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Review

Thebenefitsofphysicalactivityforhealthandwellbeing
2ndedition

C3CollaboratingforHealth* October2012

Contents
Overview PartI:Evidencesupportingthebenefitsofphysicalactivityonhealthandwellbeing 1.Theimpactofphysicalactivityonhealth 2.Literaturereviewoftheevidence PartII:Evidencesupportinginterventionstoencouragephysicalactivity 1.Thescaleoftheproblem 2.Anactiveenvironment? 3.Behaviourchange 4.Selectedinterventions PartIII:Casestudies 1.Introduction 2.Whatmakesforbestpractice? 3.Casestudies Appendix1:Selectedliteratureonthehealthbenefitsofphysicalactivity Appendix2:Physicalactivityinterventions Appendix3:Levelsofevidence Endnotes

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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 additiontoexamplesthataregroundedinscientificevidence,aselectgroupofcasestudiesarepresented thatdonotincludedetaileddata,butcanbeseenasinnovativeandpromising. Evidenceandexamplesofoneofthecheapestandsimplestofallphysicalactivitieswalkingare presentedthroughoutthereview(eachinstanceisindicatedbythefootprinticon).Walkingisalsothe subjectofaseparatereviewbyC3,Thebenefitsofregularwalkingforhealth,wellbeingandthe environment(September2012). AlmosteverycommunityaroundtheworldisfacedwiththechallengeofcombatingNCDs,andwehope thatthisreviewandcasestudieswillprovideinformationthatprovidestherationaleforactionandideas fortacklingphysicalinactivityinmanydifferentsetting.

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PartI: Evidencesupportingthebenefitsofphysicalactivityon healthandwellbeing


1.Theimpactofphysicalactivityonhealth
i)Thebenefitsofphysicalactivity
Beingphysicallyactiveplaysanessentialroleinensuringhealthandwellbeing,andthereisalargebodyof researchinvestigatingthebenefitsofexercise.iPhysicalactivitybenefitsmanypartsofthebodythe heart,skeletalmuscles,bones,blood(forexample,cholesterollevels),theimmunesystemandthenervous system1andcanreducemanyoftheriskfactorsfornoncommunicablediseases(NCDs).Theserisk factorsinclude: reducingbloodpressure; improvingbloodcholesterollevels; loweringbodymassindex(BMI).

Therolephysicalactivityplaysin manydiseases,suchastype2 diabetes,heartdiseaseandmany cancers,meansthattheWorld HealthOrganization(WHO) estimatesthat: physicalinactivityisthefourth leadingriskfactorforglobal mortality2(seeFigure1);and physicalinactivityisresponsible for6%ofdeathsglobally around3.2milliondeathsper year,including2.6millionin lowandmiddleincome countries,and670,000ofthese deathsarepremature.3

Figure1:Deathsattributedto19leadingfactors,by countryincomelevel(2004)

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

Forwhatconstitutessufficientphysicalactivity,seePartI,section2(iv)below.
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ii)Internationalactiononhealthandphysicalactivity
In2011,theUnitedNationsheldaHighlevelMeeting(attendedbyover30headsofstate,andwith statementspresentedbyover130memberstates)toaddresstheepidemicofnoncommunicablediseases. Physicalactivityasariskfactorwasrepeatedlyhighlightedanddiscussionisnowunderwaytosettargets toreducetheriskfactorsforNCDs,includingphysicalinactivity. InMay2012,theWorldHealthAssemblysetatargettoreducedeathsfromnoncommunicablediseasesby 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.Alargestudyofnurses11foundthatregular walkinggreatlyreducedtheriskofdevelopingtype2diabetesasimilarlevelofprotectiontothatfound fromundertakingtheequivalentenergyexpenditureonavigorousactivity. Formoreonthehealthbenefitsofwalking,seeC3sreviewofThebenefitsofregularwalkingforhealth, wellbeingandtheenvironment(August2012).12

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2.Literaturereviewoftheevidence
Theevidenceisresoundingthatphysicalactivityimproveshealth,andthestudiesreferredtointhisreport coveravarietyofdifferentpopulations,researchmethodologiesandphysicalactivities.iiThetablesin Appendix1coverresearchstudiesand/orreportsthatillustratethebenefitsofphysicalactivityon: overweightandobesity(Table1a)thisisamajorriskfactorforNCDs; type2diabetes(Table1b); cardiovasculardisease(Table2); coronaryarterydisease(Table3);and cancer(Table4).

Inaddition,Table5setsoutevidenceonthebenefitofphysicalactivityonmentalhealth,including reducingstressandalleviatingdepression. Theimprovementsinphysicalactivityareespeciallypronouncedforhighriskindividuals,forexamplethose whoareobeseorhavehighbloodpressure(hypertensive).13Researchhasalsoshownthatbeingphysically activedailywillreducethechancesofmortalityassociatedwithcardiovasculardisease: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:inlowandmiddleincomecountries,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.


