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Steven N. Blair Director of Research—Cooper Institute Visiting Professor and

The Public Health Importance of Physical Inactivity National Physical Activity Task Force Edinburgh June 13, 2001. Steven N. Blair Director of Research—Cooper Institute Visiting Professor and Benjamin Meaker Fellow University of Bristol. A Brief Historical Note.

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Steven N. Blair Director of Research—Cooper Institute Visiting Professor and

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  1. The Public Health Importance of Physical InactivityNational Physical Activity Task Force EdinburghJune 13, 2001 Steven N. Blair Director of Research—Cooper Institute Visiting Professor and Benjamin Meaker Fellow University of Bristol

  2. A Brief Historical Note • Systematic research on the relation of sedentary habits to coronary heart disease began in the 1950s with the pioneering work of Professor Jeremy Morris of London • Dozens of studies now present a compelling body of evidence supporting regular physical activity as a good health habit • Today I will attempt to persuade you that inactivity is one of the most important public health issues, and that governments must act to deal with this threat to health. Further, I predict that this will become widely recognized

  3. Outline of Lecture • Strength of inactivity/low fitness as predictors of mortality • Prevalence of inactivity • Population attributable risk • Hostile environment • Lifestyle physical activity interventions • Summary and conclusion

  4. Death Rates and RR for Selected Mortality Predictors, Men, ACLS Death rates and relative risks are adjusted for age and examination year Relative risks are for risk categories shown here compared with those not at risk on that predictor Blair SN et al. JAMA 1996; 276:205-10

  5. Death Rates and RR for Selected Mortality Predictors, Women, ACLS Death rates and relative risks are adjusted for age and examination year Relative risks are for risk categories shown here compared with those not at risk on that predictor Blair SN et al. JAMA 1996; 276:205-10

  6. Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men, ACLS # of risk factors Risk Factors current smoking SBP >140 mmHg Chol >240 mg/dl Cardiorespiratory Fitness Groups *Adjusted for age, exam year, and other risk factors Blair SN et al. JAMA 1996; 276:205-10

  7. Cardiorespiratory Fitness, Risk Factors, and All-Cause Mortality, Women, ACLS # of risk factors Risk factors current smoking SBP >140 mmHg Chol >240 mg/dl Cardiorespiratory Fitness Groups *Adjusted for age, exam year, and other risk factors Blair SN et al. JAMA 1996; 276:205-10

  8. Functional Health Status

  9. Fitness and Functional Limitations • Prospective study of 1,175 women and 3,495 men age 40 years and older • Medical exam during 1980-88 • Average follow-up of 5.5 years • Self-report of functional limitations in 1990 by mail-back survey • Are you physically able to do? • personal care activities • household activities • recreational activities Huang et al. MSSE 1998, 30:1430-5

  10. Prevalence of Self-reported Functional Limitations by Fitness and Age Groups *Prevalence (%) Huang et al. MSSE 1998, 30:1430-5

  11. Fitness and Functional Limitations, Women and Men, ACLS • OR for self-reported functional limitation adjusted for age, follow-up, BMI, smoking, alcohol intake, baseline disease, & disease at follow-up Huang et al. MSSE 1998, 30:1430-5

  12. Cardiorespiratory Fitness and Longevity

  13. Population Attributable Riskof Low CRFand Economic Issues

  14. Physical Activity Levels for U.S. Adults • Sedentary and Irregularly Activity • Regularly Active, Low to Moderate Intensity 22% 38% 15% 25% • Regular Vigorous Activity (3 days, 20 minutes) Surgeon General’s Report, 1996

  15. Population Attributable Risk (PAR) for All-Cause Mortality in 10,623 Normal Weight Men, ACLS RR adjusted for age, examination year, parental CVD, and all other items in the table Wei et al. JAMA 1999; 282:1547

  16. Population Attributable Risk (PAR) for All-Cause Mortality in 11,798 Overweight Men, ACLS RR adjusted for age, examination year, parental CVD, and all other items in the table Wei et al. JAMA 1999; 282:1547

