Promoting Physical Activity for Health: Benefits and Approaches

1. Let's get physical: health benefits of physical activity and approaches to increase, and sustain, participation Dr Ruth Jepson Co-Director Centre for Public Health and Population Health Research Lead for Physical Activity, Health and Diet Programme, University of Stirling Senior Scientific Advisor, Scottish Collaboration for Public Health Research and Policy, University of Edinburgh

2. Centre for Public Health & Population Health Research Programme on physical activity and diet Focuses on: • Promoting physical and healthy diet as part of everyday behaviour • Promoting physical activity through health professional referrals • Understanding the barriers to physical activity and healthy eating in different population groups (including ethnic minority groups) • Encouraging people to use the outdoors to increase their feelings of health and wellbeing (including walking and gardening)

3. What do we mean by physical activity? Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure. The energy expenditure can be measured in kilocalories. Physical activity in daily life can be categorized into occupational, sports, conditioning, household, or other activities. Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness. Physical fitness is a set of attributes that are either health- or skill-related. CaspersenPublic Health Rep. 1985; 100(2): 126–131. ‘Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.’ Plato

4. A note: Physical activity vs sedentary behaviour The field of sedentary behaviour research rests on the premise that it affects the disease process regardless of physical activity. Sedentary behaviour is not simply a lack of physical activity but is a cluster of individual behaviours where sitting or lying is the dominant mode of posture and energy expenditure is very low. Standing or low level activity: the energy expenditure associated with standing activity or low-grade ambulation is commonly referred to as non-exercise activity thermogenesis (NEAT). Supporting the mass of the body in combination with spontaneous movement or low-grade ambulation consumes around 1.5–2.5 times more energy than sitting-based activities and is thought to “switch-on” important metabolic processes. Reducing sedentary time may be as important as increasing physical activity. Biddle et al. Sedentary Behaviour and Obesity: Review of the Current Scientific Evidence 2010. DoH Yates et al. Diabetes Research and Clinical Practice 2011; 93 (2): 292–294 Katzmarzyk, PT Diabetes 2010; 59 (11) 2717-2725

5. Why do you do physical activity? • It’s just part of being human, I don’t really think about it • To get from A to B, to do tasks such as housework, or for manual work • To do the right thing (be a good citizen and look after my health) • For enjoyment and pleasure • To enable me to socialise with people I might not otherwise see often enough • To improve my fitness • To feel better mentally and/or physically • To feel a sense of accomplishment • To lower my risk factors (e.g. high blood pressure) • To reduce my weight • To reduce/manage my symptoms How many of those are the reasons why you undertake physical activity? • Only one of the reasons • For a few of the reasons • For most of the reasons • For all of the reasons Did you think your reasons fitted most into the top third, middle third, or bottom third?

6. HEALTH WALK

7. Motivators were almost exclusively external (for a purpose other than physical activity) rather than internal (for its own sake) Motivators included fun, enjoyment and socialising and health benefits People more likely to be involved in physical activity that included a social aspect Role models were seen as important Jepson et al 2012: Physical activity in South Asians: an in-depth qualitative study to explore motivations and facilitators PLoS ONE 2012 Why do South Asians take part in physical activity? “To watch us dance is to hear our hearts speak” Indian saying

8. .. it is a mistake to view physical activity only in terms of its disease-specific associations. The benefits of physical activity are far-reaching and extend beyond health alone. Being physically active is a major contributor to one's overall physical and mental wellbeing Rethinking our approach to physical activity Pamela Das, Richard Horton Lancet 2012; 380, (9838): 189–190 “All truly great thoughts are conceived while walking.” ― Friedrich Nietzsche

9. Burden of disease ‘Strong evidence shows that physical inactivity increases the risk of many adverse health conditions, including major non-communicable diseases such as coronary heart disease, type 2 diabetes, and breast and colon cancers, and shortens life expectancy. Because much of the world's population is inactive, this link presents a major public health issue’. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy The Lancet, 2012; 380 (9838): 219 – 229 Whenever I get the urge to exercise, I lie down until the feeling passes away. Mark Twain

10. Burden of disease Figure Comparison of global burden between smoking and physical inactivity Prevalence of smoking, population attributable risk (PAR), and global deaths for smoking were obtained from WHO Chi Pang Wen , Xifeng Wu . Stressing harms of physical inactivity to promote exercise. The Lancet 2012; 380 ( 9838) 192 - 193