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ButreversingthetideofphysicalinactivitycanhavestrikingimpactsonmanyofthemajorNCDsdiabetes, manycancersandheartdisease.Specificbenefitsinclude: ariskreductionforbreastcancerofapproximately2040%forthosewhodovigorousphysicalactivity for3060minutesonfivedayseachweek;21 themostactivepeopleareat30%lowerriskofcoloncancerthantheleastfit;22 a2530%reductioninstrokeamongactiveindividuals;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,studiesbothofpeoplecurrentlywithcancer26andcancersurvivors27havefoundthatphysical activityisassociatedwithhealthrelatedqualityoflife,includingphysicalfunctioning,fatigueand depression.28Physicalactivitycanalsohelptoreducetheriskofcancerrecurrenceandmortalityforbreast cancer(uptoabout40%riskreduction),coloncancer(50%)andprostatecancer(30%).29Despitethese benefits,arecentsurveyintheUKshowedthat37%ofthosesurveyedwerenotphysicallyactiveatall,the majorityhadnotbeenspokentobytheirGP(82%)oroncologist(77%)orclinicalnursespecialist(79%) aboutthebenefitsofphysicalactivity.30

ii)Mentalhealth
Inadditiontothebenefitsofphysicalactivityonimprovinghealthandreducingriskfactorsforchronic disease,ithasbeenshowntobeeffectiveinimprovingmentalhealth,whichisalsoamajorcauseof disabilityworldwide.EstimatesmadebytheWorldHealthOrganizationarethat154millionpeopleglobally sufferfromdepression,andmentalillnessesaffectandareaffectedbychronicconditionssuchascancer, heartandothercardiovasculardiseases,diabetesandHIV/AIDS.31 Theevidenceonthementalhealthbenefitsofphysicalactivityislesswelldocumentedthanforthe physicaleffectsastheeditorsofthejournalMentalHealthandPhysicalActivityputit,inthejournals inauguraleditorial:Somanyresearchquestionscometomindinthisfieldthathavebarelybeen considered.32However,thebodyofevidenceisgrowingfast,withmanystudiesandclinicaltrialshaving shownspecificbenefitsincluding:improvedmood,reducingsymptomsofstress,anger,depressionandjob burnout,33alleviatinganxiety34andslowingcognitivedecline.Ithasbeensuggestedthatphysicalactivity mayhaveeffectsontreatingdepressioncomparabletoProzacorbehaviouraltherapy.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(includingtestsofgeneralcognition,verbalmemoryandattention).38

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TheWorldAlzheimerReport2009estimatedthatthereare35.6millionpeoplelivingwithdementia worldwide,withthisfiguresettoincreaseto65.7millionpeopleby2030and115.4millionby2050.39 ThereisalsosomeevidencethatphysicalactivitymayhelptoslowtheprogressionofAlzheimers40and 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 thosesurveyedsaidthattheyfeelthatgreenexercisebenefitstheirphysicalhealthbutanevenhigher 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 longeringoodhealthanexampleofcompressionofmorbidity.Thosewiththehighestlevelsofmidlife fitnessspent34%moretimethantheleastfit withoneornochronicdisease.48 Amongolderadults,engagementinroutine exerciseonaregularbasisleadstoimproved functionalabilitiessuchasmobility49and reducedriskoffalls,andisrelatedto increasedlongevityandtoreduced inflammation(inflammationisthoughtto contributetolossofstrengthandmuscle power,cardiovasculardiseaseand depression).50Itmayalsohavebenefitsfor cognitivefunction.51
TaichiinLondon
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Inmanypartsoftheworld,physicalactivitydeclinessubstantiallyasweage(seeFigure2,below,forthe UnitedKingdom52).However,thisisnotalwaysthecaseinChinaandsomeeastAsiannations,physical activityincreaseswhenpeopleretire.53

Men

Women

Figure2:LevelsofphysicalactivityamongadultsinEngland(selfreported) Animportant,andoftenunderserved,grouparepeoplewithdisabilities,whonumberoverabillion worldwideandwhomayfacesubstantialbarrierstoparticipatinginphysicalactivity.IntheUnitedStates, forexample,adultswithadisabilityaretwiceaslikelytobeinactiveasthosewithnodisabilityleaving thematevengreaterriskofthehealthproblemsattendantonsedentarylifestyles.54

iv)Recommendedlevelsofphysicalactivity
Therecommendedguidelinesfortheamountofphysicalactivitythatindividualsshouldengageinona routinebasisinordertoobtainand/ormaintainhealthandwellnesshasbeendevelopedbyleading national/internationalbodiesand,althoughtheymayvaryonspecifics,thegeneralfeaturesareallsimilar. Theexamplepresentedbelow(p.10)istakenfromtheAmericanCollegeofSportsMedicineandthe AmericanHeartAssociationguidelinesandiswidelyused.55Theadditionalinformationforolderadultsis alsofromtheACSMandAHAandtheinformationforchildrenfromtheUSCDC.56Evensmallamountsof physicalactivity15minutesadaycanhaveasignificanthealthimpacts,increasinglifeexpectancyby threeyearscomparedtoaninactivegroup.57 Inaddition,thereisnowevidencethatsittingforlongperiodsregardlessofphysicalactivitylevelstherest ofthetimeisalsoariskfactorforallcausemortality:theriskofdeathwithinthreeyearsis15%greater amongthosewhositforbetween8and11hoursadaycomparedtothosewhositforfewerthanfour hours,and40%greateramongthosewhositforover11hoursaday.58 Aneasyruleofthumb(usingwordingfromtheUSCDC)isthetalktest:ifyou'redoingmoderateintensity activityyoucantalk,butnotsing,duringtheactivity.Ifyou'redoingvigorousintensityactivity,youwillnot beabletosaymorethanafewwordswithoutpausingforabreath.iii

