Physical Activity Promotion: Prevention of Chronic Disease Morbidity & Mortality

1. Physical Activity Promotion: Prevention of Chronic Disease Morbidity & Mortality Antronette (Toni) Yancey, MD, MPH, FACPM Associate Professor, Dept. of Health Services, Co-Director, Ctr. to Eliminate Health Disparities UCLA School of Public Health www.ph.ucla.edu/cehd www.toniyancey.com

2. Unhealthy eating and inactivity are leading causes of death in the U.S. Leading Contributorsto Premature Death1 • HHS estimates that unhealthy eating and inactivity contribute to 310,000 to 580,000 deathseach year. That’s 5 times more than are killed by guns, HIV, and drug use combined.1 • The typical American diet is too high in saturated fat, cholesterol, salt, and refined sugar and too low in fruits, vegetables, whole grains, calcium, and fiber. • Such a diet contributes to four of the seven leading causes of death and increases the risk of numerous diseases, including: heart disease diabetes cancer high blood pressure • obesity osteoporosis • stroke • 60% of Americans are at risk for health problems related to lack of physical activity (ie: get less than 30 minutes of moderate activity 5 or more times per week). 2 Leading Causes of Death3 (Diet is a leading risk factor for causes of death shown in bold or green.)

3. DIABETES PREVENTION PROGRAM • The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin • All patients had impaired fasting blood sugars, but were not diabetic • Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week • They were followed over 2.8 years

4. DIABETES PREVENTION PROGRAM Lifestyle intervention was much more effective than either placebo or metformin DPP Research Group. N Engl J Med. 2002;346:393-403.

5. Fitness & Mortality • Low fitness is bad for health

6. Walking & CVD • Walking as little as 5 mins. daily is beneficial for fitness • 30 mins. daily provides best health benefit (heart disease prevention) • 60 mins daily can cause reversal of heart disease

7. Physical Activity& Risk of Common Cancers • Colon: 30-40% decreased risk among active men & women (Rectal—no association) • Breast: substantial evidence for dec risk; strength of assn--time period may be critical • Prostate: findings inconclusive • Possible mechanisms: 1. decreased GI transit time (dec carc expos) 2. enhanced immune function (moderate PA) 3. lowered levels of reproductive hormones

8. Population Attributable Fraction Cancer Mortality – Male Never Smokers Population BMI Exposure* RR† PAR (%) 25.0-29.9 42% 1.1 4.0% 30.0-34.9 21% 1.4 6.8% >35.0 13% 1.3 3.4% 14.2% *NHANES 2000, men age 50-69

9. Population Attributable Fraction Cancer Mortality – Women Never Smokers Population BMI Exposure* RR† PAR (%) 25.0-29.9 29% 1.1 3.3% 30.0-34.9 23% 1.3 6.1% 35.0-39.9 11% 1.4 3.5% >40.0 8% 1.9 7.0% 19.8% *NHANES 2000, women age 50-69

10. http://apps.nccd.cdc.gov/brfss/Trends/trendchart_c.asp?state_c=CA&state=US&qkey=10020&SUBMIT1=Gohttp://apps.nccd.cdc.gov/brfss/Trends/trendchart_c.asp?state_c=CA&state=US&qkey=10020&SUBMIT1=Go YEAR % Obese % No LTPA 1991 10% 23.3% 1995 14.4% 22.7% 1998 16.8% 25.5% 1999 19.6% no data 2000 19.2% 26.5% BRFSS DATA 20 15 10 5 30 25 20 15 % No LTPA % obese 1991 1995 1998 2000

11. Lesser Effectiveness of Key Environmental Interventions in Underserved Groups: Example Posting of Signs Promoting Stair Usage (suburban Baltimore mall) • Overall, stair use increased from 4.8% to 6.9%, 7.2%, depending upon which of 2 signs used • Among whites, increased from 5.1% to 7.5%, 7.8% • Among blacks, changed from 4.1% to 3.4%, 5.0% • Among n’l wt, inc from 5.4% to 7.2%, 6.9% • Among overwt, inc from 3.8% to 6.3%, 7.8% Andersen, Franckowiak, Snyder et al., Ann Int Med, 1998;129:363-369.