  17. Population Attributable Risk (PAR) for All-Cause Mortality in 3293 Obese Men, ACLS RR adjusted for age, examination year, parental CVD, and all other items in the table Wei et al. JAMA 1999; 282:1547

  18. Physical Inactivity and Direct Medical Costs • Cross-sectional stratified analysis of 1987 National Medical Expenditures Survey • Non-institutionalized women and men 15 years and older • 35,000 persons in 14,000 households • Detailed information on health care costs were collected and confirmed by an additional survey of medical providers • 20,041 non-pregnant participants included in the analyses Pratt M et al. Physician & Sportsmedicine 2000

  19. Physical Inactivity and Direct Medical Costs • Physical activity categories • Physically active=30 minutes of moderate or strenuous activity 3 or more days/week • Physically inactive=all others • Medical care costs included • Hospital admissions • Physician visits • Medication use Pratt M et al. Physician & Sportsmedicine 2000

  20. Physical Inactivity and Direct Medical Costs • Total medical care costs • All respondents=$1,690 • Physically active=$1,242 • Physically inactive=$2,277 • Differences in costs between active and inactive individuals were present by categories of smoking habit, gender, and age groups • Total cost of inactivity for medical care for the U.S. in 2000 is estimated at $76.6 billion Pratt M et al. Physician & Sportsmedicine 2000

  21. Summary: Physical Inactivity and Health • A sedentary and unfit way of life is harmful to health and function • A high proportion of adults in most countries are sedentary • Population attributable risks and health care costs of physical inactivity are substantial • There is a crucial need to develop policies to address this major public health problem

  22. Decline in Energy Expenditure in the United Kingdom, 1970-1995 • Estimate of energy intake from surveys of household food intakes and making assumptions about food and drink outside the home • Decline of 750 kcal per day • Average weight gain of 2.5 kg in the population over the same period • Accounts for an additional 50 kcal per day • Therefore, the average decline in the UK is about 800 kcal per day in the past 25 years James PT. Int J Obes 1995

  23. Lifestyle and Energy Expenditure Kcal estimates for 150-160 pound person Taken from article by L. Beil, Dallas Morning News, 1999

  24. Lifestyle and Energy Expenditure Kcal estimates for 150-160 pound person Taken from article by L. Beil, Dallas Morning News, 1999

  25. Lifestyle and Energy Expenditure Kcal estimates for 150-160 pound person Taken from article by L. Beil, Dallas Morning News, 1999

  26. Lifestyle and Energy Expenditure Kcal estimates for 150-160 pound person Taken from article by L. Beil, Dallas Morning News, 1999

  27. Lifestyle and Energy Expenditure Kcal estimates for 150-160 pound person Taken from article by L. Beil, Dallas Morning News, 1999

  28. Lifestyle and Energy Expenditure • Assume a person’s caloric intake remains the same • Completing all of the tasks reviewed daily or as listed • Active way=10,500 kcal/month • Sedentary way=1,700 kcal/month • Difference of 8,800 kcal/month is energy equivalent of 2.5 pounds/month or 30 pounds/year Kcal estimates for 150-160 pound person Taken from article by L. Beil, Dallas Morning News, 1999

  29. Lifestyle Physical Activity Interventions

  30. Experimental Design • Two year, parallel randomized design • Two treatment groups: • Lifestyle • Structured • Six months of active intervention; • 18 months of follow-up intervention • Three successive recruitment cohorts Dunn A et al. JAMA 1999 Project Active

  31. Structured Intervention: Project Active • Exercise prescription model, e.g., 50-85% of maximal aerobic power for 20-60 minutes per session, at least 3 and preferably 5 days per week • State-of-the-art fitness center for first 6 months • Follow-up includes quarterly newsletter and group activities, e.g., fun runs Project Active Dunn A et al. JAMA 1999

  32. Lifestyle Intervention: Project Active • Goal is to increase energy expenditure using behavioral interventions and processes matched to stage of motivational readiness • Small group meetings once per week for four months, then every two weeks for two months • Follow-up includes monthly meetings through the end of year 1 then graduated down through year 2 Dunn A et al. JAMA 1999 Project Active