Anexample:Walking
Forgoodhealth,10,000stepsadayisrecommendedthisisabout5miles(8km),dependingon stridelength,andistheequivalentofwalkingbrisklyforabout90minutes.Thiscanbespreadthroughout theday.Briskwalkingisanexampleofmoderateintensityactivity;racewalkingbecomesvigorousactivity. CaseStudy5inPartIIIfocusesparticularlyonwalkingandmoreexamplesofwalkinginitiativesare includedinC3sreviewoftheevidenceonwalking.59


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Physicalactivityguidelines
Topromoteandmaintaingoodhealth,adultsaged1865yearsshouldmaintainaphysically activelifestyle. Theyshouldperformmoderateintensityaerobic(endurance)physicalactivityforaminimum of30minutesonfivedayseachweekorvigorousintensityaerobicactivityforaminimumof 20minutesonthreedayseachweek. Combinationsofmoderateandvigorousintensityactivitycanbeperformedtomeetthis recommendation.Forexample,apersoncanmeettherecommendationbywalkingbrisklyfor 30minutestwiceduringtheweekandthenjoggingfor20minutesontwootherdays. Thesemoderateorvigorousintensityactivitiesareinadditiontothelightintensityactivities 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 beincludedonatleastthreedayseachweek).Musclestrengtheningactivities(suchas 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 lowestamountofactivityincreasesasincomefalls23%ofmeninthehighestquintileachieveonlylow levelsofphysicalactivity,comparedwith46%inthelowestquintile,andtheequivalentforwomenis28% (highestquintile)and45%(lowestquintile).

Figure3:ProportionofpeopleinEnglandmeetingthephysicalactivityrecommendationsby equivalisedhouseholdincomeandsex Therehavebeensomestudiesintowhypatternsofphysicalactivityvarybetweendifferentsocioeconomic groupsandtherearecertainlyintuitivereasonswhythismaybeso,evenwherestrongempirical evidenceislacking.Forexample,thestreetsinpoorerneighbourhoodsareoftenlesssafeforwalkingor cyclingbecauseoftrafficandaperceivedfearofcrime.Theinfrastructureforactivelivingmayalsonotbe inplaceinsuchareas:onestudyintheUnitedStatesfoundthatmovingfromacommunitywitha1% povertyratetoa10%povertyrateisassociatedwithadecreasedprevalenceofbikepathsfrom57%to9% respectively64astheareagotpoorer,theavailabilityofbikepathsfelldramatically.Inaddition,access bothtoattractive,safegreenspaceandtocommercialresourcesforstructuredphysicalactivitysuchas gyms65maybemorelimitedinsomemoredeprivedareas. Itisanunfortunatefactthathealthpromotionmessagesareoftenadoptedfirstbythemoresocially advantaged,withevidenceindicatingthathealthcampaignstendtohavethedualimpactofimproving healthonaverageacrossthepopulation,butalsowideninghealthinequalities.66Thismakescreating opportunitiesforactivelivingmakingiteasytobephysicallyactiveparticularlyimportantinmore deprivedareas:campaignstoencourageexercisewilldolittletoincreaseactivitylevelsamongtheleast welloffunlesstheyhavethemeanstomakethechange.

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PartII: Evidencesupportinginterventionstoencouragephysical activity


1.Thescaleoftheproblem
Despitethelargebodyofevidencethatsupportthebenefitsofbeingphysicallyactive,indeveloped countriesthemajorityofadultsdonotmeettherecommendedlevel.Comparingphysicalactivitylevels betweencountriesischallenging,becausetherearenocommontoolsbywhichitismeasured:the internationaltoolssuchastheInternationalPhysicalActivityQuestionnaireandtheWHOsGlobalPhysical ActivityQuestionnaireareoftennotpartofnationalsurveys.However,itisclearthatindeveloped countriesonlyaminorityofadultsachievetherecommendedlevelsofphysicalactivity.InEngland,for example(asFigure2shows,above),only39%ofadultmenand29%ofadultwomenmeetthe recommendations. However,thislackofcleardatashouldnotstopeffortstoincreasephysicalactivity,asthehealthbenefits areevident(seePartI).