12. Pervasive targeted commercial marketing Distance to private fitness facilities Few worksite fitness opportunities Few/poor neighborhood recreation facilities Lesser neighborhood safety Poorer public/less reliable private transportation Poorly equipped facilities Poorly maintained sidewalks, e.g., cracks, litter, overgr. foliage Fewer traffic calming devices, e.g., speed bumps Ample car “accommodation,” e.g., parking, high- speed/multi-lane roads =“Move insecurity”1, 2 1Jahns & Jones, AJPM 2004;26:1862Yancey, AJPM 2003;25(3Si) Adapted from Kumanyika S. Obesity in Minority Populations. In Fairburn G & Brownell K, Eating Disorders and Obesity. A Comprehensive Handbook, 2002. Excess physical environmental risk in underserved communities:

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

15. Media Project: five-city outdoor advertising content analysis Funded by CA DHS, UT, Penn & RWJF Cities: LA, Philadelphia, Austin, Sacramento, Fresno Comparing high & low SES predominantly black, Latino, & white neighborhoods (all 6 categories not available in all cities, e.g., high SES black in Sacramento and Fresno) Utilizing secondary data from CHIS, LACHS, grocery store scanner (MOU with major supermarket chain) purchase data for correlational analyses

18. Preliminary findings • Absence of billboards and near-absence of other outdoor advertising in affluent white neighborhoods—existing ads unrel. to weight • Essentially no outdoor advertising of PA-promoting goods & services in any community, but large amount sedentary entertainment & transportation ads in low-inc. communities • Pervasiveness of advertising in low-inc. white & Latino communities, but more fast food, sugar-sweetened and alcoholic beverages in latter • City of LA has moratorium on new billboards, but in low-inc. Latino comm., large # of new side of building ads similarly framed Findings must be interpreted in light of historical covenants, fewer ads trad. In unincorp. areas

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

20. LA’s ESPN Radio 710 AM Ad “We’re the prime rib on a dial full of tofu” --March 2006

21. Cultural reverence for SUVs?

23. AVERAGE ENERGY EXPENDITURE ESTIMATES Hunter-gatherers 5000 cal 1 million yrs ago Agriculture 6000 cal 10,000 yrs ago Laborers 3000 cal 1915 Office Workers 1800 cal NOW

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

25. Physical Inactivity Levels:TV viewing/computer use, %L.A. County Adults, 1999

26. Self-Perceived Overweight by Ethnicity & Gender, % LA County Adults

27. Influence of Self-Perceived Weight Status on PA,% LA County Adults • Overall, regardless of BMI, those perceiving themselves as overweight more sedentary than those with average wt. self-perception (45% vs. 30%) • Influence most pronounced for males and normal weight individuals • Overwt. self-perception not assoc. with sedentariness among white women, the only one of the 6 ethnic-gender groups included in which BMI<25 normative • In multivariate analysis, self-perceived overweight, not BMI, predicts sedentary behavior (OR=1.40, CI 1.19, 1.64) Yancey, Simon et al., Obes (Res) 2006;14:980-8. Yancey, Wold et al., Am J Prev Med, 2004;27:146-52.

28. Current Population Status • Little change in leisure time physical activity (PA) during past several decades of obesity increases (1 in 5), but marked increases in sedentary entertainment, transportation, and other ADLs (Sturm, 2004) • PA levels within increasingly sedentary, deconditioned, overweight population are unlikely to increase primarily through individual motivation and volition—relatively little demand for goods & services or political will to push for aggressive legislative policy change, e.g., radical alteration in the built environment favoring bicycle, pedestrian, and mass transit over private automobile transportation

30. Daily “Dose” (Rx) of Physical Activity • 30-60 minutes/day on most (at least 5) days of the week • At least moderate intensity (=walking 1 ½ to 2 miles in 30 minutes) • Can be broken up into 10-minute stretches throughout the day • Every calorie burned is one that doesn’t end up around your waist!

31. AFRICAN AMERICAN WOMEN & HEART DISEASE DIABETES PREVENTION PROGRAM • The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin • All patients had impaired fasting blood sugars, but were not diabetic • Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week • They were followed over 2.8 years

32. How much is enough?

33. Population benefit estimates of risk factor change: PA • 3-minute bouts of PA 10 times per day lowers serum triglycerides to same extent as 1 continuous 30-minute bout of PA (Miyashita et al., 2006) • Maintenance of moderate PA is assoc. with a 1/3 to 2/3 lowering of Type 2 diabetes (DM) incidence over 4-14 yrs (Clark, 1997) • Type 2 DM risk was 50% lower among individuals physically active at any level, and 66% lower among those at least moderately active (James et al., 1998) • Sedentary behaviors (e.g., TV watching) as well as sub-optimal >moderate PA levels contributed to DM & obesity risk over 6 yrs in women (Hu et al., 2003)

34. Population Obesity Control: Early stage in development Strategically, why focus on PA promotion first? • Less controversy, conflict, stigma than surrounding diet/nutrition • “Deep pocket” business interests, e.g., Nike & 24-Hour Fitness, stand to benefit from success of efforts (vs. “Big Food” losing $ because can’t as readily induce over-consumption of H2O, whole grains, legumes, F+V) • Cheaper & easier—10 min. supply 1/3 of PA “RDA” • May positively influence food preferences

35. Population Obesity Control: Early stage in development To avoid exacerbating health risk/disease burden disparities, push strategies (skip-stop/slowed hydraulic elevators, restricted proximal parking, non-discretionary time exercise breaks, walking meetings) should be prioritized over pull strategies (building trails & parks, offering gym membership subsidies/discounts) at this early stage of development of environmental and policy approaches—make it easier to do it than notto do it!

