatively little demand for goods & services or political will to push for aggressive legislative policy change, e.g., radical alteration in the built environment favoring bicycle, pedestrian, and mass transit over private automobile transportation

Daily “Dose” (Rx) of Physical Activity

30-60 minutes/day on most (at least 5) days of the week

At least moderate intensity (=walking 1 ½ to 2 miles in 30 minutes)

Can be broken up into 10-minute stretches throughout the day

Every calorie burned is one that doesn’t end up around your waist!

The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin

All patients had impaired fasting blood sugars, but were not diabetic

Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week

They were followed over 2.8 years

AFRICAN AMERICAN WOMEN & HEART DISEASEAFRICAN AMERICAN WOMEN & HEART DISEASE

DIABETES PREVENTION PROGRAMDIABETES PREVENTION PROGRAM

How much is enough?

Population benefit estimates of risk factor

change: PA 3-minute bouts of PA 10 times per day lowers

serum triglycerides to same extent as 1 continuous 30-minute bout of PA (Miyashita et al., 2006)

Maintenance of moderate PA is assoc. with a 1/3 to 2/3 lowering of Type 2 diabetes (DM) incidence over 4-14 yrs (Clark, 1997)

Type 2 DM risk was 50% lower among individuals physically active at any level, and 66% lower among those at least moderately active (James et al., 1998)

Sedentary behaviors (e.g., TV watching) as well as sub-optimal >moderate PA levels contributed to DM & obesity risk over 6 yrs in women (Hu et al., 2003)

Population Obesity Control:

Early stage in developmentStrategically, why focus on PA promotion first? Less controversy, conflict, stigma than surrounding

diet/nutrition “Deep pocket” business interests, e.g., Nike & 24-

Hour Fitness, stand to benefit from success of efforts (vs. “Big Food” losing $ because can’t as readily induce over-consumption of H2O, whole grains, legumes, F+V)

Cheaper & easier—10 min. supply 1/3 of PA “RDA” May positively influence food preferences

Population Obesity Control:

Early stage in developmentTo avoid exacerbating health risk/disease

burden disparities, push strategies (skip-stop/slowed hydraulic elevators, restricted proximal parking, non-discretionary time exercise breaks, walking meetings) should be prioritized over pull strategies (building trails & parks, offering gym membership subsidies/discounts) at this early stage of development of environmental and policy approaches—make it easier to do it than not to do it!

Population Obesity Control:

Early stage in development (cont.) Synergy will occur when supply (physical

environmental access & appeal) meets demand (individual/ sociocultural motivation, prioritization, valuation, skills/interests, political will)

Demand must be created—need to structure in “unavoidable” experiences which increase aerobic conditioning, build skills & self-efficacy, foster enjoyment, elevate mood & energy, increase taste for water-bearing foods & less highly-sweetened beverages

Spectrum of Prevention:Health behavior change

model Level 1: Strengthening individual knowledge

and skills Level 2: Promoting community education Level 3: Educating service providers Level 4: Fostering coalitions and networks Level 5: Changing organizational practice Level 6: Influencing policy and legislation

Spectrum of Prevention:

Shift in health promotion fieldThe most effective and sustainable PH

intervention approaches of the past two decades are the more “upstream” ones (structural/environmental vs. individual-level), involving social norm change:

Tobacco control Alcohol consumption and driving Breastfeeding Littering and recycling

Spectrum of Prevention(2nd level)

Level of Prevention

Definition of Level

Examples of Obesity Prev.Efforts

Promoting community education

Reaching groups of people with information and resources to promote health

Community walkathons / fitness eventsMedia campaignsNeighborhood canvassing for healthy food optionsCommunity gardens

ROCK! Richmond

Community-level fitness promotion initiative of Richmond City DPH/Medical College of Virginia

3 major components: (1) free fitness instruction in CBOs in underserved areas; (2) environmental changes in conduct of city business (e.g., low-fat/ high-fiber food choices at city functions); (3) social marketing effort to reinforce norms supporting PA & healthy eating

Successful in recruiting disproportionately among population segments at highest risk for chronic disease (older, black, female, family hx of CA, CVD)