2.Anactiveenvironment?
AstheratesofNCDscontinuetorise,recentlygreatereffortsandresourcesarebeinginvestedinhowto bestencouragepeopletoliveahealthierlifestyle,includingmakingbetterphysicalactivitychoices. Researchoverthepastfewdecadeshasprovidedagreaterunderstandingofthefactorsinfluencing whetherornotanindividualorcommunityisphysicallyactive,andFigure4depictsaconceptualmodelof themultiplefactorsandinfluencesinvolvedinlivingahealthyphysicallyactivelifestyle.Interventionsthat takeintoconsiderationthesemultiplelayersofinfluencearemorelikelytobeeffectivethansingle interventionstargetingaparticularfactor.Tacklingthesemultiplefactorsistoencourageactiveliving.

Figure4:Layersofinfluenceaffectingengagementinphysicalactivity67 Inrecentyearstherehasbeenshiftawayfromencouragingindividualbehaviourchangetoanapproach thataddresseswider,populationlevelfactors.Individualisedbehaviourchangeisoftennotsustainableor effective6869unlessitbecomeshabitforming.Changingtheoverallenvironmentmakesbehaviourchange moresustainableashashappenedwithsmokingincountriessuchastheUK:initiallytheburdenof responsibilitywasputsolelyonindividuals.Oncethatviewexpandedtoincluderecognitionofsocietal responsibilityaswell,populationlevelactionandchangesinsmokingprevalencefollowed.Physicalactivity hastolearnfromtheseexamples.70

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Therearedifferentleversthatcanbeusedatthepopulationleveltochangeboththesocialenvironment andthebuiltenvironment,whichtogetherinfluencethehealthchoicesmadebyindividuals. Factorsinthesocialenvironmentsknowntoinfluenceparticipationinphysicalactivityare socioeconomicstatus,culturalbeliefs,andopportunitiestoimprovesocialcohesioninthe neighbourhood,cityandregions.Factorsinthebuiltenvironmentthatinfluenceparticipationin physicalactivityareurbandesign,transport(traffic),availabilityofgreenspace,andlanduse patterns.Newinfrastructuresuchasbikepathsorfitnessequipmentinparksandincreasedaccessto facilities(suchasexpandedhoursofoperationoffitnessareas,orincreasedlightingtoimproveperceptions ofsafety)canbeeffectiveinencouragingphysicalactivity.71

Anexampleofcreatinganactiveenvironment:walkingandcycling
Encouragingwalkingandcyclingisagoodwayofincreasingphysicalactivity,andsuccessful interventionstopromotewalkingorcyclingcouldaddressfactorseitherinthebuiltenvironment orsocialenvironment. Changingthebuiltenvironmentthroughimprovementsintheroadsandpavementsmaybeafeasible optionforcitiesthatareprioritisingthealleviationoftrafficcongestionandreductionofthecitys carbonfootprint.InLondon,forexample,cyclinghasbeenastatedpriorityforthemayor,and improvementstocyclinginfrastructurehaveresultedinanincreaseof123%incycletripsbetween 2001and2009(seeCaseStudy2). However,iftheresourcesorpoliticalwillisnotyetinlinetomakemajorenvironmentalchanges, anotherstrategyistoaddressthesocialfactorstopromotewalkingorcycling.Creatingcommunity walkingorbikinggroupsaresimplewaystoencouragepeopletowalkandbike. Anexampleofasuccessfulactiveenvironmentistheciclovas72whichtranslatesasbikepaths initiatives(originatinginBogot)totransformbusystreets,ononedayoftheweek,bybanningall formsofmotorisedtransport,leavingthemopenforwalkers,runnersandcyclists.73Inaddition,free yogaandotherexerciseclasses(knownastherecreova)areheldinlocalparks.74Thepublichealth benefitsaresignificant:costbenefitratiosareestimatedat3.234.26forBogot.75

3.Behaviourchange
IntheUnitedKingdom,atleast,thegreatmajorityofthepopulationalmost95%acceptandknow aboutthelinkbetweenphysicalactivityandhealth.However,themajorityofusdonotdonotachievethe recommendedamountsofactivity(seeFigure2),apatternseenacrossthedevelopedworldand, increasingly,amongurbandwellersinlowerincomecountries.76Fosteringlongtermbehaviourchange requiresovercominganumberofperceivedbarriersthatneedtobeovercomeinordertotakeregular exercise,includingalackofmotivationandashortageoftimeoverathirdclaimthatworkcommitments preventthemfromtakingphysicalactivity,andaquarterusefamilycommitmentsasanexcuse.77Finding waystoovercomethesebarriersisessential,throughaddressingindividualdeterminantsandthesocial environmentforexample,promotingactiveliving,ratherthanexercisinginagym,canhelppeopleto buildexerciseintotheworkingday,asfitnessgoalscanbeachievedthrough10minuteboutsofmoderate physicalactivity. Thesocialaspectsofphysicalactivity(see,forexample,CaseStudies5and6)canalsoactasapowerful incentive,andthereisevidencethatinterventionsthatprovidesocialsupportareeffectiveindriving behaviourchange,eitherthroughsocialnetworkingorthroughpeertopeerinteractions.78 Carefullytargetedinterventionsthataretailoredtospecificgroupsandindividualsforexample, 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,couldbeaneffectivewaytoincreasephysicalactivity81:atippingpointfor behaviourchange. Motivationalinterviewingisoneofthemostcommontherapeuticstrategiesusedtoinitiatebehaviour changeitgaugesapersonsreadinesstochangetheirbehaviour,andisusedtohelptoprimepeoplefor thechange.Itiscommonlyusedonpeoplewithaddictivebehaviours(suchastobaccouseandalcohol), andistypicallyusedintherapyenvironmentsalthoughphysicalactivitycouldalsomakeuseofsomeof thesamebasicprinciples.