11. Burden of physical activity-related ill health in the UK I am pushing sixty. That is enough exercise for me. Mark Twain Our analysis suggests that, in 2003–4, over 35 000 deaths could have been avoided if the population were physically active at the levels recommended by the UK government. We found that physical inactivity was responsible for 3.1% of morbidity and mortality in the UK, contributing over £1 billion to the direct health cost burden to the UK NHS Allender et al. J Epidemiol Community Health 2007;61:344-348 doi:10.1136/jech.2006.050807

12. How much physical activity do we need? Physical Activity Guidelines Likely to depend on the health outcome we want to achieve: Weight loss Risk factor reduction Mental wellbeing Independent living Fall reduction Physical fitness Symptom reduction/management Adults (all ages) should aim to be active daily. Over a week, activity should add up to at least 150 minutes (2½ hours) of moderate intensity activity in bouts of 10 minutes or more – one way to approach this is to do 30 minutes on at least 5 days a week. Can one guideline fit all? Are they achievable for all? Are they sustainable for all?

13. Scottish Government Strategy Recommendations of five-year review of ‘Let’s Make Scotland More Active’ – A strategy for physical activity Local Coordination and Leadership. Local authorities should be recognised as the most important local delivery agency for physical activity. Environment. Creation and provision of environments that encourage and support physical activity offers the greatest potential to get the nation active. Performance Monitoring Explicit physical activity targets/outcomes should be included within the National Performance Framework and/or NHS HEAT targets.

14. interventions “My grandmother started walking five miles a day when she was sixty. She's ninety-seven now, and we don't know where the heck she is.” ― Ellen DeGeneres

15. What interventions are effective? Effective physical activity interventions • Public communication and informational approaches • Initiatives to increase social support for physical activity • Environmental and policy approaches can create or enhance access to places for physical activity with outreach activities • Multi-agency and multi-sector • ‘Although individuals need to be informed and motivated to adopt physical activity, the public health priority should be to ensure that environments are safe and supportive of health and wellbeing’ Health et al. Lancet 2012: 380, Issue 9838, 21–27

16. Walking for depression Robertson R, Robertson A, Jepson R, Maxwell M.Mental Health & Physical Activity 2012 (5}, 66–75

17. • Is it possible to run a programme of health walks 3 times/week? Do health practitioners (HPs) refer onto the service? • Do sedentary patients/people with depression utilise the service? • Can the model be improved? What positive and negative impacts do people report? • Is there any evidence of benefits to participants? Musselburgh health walks for sedentary people and/or mental health problemsRoma Robertson PhD in partnership with CHANGES community health partnership and Paths to Health "Walk while ye have the light, lest darkness come upon you.“ John Ruskin

18. Benefits Is there any evidence of benefits to participants? • Collected data at baseline, 6 weeks and 6 months • Used validated measures of health outcomes • Collected data on mental wellbeing, physical activity, social networks, general health Physical activity Immediately after the intervention and 6 months later more people reported that they took at least 20 minutes exercise on 3 days each week than before the study Mental wellbeing Scores for mental health improved after 12 weeks of walks, but the improvement had reduced and was no longer statistically significant 6 months later General health and other outcomes There did not seem to be any improvement in the participants’ general health or for other outcomes "The sovereign invigorator of the body is exercise, and of all the exercises walking is the best." Thomas Jefferson

19. More Active MuMs in Stirling (MAMMIS) study Alyssia Hughes (PhD student) RCT of buggy walking for mothers Group based physical activity programme with motivational component Analysis ongoing Process evaluation The MAMMiS intervention was acceptable and responsive to the needs of postnatal women combining social appeal through the group pram walking and an individualised approach to adopting and maintaining PA. Participating in the trial itself facilitated new ways of thinking about PA and stimulated behaviour change, even among mothers assigned to the control group. Next steps Applying for 2 year follow up to see whether physical activity has been maintained.