Yancey, Jordan, Bradford et al., Health Prom Practice, 2003

Spectrum of Prevention(5th level)

Level of Prevention

Definition of Level

Examples of Obesity Prev.Efforts

Changing organizational practice & policy

Adopting regulations and shaping norms to improve health

Protocols for MD assessment, sliding fees, counseling & referralWorksite policies (movement breaks, vending, refreshments)School PE content & delivery

Translating Evidence-Based CDC/ACSM Recommendations

into Culturally-Targeted Intervention Integrating 10-’ PA bouts into organizational routine:

Minimal intensity environmental intervention, e.g., stair prompts

Short bouts accommodate higher proportion sedentary individuals (incremental change)

Variable (max moderate) intensity, low-impact PA accommodates higher proportion overweight/obese and disabled individuals (higher perceived exertion, discomfort, functional limitations)

Passive (“push”) strategy relies less on individual motivation & facility access (early adopters scarce)

Translating Evidence-Based CDC/ACSM Recommendation

into Culturally-Targeted Intervention Integrating 10-’ PA into organizational routine:

Movement to music integral to African-American, Latino culture—dancing normative for adults

Short bouts minimize perspiration, hairstyle disturbance

Social support & conformity desires drive participation (collectivist vs. indiv. orientation)

Addresses less activity conducive outdoor environments (safety, utility, aesthetics)

Designed for organizational settings for work, worship, other purposes--less disposable t, $

Lift Offs Work!: the Rapidly Growing Evidence

Base Documented individual and organizational

receptivity to integrating PA on paid work time Contribute meaningfully to daily accumulation of

MVPA Motivational “teachable moment” linking

sedentariness to health status for inactive folks Improvements in clinical outcomes from as little as

one 10-min. break/day—BP, BMI, waist circ., mood, attention span, cumulative trauma disorders

“Spill-over” or generalization to inc. active leisure Favorable cost-benefit ratio, eg, L.L. Bean mfg

plant

LAC Fitness & Wellness Study:design

Randomized, controlled, post-test only, intervention trial testing the effects of incorporation of a 10-min exercise break into staff meetings & training seminars lasting > 1 hr

Outcome measures: (1) participation by sedentary/overweight individuals; (2) mood/affect; (3) satisfaction with health status/fitness level

26 meetings (11 intervention, 15 control) with 449 county employees, mostly women of color

LAC Fitness & Wellness Study:

Results (cont.) More than 90% of meeting attendees participated in the exercises

Among relatively sedentary participants: Intervention participants’ satisfaction with fitness

levels more highly correlated with PA stage of change (r=0.59) than controls (r=0.38, z=-2.32, p=0.02)

Among sedentary participants: Intervention participants’ self-perceived health

status ratings were significantly lower than controls (OR=0.17; 95% CI=0.05, 0.60; p=.0003

Yancey, McCarthy, Taylor et al. 2004;38:848-856

Fuel Up/Lift Off! LA

Video/audio (DVD/CD) excerpt: movement break (Lift Off)

demonstrationwww.ph.ucla.edu/cehd

Propuesta de colaboraciónImplementación de la pausa para la Salud:

Evaluar los factores de riesgo cardiovascular previo

a la intervención de actividad física.

Promover de 15 a 20 minutos de actividad física dentro de la jornada laboral, iniciando con 10 minutos hasta alcanzar máximo 20 minutos.

Promover la orientación alimentaria dentro de la jornada laboral.

Logros alcanzados en un año 0.4 kg/m2 menos de BMI (1 kg) y 1.6 cm menos de cintura promedio en los trabajadores en un año.

Lara A, Yancey A, Tapia-Conyer R et al., in preparation, 2006

Community Health Council’s (CHC’s) REACH 2010 demonstration project--

African Americans Building a Legacy of Health

Intervention: Multi-component, centered around modeling the behaviors promoted (“walking the talk”)–(1) incorporation of fitness breaks into meetings, events and other gatherings; (2) provision of wellness training focused on changing the norms of organizations to incorporate PA & healthy food choices into their regular conduct of business (organizational wellness); (3) provision of a personal training experience to key organizational leaders; (4) development of a small grants program for ID/creation/promotion of PA opportunities.Sloane, Diamant, Lewis et al., J Gen Int Med 2003;18:1-8

CHC’s African Americans Building a Legacy of Health:

Process evaluation

Measures: Primary dependent measure–level of organizational support for physical activity integration, as reflected in intensity of interventions selected for participation; Results: Nearly half (>100) of the 220 participating organizations demonstrated active support for physical activity integration, with >25% committed at the highest level of support.