Prescribingphysicalactivity
EncouragingGPstoprescribewalkingandotherphysicalactivity(alsoknownasexercisereferral)canalso 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,86butthemediumandlongtermeffectsofprescribingexerciseareoftennottracked,andthere havebeenrelativelyfewrandomisedcontrolledtrialsthathaveassessedtheimpactofprescribing exercise.87

4.Selectedinterventions
Table7inAppendix2providesaselectlistofinterventionsthathavebeenidentifiedbytheUSCentersfor DiseaseControlasbeingeffectiveinpromotingphysicalactivity.Thetableincludestheintervention components,outcomesandeffectsize(ifavailable),andkeyimplementationfactorsthatarelinkedtothe contextandareimportanttoconsiderinseekingtoreplicatethefindings.Thecomprehensivereviewon whichthetableisbasedidentified94studiesthatmetitseligibilitycriteriaforinclusion,andthreemain typesofinterventionsforincreasingphysicalactivity: informationbased; behaviouralandsocial;and environmentalandpolicyinterventions.

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Theresultsofthereviewrevealedstrongandconsistenceevidencefortheimpactofcommunitywide education,communitysocialsupport,individuallytailoredhealthbehaviourchangeprogrammes,and enhancedaccesstoplacesforphysicalactivity.Therewassufficientevidencetodemonstratethe effectivenessofpointofdecisionprompts.However,therewasonlylimitedevidencefortheefficacyof massmediacampaigns,andcollegebasedhealtheducation. Table8presentstheresultsofanothersystematicreview(unpublished).Thereviewwascompletedduring thepreparatoryphaseoftheCommunityInterventionsforHealth(CIH)project(www.cih.net),toidentify effectiveinterventionsthatpromotephysicalactivity.Thereviewfocusedonevidencebasedstrategies; thetableincludesthegoverningbodiesthatendorsedthestrategies. Aswellasrecommendationsoncommunitycoalitionbuildingandhealtheducation/media,mostofthe recommendationsoftheCIHreviewfocusonstructuralchanges,asthereisagrowingbodyofresearch thatindicatessuchinterventionsareeffective.88Oneofthemajorchallengesinimplementingstructural changeisthetimeandresourcesrequiredtomakedifferenttypesofchanges.Ofteninordertoadvocate forthechangesthatsupportphysicalactivity,consensusbuildingisrequiredamongabroadrangeof stakeholders,especiallythoserelatedtourbanplanning. LargescaleinterventionprojectssuchasAgitaSoPaulo(seeCaseStudy1,below)adoptthestrategyof promotingactiveliving.Itskeymessageisaboutmovingandbeingphysicallyactiveduringdailyactivities, andAgitahasdevelopeddifferentmaterialstodemonstratehoweverydayactivities(gardening, housework,walkingetc.)counttowardsthephysicalactivitytotal. Althoughnotasrigorouslystudiedastheactivitiesdescribedabove,therearesomegroupactivitieswhich haveshownsomesuccessinimprovinglevelsofphysicalactivity,includingcommunitygardeningand dancing.Thesetypesofactivitiesoftenaddressseveralaspectsofthesocialenvironmentandindividual determinants,asoutlinedinFigure4.Forexample,communitygardenshavebeenshowntoimprovesocial cohesioninacommunity89andculturallyappropriateformsofdancingcanserveasanimportantfacilitator forcertainculturalgroups,improvingbothphysicalandemotionalwellbeing(forexample,amongAfrican AmericanandLatinogroupsintheUnitedStatesseeCaseStudy4,below).90 Greenexercisephysicalactivitysuchaswalking/hikinginoutdoorsettingshasalsobeenshowntobea goodwaytoimprovementalandphysicalhealth.91AUKreportfrom2004,NaturalFit:CanGreenSpace andBiodiversityIncreaseLevelsofPhysicalActivity?,setsoutthebenefitsofexercisinginnatural surroundingsforexample,greengyms(inwhichconservationworkisusedtoincreasephysicalactivity) havefoundthatalthoughkeepingfitwasaprimaryreasonforjoining,themainreasonforcontinuing participationwasthechancetobeinthecountryside:beingintheopenairmakesthephysicalactivity moresustainable,andthephysicalactivitybecomeabyproductratherthantheprimarymotivation92(see CaseStudy6,below).Thegreengymapproachhasalsobeenpickedup,inEngland,bythegovernments Change4Lifeinitiative,partofwhichisMuckIn4Life.93Onereviewofseveralstudiesfoundthatthereis thegreatestmentalhealthbenefit(intermsofselfesteemandmood)inthefirstfewminutes,withlonger periodsintheenvironmentshowingdiminishingbutstillpositivereturns.Theeffectwasshowninevery greenenvironment,butisevengreaterinthepresenceofwater.94

