c3a review of physical activity and health v 2 a 20121011
TRANSCRIPT
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Review
Thebenefitsofphysicalactivityforhealthandwellbeing
2ndedition
C3CollaboratingforHealth*
October2012
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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,
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United
Kingdom;
Tel
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C3CollaboratingforHealthisaregisteredcharity(no.1135930)
andacompanylimitedbyguarantee(no.6941278),registeredinEnglandandWales.
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3 Review:Thebenefitsofphysicalactivityonhealthandwellbeing(2nd
edition) www.c3health.org
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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edition) www.c3health.org
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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edition) www.c3health.org
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
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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
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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
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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.
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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
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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.
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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
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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.
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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.
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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
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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.
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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).
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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:
http://www.ncbi.nlm.nih.gov/pubmed/20459783
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:
http://www.ncbi.nlm.nih.gov/pubmed/11427103
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:
http://www.ncbi.nlm.nih.gov/pubmed/14514602
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:
http://www.ncbi.nlm.nih.gov/pubmed/15353531
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edition) www.c3health.org
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:
http://www.ncbi.nlm.nih.gov/pubmed/7707596
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
Myers,J.,A.Kaykha,S.George,J.Abella,N.Zaheer,S.Lear,T. YamazakiandV.FroelicherV:Fitnessversusphysical
activitypatternsinpredictingmortalityinmen,AmJMed(2004)117:91218:
http://www.ncbi.nlm.nih.gov/pubmed/15629729
Penedo,F.J.andJ.R.Dahn,Exerciseandwellbeing:areviewofmentalandphysicalhealthbenefitsassociatedwith
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
Warburton,D.E.R.,S.Charlesworth,A.Ivey,L.NettlefoldandS.S.D.Bredin,Asystematicreviewoftheevidenceof
CanadasPhysicalActivityGuidelinesforAdults,IntJBehavNutrPhysAct(2010)7:39:
http://www.ncbi.nlm.nih.gov/pubmed/20459783
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:
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185649v1
Miller,T.D.,G.J.BaladyandG.F.Fletcher,Exerciseanditsroleintheprevention
andrehabilitationofcardiovasculardisease,AnnBehavMed(1997)19(3):2209:
http://www.ncbi.nlm.nih.gov/pubmed/9603697
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:
http://www.ncbi.nlm.nih.gov/pubmed/20459783
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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/
Warburton,D.E.R.,S.Charlesworth,A.Ivey,L.NettlefoldandS.S.D.Bredin,Asystematicreviewoftheevidenceof
CanadasPhysicalActivityGuidelinesforAdults,IntJBehavNutrPhysAct(2010)7:39:
http://www.ncbi.nlm.nih.gov/pubmed/20459783
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
Penedo,F.J.andJ.R.Dahn,Exerciseandwellbeing:areviewofmentalandphysicalhealthbenefitsassociatedwith
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/
Warburton,D.E.R.,S.Charlesworth,A.Ivey,L.NettlefoldandS.S.D.Bredin,Asystematicreviewoftheevidenceof
CanadasPhysicalActivityGuidelinesforAdults,IntJBehavNutrPhysAct(2010)7:39:
http://www.ncbi.nlm.nih.gov/pubmed/20459783
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:
http://www.ncbi.nlm.nih.gov/pubmed/20459784
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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:
http://www.ncbi.nlm.nih.gov/pubmed/9279845
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:
http://www.ncbi.nlm.nih.gov/pubmed/19752405
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:
http://www.ncbi.nlm.nih.gov/pubmed/19752405
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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33 Review:Thebenefitsofphysicalactivityonhealthandwellbeing(2nd
edition) www.c3health.org
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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7/30/2019 C3a Review of Physical Activity and Health v 2 a 20121011
34/39
34 Review:Thebenefitsofphysicalactivityonhealthandwellbeing(2nd
edition) www.c3health.org
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/