36. Population Obesity Control: Early stage in development (cont.) • Synergy will occur when supply (physical environmental access & appeal) meets demand (individual/ sociocultural motivation, prioritization, valuation, skills/interests, political will) • Demand must be created—need to structure in “unavoidable” experiences which increase aerobic conditioning, build skills & self-efficacy, foster enjoyment, elevate mood & energy, increase taste for water-bearing foods & less highly-sweetened beverages

37. Spectrum of Prevention:Health behavior change model • Level 1: Strengthening individual knowledge and skills • Level 2: Promoting community education • Level 3: Educating service providers • Level 4: Fostering coalitions and networks • Level 5: Changing organizational practice • Level 6: Influencing policy and legislation

38. Spectrum of Prevention:Shift in health promotion field The most effective and sustainable PH intervention approaches of the past two decades are the more “upstream” ones (structural/environmental vs. individual-level), involving social norm change: • Tobacco control • Alcohol consumption and driving • Breastfeeding • Littering and recycling

39. Spectrum of Prevention(2nd level)

40. ROCK! Richmond • Community-level fitness promotion initiative of Richmond City DPH/Medical College of Virginia • 3 major components: (1) free fitness instruction in CBOs in underserved areas; (2) environmental changes in conduct of city business (e.g., low-fat/ high-fiber food choices at city functions); (3) social marketing effort to reinforce norms supporting PA & healthy eating • Successful in recruiting disproportionately among population segments at highest risk for chronic disease (older, black, female, family hx of CA, CVD) Yancey, Jordan, Bradford et al., Health Prom Practice, 2003

44. Spectrum of Prevention(5th level)

45. Translating Evidence-Based CDC/ACSM Recommendations into Culturally-Targeted Intervention Integrating 10-’ PA bouts into organizational routine: • Minimal intensity environmental intervention, e.g., stair prompts • Short bouts accommodate higher proportion sedentary individuals (incremental change) • Variable (max moderate) intensity, low-impact PA accommodates higher proportion overweight/obese and disabled individuals (higher perceived exertion, discomfort, functional limitations) • Passive (“push”) strategy relies less on individual motivation & facility access (early adopters scarce)

46. Translating Evidence-Based CDC/ACSM Recommendation into Culturally-Targeted Intervention Integrating 10-’ PA into organizational routine: • Movement to music integral to African-American, Latino culture—dancing normative for adults • Short bouts minimize perspiration, hairstyle disturbance • Social support & conformity desires drive participation (collectivist vs. indiv. orientation) • Addresses less activity conducive outdoor environments (safety, utility, aesthetics) • Designed for organizational settings for work, worship, other purposes--less disposable t, $

47. Lift Offs Work!: the Rapidly Growing Evidence Base • Documented individual and organizational receptivity to integrating PA on paid work time • Contribute meaningfully to daily accumulation of MVPA • Motivational “teachable moment” linking sedentariness to health status for inactive folks • Improvements in clinical outcomes from as little as one 10-min. break/day—BP, BMI, waist circ., mood, attention span, cumulative trauma disorders • “Spill-over” or generalization to inc. active leisure • Favorable cost-benefit ratio, eg, L.L. Bean mfg plant

49. LAC Fitness & Wellness Study:design • Randomized, controlled, post-test only, intervention trial testing the effects of incorporation of a 10-min exercise break into staff meetings & training seminars lasting > 1 hr • Outcome measures: (1) participation by sedentary/overweight individuals; (2) mood/affect; (3) satisfaction with health status/fitness level • 26 meetings (11 intervention, 15 control) with 449 county employees, mostly women of color

50. LAC Fitness & Wellness Study:Results (cont.) • More than 90% of meeting attendees participated in the exercises Among relatively sedentary participants: • Intervention participants’ satisfaction with fitness levels more highly correlated with PA stage of change (r=0.59) than controls (r=0.38, z=-2.32, p=0.02) Among sedentary participants: • Intervention participants’ self-perceived health status ratings were significantly lower than controls (OR=0.17; 95% CI=0.05, 0.60; p=.0003 Yancey, McCarthy, Taylor et al. 2004;38:848-856