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Increasingphysicalactivity
Leisuretimeactivitiesareactivitiesdoneinperiodsoftimeoutsideofworkandessentialdomestic activities.Thestrategyistoencouragesportparticipationordifferentsocialgroupswhichengagein physicalactivity(e.g.walkinggroups,cyclinggroups,dancingorcommunitygardening). Activetransportreferstowalkingorbikingasameansoftransportationandnotpurelyasaformof recreation.Encouragingwalkingorbikingtoworkorschool,orgoingaboutdailyactivitiessuchas 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 thatarecurrentlyunderwayandtosparkideasthatcanbefurtherexploredinlocalcommunities.This samplingofcasestudieswaschosentoreflectgeographicandculturaldiversityaswellasacombinationof thedifferenttypesofphysicalactivities/programmespossible(e.g.leisuretimeactivitiesandactive transport).Onesizedoesnotfitallanyinitiativemustbeadaptedtosuitthecircumstancesinwhichitis beingestablishedandthepopulationatwhichitisaimed. Whilehealthbenefitsoftheinitiativesinthecasestudieshavebeenincludedwhereknown(andthe majorityhaveevaluatedatleastsomeofthementalorphysicalhealthbenefits),pleasenotethatmanyare notsubjecttorigorousscientificstudy(seeAppendix3).However,evenifnotformallyassessedaspartofa researchstudy,thespecificactivitiesthemselvesmaybeevidencebased:forexample,buildingonthe evidenceofthebenefitsofpeersupportinpromotingphysicalactivity,thebenefitsofwalkingandofthe useofpedometers.Thereisampleevidenceregardingthevalueofphysicalactivityinmaintainingand/or improvinghealth. Lackofevaluationwhile,ofcourse,innowaydiminishingtheeffectsoftheinitiativeonthosetakingpart maymakethevalueoftheprojectlessobvioustoothers,andmakeitlesslikelytobereplicated elsewhere.Tobeabestpracticecasestudy,anynewinitiativesshouldconsiderevaluatingitsparticipation ratesandmental/physicalhealthimpacts.

2.Whatmakesforbestpractice?
Anadditionalreferencetoconsiderforthereviewofbestpractices/casestudiesmaybefoundinareport, publishedbytheWorldHealthOrganization,ReviewofBestPracticesinInterventionstoPromotePhysical ActivityinDevelopingCountries(2008),whichisalsohighlyrelevanttodevelopedcountries. TheWHOnotedthatthefollowingfeaturesofaninterventionshouldbeinplaceifitistobeseenasan exampleofbestpractice: reachalargeproportionofthepopulation,orofadefinedpopulationgroup; havemidtolongtermexperience/sustainability(atleast13years); aretargetedtothewholepopulationaswellasspecificpopulationgroups(e.g.adults,children,senior citizens,employees,disabledpeople,women); defineclearobjectives(e.g.raisingawarenessontheimportance/healthbenefitsofphysicalactivity, increasingpopulationlevelsofphysicalactivity); 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); distributedtheinterventioncomponentsusingvariouschannels(e.g.printmedia,electronicmedia, events,powerfulindividuals,advocates); includesomeclearevaluationoftheprogrammeoritselements.
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3.Casestudies
Casestudy1:BrazilAgita
AgitaSoPauloisanongoing,communitywideandverysuccessfulinterventiontopromotephysical activity.ItwasoriginallyimplementedinSoPaulo,Brazil,astatewith34millioninhabitants,andwas launchedin1996bytheCentreforLaboratoryStudiesonPhysicalFitnessofSoCaetanodoSul (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 focusismoreonactivelivingandphysicalactivityforhealththanon 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 impactonphysicalhealth.InSorocaba,themayorandlocal 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 sinceitsestablishmentin1977,andwhichcoordinatespartnershipswithlocaltransportauthoritiesand publichealthteams,NGOsandover3,000regularvolunteers. SustransNationalCycleNetworkconsistsofover20,000kmofdedicatedbikepathsandtrafficcalmed roads,andaimstoincreasetheproportionofjourneysunderfivemilesthatarecycledfromitscurrent levelofaround2%to20%.SustransBikeItinitiativeencouragesmoreschoolchildrentocycletoschool, andinBikeItschoolstripsbybikehavemorethantrebledtoaround10%. Inparticular,therebeensignificantincreasesincyclinginLondon:thenumberofpeopleenteringcentral Londonbybicycleduringtheweekdaymorningpeakgrewby123%between2001and2009andby15% in200809alone.Despitethisrise,bytheendof2009fatalitiesandseriousinjuriestocyclistshadfallen 24%fromtheratein199498andby3%in2009.102Thisincreaseisduetoavarietyoffactors,including theintroductionofaCongestionChargeformotorvehicles,improvementstocyclinginfrastructureandthe recentestablishmentbyTransportforLondonandBarclaysBankofafleetof5,000hirebicycles(3million journeysweremadeonthebikesinthefirsteightmonthsofoperation).