Yancey, Lewis, Sloane et al., J Pub Health Mgmt Prac, 2004;10(2):118-123

CHC’s African Americans Building a Legacy of Health:

Organizational wellness outcome evaluation

Participants: 35 organizations, >700 staff/ members/clients, 1o overwt./obese black women

Measures: Primary dependent—BMI; Secondary—affect, F+V intake, PA level

Results (post-intervention f/u):12-week intervention—dec. feelings of

sadness/depr. (p=0.00), inc. F+V (+0.5 svgs, p=0.00), marginally dec. BMI (-0.5 kg/m2 , p=0.08)

6-week intervention (re-tooled)—inc. #days in which participated in vigorous PA (+0.3 days, p=0.00)

Yancey, Lewis, Guinyard et al., Health Prom Prac, 2006;7(3):233S-246S

California Fit WIC Staff Wellness Training

AIMS: To provide skills and tools to influence

workplace organizational practices and cultural norms to promote physical activity & healthy eating among staff

To provide skills and tools to influence staff to promote physical activity & healthy eating among WIC clients/families

California Fit WIC Staff Wellness Training

Training sessions included: Engagement around ubiquitous nature of the

problem (“toxic” environment surrounding us) Skills training in workplace practice change

(e.g., movement breaks, walking meetings, leading co-workers to stairs vs. elev., healthy refreshments & identifying practical strategies to integrate PA (parking farther away, walking around children’s play area, carrying a basket vs. pushing a grocery cart)

Empowerment thru provision of tools, e.g., videos, audiotapes, bands, pedometers

WIC Staff Wellness TrainingWIC Staff Wellness Training

California Fit WIC Staff Wellness Training

Significant findings: Increased perceived workplace support for staff

PA (96 vs 58%, p=.002) and healthy food choices (85 vs 28%, p=.001)

Change in types of foods served during meetings (72 vs 24%, p=.002) & PA priority in workplace (96 vs 71%, p<.02)

Increased self-reported counseling behaviors with WIC parents promoting physical activity (64 vs 35%, p<.05) & sensitivity in handling weight-related issues (92 vs 58%, p<.01)

Crawford, Gosliner, Strode et al., Am J Public Health, 2004

Community “Cost-Sharing”

1. Leverage funder and/or regulatory roles (foundation, especially government) to mandate healthy/fit workplace practices, with added resource allocation (e.g., 5%)

2. Change internal organizational culture (social norms) to create healthy/fit health & social services agency workplaces (“Walking the Talk”)

Community “Cost-Sharing”

“Healthy/fit” organizational PA promotion practices include core & elective components, e.g., 10’ movement (or walking) breaks in meetings/ functions & at certain time(s) of day; walking meetings; stair prompts; leading employee groups to stairs in moving between work activities; restricted near parking; incentives for distant parking; model & reward fidgeting and lifestyle PA integration (e.g., less high heel & tie wearing, more pedometer wearing, formal recognition/kudos to those who jog or swim during lunchtime)

Community “Cost-Sharing”

3. Encourage local school officials to:a. Train teachers of PE in SPARK-type models emphasizing coop. vs. compet., engaging all kidsb. Move student drop-off location as far away from door as possible, e.g., behind playing field, to maximize distance youth must walk to attend classc. Incorporate Take 10!, Lift Off! or other exercise breaks into academic curriculum 2x/day, eg, mathd. Incorporate structured exercise breaks into PTA meetings, school board meetings, community dialogues, staff meetings & other gatherings to raise visibilty/priority of PA promotion in addressing childhood obesity

“We must become the

change we wish to see in the world.”--Mahatma Gandhi

Community “Cost-Sharing”