  33. Behavioral Approaches to Physical Activity Interventions • Theoretical foundations • Social Learning Theory • Stages of Change Model • Environmental/Ecological Model • Methods • Problem solving • Self-monitoring • Goal setting • Social support • Cognitive restructuring • Incremental changes • Manipulating the environment Dunn A et al. JAMA 1999

  34. Curriculum Overview Dunn A et al. JAMA 1999

  35. How Do People Change? Cognitive Strategies Increasing Knowledge Encourage person to read and think about physical activity Warning of Risks Provide person with message that being inactive is very unhealthy Caring about Consequences Encourage person to recognize to Others how his/her inactivity affects his/her family and friends Comprehending Benefits Help person to think about the personal benefits of being active Increasing Healthy Help person to become aware of Opportunities societal changes in regard to physical activity Dunn A et al. JAMA 1999 Project Active

  36. How Do People Change? Behavioral Strategies Substituting Alternatives Encourage person to engage in physical activity when it might be most beneficial, yet is rarely done Enlisting Social Support Encourage person to find a friend or family member who will provide support for being active Rewarding Yourself Encourage person to reward and praise self for being active Committing Yourself Encourage person to make commitment to be active Reminding Yourself Help person to set up reminders to be active Dunn A et al. JAMA 1999 Project Active

  37. Mean Peak Oxygen Consumption ml.kg-1 .min-1 time in months Project Active Dunn A et al. JAMA 1999

  38. 24-Month Change in Weight and Percent Body Fat Weight Percent Body Fat 1.5 1.5 0 0 percent kilograms -1.5 -1.5 Lifestyle Structured * * - 3 - 3 * p < 0.001 within group Project Active Dunn A et al. JAMA 1999

  39. 24-Month Reduction in Blood Pressure Systolic Diastolic mm Hg * * * * Project Active * p < 0.01 within group Dunn A et al. JAMA 1999

  40. Seeking out others to provide support for and encourage participation in physical activity I have a healthy friend that encourages me to be physically active when I don’t feel up to it I have someone on whom I can depend when I am having problems with being physically active Enlisting social support

  41. Using rewards to encourage or maintain physical activity behavior I reward myself when I am physically active I do something nice for myself for making efforts to be more physically active Rewarding yourself

  42. Positive reminders to engage in physical activity I put things around my home to remind me of exercising I keep things around my place of work that remind me to be physically active Reminding yourself

  43. Replacing sedentary pursuits with more active behaviors Instead of remaining inactive, I engage in some physical activity When I’m feeling tense, I find that being physically active helps relieve my worries Substituting alternatives

  44. Making commitments toward being more physically active I make commitments to be physically active I am the only one responsible for my health, and only I can decide whether or not I will be physically active Committing yourself

  45. Measures • Independent Measures • Processes of Change - 40-item questionnaire • Marcus, Rossi, Selby, Niaura, & Abrams, 1992 • 5 Cognitive Processes • 5 Behavioral Processes

  46. Implications • Effective measurement of these key mediating constructs exist • Interventions have been shown to be effective in modifying these variables • Change in the mediating variables is associated with changes in behavior • Researchers and practitioners should address behavioral and cognitive strategies in the promotion of short- and long-term physical activity

  47. Public Health Recommendations for Physical Activity

  48. Public Health Recommendation for Physical Activity • Recent statements from the American College of Sports Medicine/Centers for Disease Control and Prevention, American Heart Association, NIH, and the office of the US Surgeon General conclude: • All adults should accumulate at least 30 minutes of at least moderate intensity physical activity each day • This is equivalent to walking about 2 miles at a pace of 3 to 4 mph

  49. Summary • Physical inactivity and low levels of cardiorespiratory fitness are strong predictors of mortality and other health problems • There is a high prevalence of sedentary habits—40-50 million adults in the U.S. • Population attributable risks and economic costs of inactivity are high

  50. Best Exercise Advice to Give to the Public? • Traditional, structured program--3-5 times/week, 20-60 minutes/session, relatively vigorous • Consensus recommendation--accumulate at least 30 minutes of moderate intensity exercise each day • The important question is not whether one approach is better than the other, but do both approaches work?

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