Healthbenefits
Since2000,Sustranshasbeenevaluatingthebenefits ofitsprojects103:407millionjourneysweremadeon theNationalCycleNetworkin2009(6%upon2008), withanestimatedhealthbenefitfromcyclingof288 million.Thiscostbenefitofimprovingcycling infrastructureisestimatedasbeingnearly4:1overjust 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 levelswillincreasefortheperiodoftheChallenge,butthatthelengthoftimeforwhichtheChallengeruns 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:initsfirstyear,over90,000childrentookpart.

Healthbenefits
Theaverageofficeworkerisestimatedtowalkonly3,000 stepsperday,sothe12,000stepsadayaveragedin2010 isafourfoldincreasesignificantincreaseindailyphysical activity.This,coupledwithadviceonbetternutrition,has alastingimpactonthehealthandwellbeingofGCC participants.IndependenthealthscreeningbyMonash UniversityfortheFoundationforChronicDisease Preventionhasverifiedsignificantreductionsin participantwaistmeasurementsaswellasbothsystolic 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 meetingattendeesparticipatedintheexercises.Thesamemodelhasnowbeenexpandedtoothersettings 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),andwaistcircumferenceforbothsexesdecreased 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 physicalandmentalhealthof1014yearolds.Initsfirstseason(SeptemberNovember2010),32teams 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.Theevaluationwascarried outbyaresearchteamthatworked withlocalschools.Mentalhealthwas measuredusingalocallydeveloped tool,andphysicalhealthusingabeep test,standingjumpandBMIforage. Preliminaryanalysisofbaselinedata suggestsnormalgrowthpatterns,but identifiedapopulationwidedeficitin physicalfitnessandpersistentmental healthchallenges.Finalresultsonthe impactoftheinterventionwillbe postedontheOAProjectswebsite.

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Casestudy6:UKGreenGymatHerewardGPPractice,Bourne
ThisisanexampleofphysicalactivitythatisprescribedbyGPs,anddeliveredthroughaGreenGyma schemeinwhichparticipantsaregiventheopportunitytotacklephysicaljobsintheoutdoors,improving strength,practicalskillsandconfidence,andbenefitingthelocalnaturalenvironment.BourneGreen Gym111waslaunchedinmid2009itnowhasover50members.ItistheonlyGreenGyminthecountryto befundedbytheNHSandrunfromaGPsurgery,andisalsosupportedbytheBritishTrustConservation Volunteers(BTCV).PatientsarereferredorencouragedtojoinbytheirGP,whogivesadviceonthecorrect levelofexercise.Itispromotedwithpostersinthesurgeryswaitingroom.Projectstakeplacein communitygardensandtherearealsosomeconservationeffortsinAbbeyLawns,TheWellheadand BourneWoods.

Healthbenefits
Thelatestresults(assessedaftersixmonths)aredrawnfromaselfperceptionquestionnaireissuedto members(80%ofwhomhadspecificheartproblems,suchasheartconditions,diabetesetc.).Therewere clearphysicalandmentalhealthbenefitsas,inadditiontothe pleasurefeltinlearningnewskillsandmakingnewfriends: 70%feltthattheirenergylevelshadimproved; 90%reportedimprovedemotionalwellbeing; 80%feltthattheirphysicalcapabilitieshadimproved;and 50%hadachievedweightloss(ofuptohalfastonearound 3kg).

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Appendix1:Selectedliteratureonthehealthbenefitsof physicalactivity
Tables14provideselectexamplesofkeyresearchstudiesand/orreportsthatsupporttheimpactof physicalactivityonthepreventionandcontrolof,inparticular,threemajorNCDs:cardiovasculardisease, type2diabetesandmanycancers.Table5providesinformationonthementalhealthbenefitsofphysical 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,CurOpinPsychiatry(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:Preventionoftype2diabetes
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.BuringandJ.M.Gaziano,Relationshipofphysical activityvsbodymassindexwithtype2diabetesinwomen,JAMA(2004)292:118894: http://www.ncbi.nlm.nih.gov/pubmed/15353531
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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
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

Decreasesintotaland Miller,T.D.,G.J.BaladyandG.F.Fletcher,Exerciseanditsroleintheprevention lowdensitylipoprotein andrehabilitationofcardiovasculardisease,AnnBehavMed(1997)19(3):2209: http://www.ncbi.nlm.nih.gov/pubmed/9603697 (LDL)cholesterol Increasesinhigh densitylipoprotein (HDL)cholesterol


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 PreventionofCancer:aGlobalPerspective(WashingtonDC: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 Janseen,I. andA.LeBlanc, Systematicreviewofthehealthbenefits ofphysicalactivityandfitnessinschoolagedchildrenandyouth,IntJ BehavNutrPhysAct(2010)7:40: http://www.ncbi.nlm.nih.gov/pubmed/20459784