20. RCT & patient preference trial of Exercise Referral Schemes: indoor versus outdoor activities Led by Ruth Jepson and Larry Doi, SCPHRP in partnership with Local Authority, & the Conservation Trust for Volunteers Aim To test the feasibility, acceptability and effectiveness of randomising patients to ERS in either indoor or outdoor activities. Setting: Bathgate, West Lothian Interventions 1) Indoor ERS(normal activities in leisure centre) 2) Outdoor ERS Will roughly equate with duration and exercise intensify to the indoor intervention. Components may include: • Green gym / Led walks / Other outdoor activities Duration of the intervention period would be 12 weeks. Participants will be asked to only do activities in the arm of the trial to which they have been allocated. After the 12 weeks all participants will be able to continue with the physical activities of their choice. All the outdoor activities (e.g. green gym, led walks) will remain in place for a minimum of 48 weeks (making the duration of both interventions a year in total). All participants will be followed up at one year in the first instance.

21. Effects of community gardening on health outcomesProject by Di Blackmore, PhD student, in partnership with TRELLIS Aim to investigate the effect of community gardens on health and related outcomes. Objectives: • Explore the feasibility of using a range of different outcome measures • explore a range of health effects for the individuals • explore mechanisms by which the community gardening project affects health • determine how/if the outcomes vary between the different community gardens and other variables such as the amount of time spent in the garden Setting: 4 community gardens in socially deprived areas of Scotland

22. Methods Recruited participants near the start of their gardening experience, and take baseline measures of stress level and physical health: blood pressure, body mass index, activity level and salivary cortisol. In addition, participants will be asked to complete validated questionnaires that examine aspects of mental wellbeing, physical activity, quality adjusted life years, loneliness, community cohesion and social capital. This data will be collected at baseline, some measures again at 6 weeks and all measures at 12 weeks. Also collecting qualitative data to explore participants experiences of being involved in the projects, and how they felt they benefited from them (mechanisms of action)

23. GPs will quiz obese on exercise to battle ‘pandemic’ • Scotsman on Sunday • (Sunday 11th Nov 2012) Physical Activity Brief Advice Interventions The Scottish government’s new approach A bear, however hard he tries, grows tubby without exercise. A.A. Milne

24. The Screening Tool Brief Advice for Physical Activity The Brief Advice Patients will be asked to think of at least one activity they might enjoy and get ­advice on local exercise classes. They will also be told how to be more active. They are likely to be given a 12-week “walking plan” aimed at building up their walking until it meets the recommended levels.

25. ‘One might conclude that this Series [on physical activity] should not be published in The Lancet . Physical activity is not a medical or pathological predicament but more a cultural challenge: to create a lifestyle inclusive of activity’ How involved should the medical profession be? And should we take a population or individual approach? "Walking is a man's best medicine."- Hippocrates

26. Should inactivity be medicalised? If deconditioning [inactivity] were a recognized syndrome or diagnosis like hypertension, diabetes ..., it would be easier to educate the general public and medical community about the one universally effective treatment for it – exercise training J Physiol 590.15 (2012) pp 3413–3414

27. Medicalisation of the problem - “PANDEMIC” - really? Pandemic "An epidemic occurring worldwide or over a very wide area, crossing international boundaries, and usually affecting a large number of people. A disease or condition is not a pandemic merely because it is widespread or kills many people; it must also be infectious “Physical inactivity has now been listed as a pandemichealth issue. Recent research shows that the risks of lack of activity are worse than smoking, obesity and diabetes put together” Professor Nanette Mutrie, Edinburgh University

28. How well are we teaching physical activity to health professionals? ...physical activity is generally taught in the context of general healthy lifestyles or for specific conditions such as treatment for injury, but not in its own right. Not given the same emphasis as diet, smoking cessation and reducing alcohol misuse abuse Barriers to the teaching of physical activity included competing priorities within very busy curricula.. ..physical activity, both from a theoretical, health related perspective and from a practical promotion perspective could be taught more intensively to health professional students. Jepson et al. A review of the prevalence of physical activity in health professional undergraduate, postgraduate, pre qualification courses and Continuous Professional Development activities December 2009 NHS Health Scotland

29. Summary Both inactivity and sedentary behaviour impact significantly on health People are involved in physical activity for multiple reasons. Trying to make people physically active ‘for the good of their health’ may not be enough to sustain behaviour change. It might be enough to try and make people less sedentary, or make small changes Guidelines may not be sensitive enough to be applicable for all health outcomes – people may not need to achieve them to gain the health benefits they want

30. Summary 2 Medicalisation of physical inactivity may not be an effective approach Sustained behaviour change will only occur when people are participating for a number of reasons. Health may not be enough of a reason to maintain behaviour change