Preventobesity

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Midlife

Improvehealthinoldage

Willis,B.L. etal.,Midlifefitnessandthedevelopmentofchronic conditionsinlaterlife,ArchInternMed(2012)172(17):18: http://archinte.jamanetwork.com/article.aspx?articleid=1352789 Allison, M.andC.Keller, Physicalactivityintheelderly:benefitsand interventionsstrategies,NursePract(1997)8:534: http://www.ncbi.nlm.nih.gov/pubmed/9279845 Howe,T.E.,L.Rochester,F.Neil,D.A.SkeltonandC.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

Elderly adults

Increaseinfunctionalability

Improvelongevity

Stessman, J.,R.HammermanRozenberg,A.Cohen,E.EinMor and J.M.Jacobs,Physicalactivity,functionandlongevityamongthevery old,ArchInterMed(2009)169:147683: http://www.ncbi.nlm.nih.gov/pubmed/19752405 Larson,E.B.etal.,Exercise isassociatedwithreducedriskforincident dementiaamongpersons65yearsofageandolder,AnnInternMed (2006)144(2):7381: http://annals.org/article.aspx?volume=144&issue=2&page=73

Cognitivefunction

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Appendix2:Physicalactivityinterventions
ThesystematicreviewpresentedinTable7isavailableonwww.thecommunityguide.org,andpartshavebeen publishedintheAmericanJournalofPreventiveMedicine2002,22(4S):73107aswellasbytheUSDepartmentof HumanServices,IncreasingPhysicalActivity:aReportontheRecommendationsoftheTaskForceonCommunity PreventiveServices(2001).ThereviewfocusedonstudiesthatwereavailableforreviewinEnglish,wereeitherRCTs ornonRCTswithconcurrentcontrolgroup,andincludedbaselineandpostinterventionmeasuresofoutcomes. Multipleelectronicdatabasescoveringresearchworldwidewereexaminedovera20yearperiod(19802000).

Table7:Physicalactivityinterventions
Intervention type Socialmarketing: Communitywide Campaigns Components Mediacampaigns(print, electronic,advertising, press/publicity) Communityparticipation throughselfhelpgroups Educationandcounselling atworksites,schools, communitygroups, communityevents Advocacyfor environmentalchange Outcomes/effectsize 4.2%median increaseinphysical activity(range2.9 9.4%) 16.3%median increaseinenergy expenditure(range 7.621.4%) Implementationfactors Studiesincludedallsocio economicgroups,urban andrural,minoritiesin theUSAandelsewhere (Sweden,Denmark, Scotland,Wales, Australia) Communityparticipation ledtosocialcapitalbuild upandgreatercohesion Carefulplanning, coordination,welltrained staff,sufficientresources required Increasesinphysical PrimarilyUSbased studies activitymedian 35.4%(range16.7 Volunteersampleslimit 83.3%) generalisability Increasesinenergy expenditure median64.3% (range3185.5%)

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 Focusonbuilding, strengtheningand maintainingsocial networksincluding creatingnewsocial networksorbuildingon existingnetworksoutside

Community participation socialsupport interventionsin community settings

Increasesintime spentinphysical activitymedian 44.4%(range19.9 45.6%) Increasein

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ofthefamilysuchasthe workplace.Examples include: Policyand environments: activetransport increasing physicalactivity asameansof transport Settingupbuddysystem Contractingwithanother persontomeetgoals Establishingwalking groups Reinforcedbyphonecalls anddiscussiongroups Telephonemarketing Informationandaccess maps Traveldiaries Workplacefacilitiesand incentivesforactive transport Greentransport promotioncampaignsand events(e.g.ridetowork)

frequencyof physicalactivity median19.6% (range14.657.6%) Decreasedadiposity median7.3% (range6.88.1%)

16%increasein walkingtrips 10%decreasein singlepersoncar trips 27%increasein publictransportuse

Primarilystudiedin Australiawiththree internationalstudies. Evidenceislimitedbutis promising.

Table8:Interventionframeworkforpromotionofphysicalactivity(CIHprogramme)
Intervention Communitycoalitionbuildingiv Advocateforpolicyandstructuralchange Collaboratewithrelevantstakeholders Supportlinksbetweensettingsandcommunityprogrammesthat supportphysicalactivitytoencourageindividualhealthbehaviour change Workwithinexistingnetworks Rapidmonitoringandfeedbacktothecommunity,tokeepthe communityinformedofdevelopmentsandmaintaintheirinterestin specificinterventions CIHEvaluationTeam CDC CDC/COMPASS COMPASS Recommendedby


ivFormoreinformationabouttheeffectivenessofCommunityCoalitions,pleaseseeA.Hilletal.,Fromprogramto policy:expandingtheroleofcommunitycoalitionsandK.Hannietal.,Amethodologyforevaluatingorganizational changeincommunitybasedchronicdiseaseinterventions,bothfromCDC:PreventingChronicDisease(2007)4(4).
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Structuralchanges Create,supportandimplementpoliciesandpracticestoencouragephysicalactivity Createandimplementtransportationpolicyandenvironmentaldesign: Limittheroleofautomobilesv Promotewalkingandbicycleridingvi Designstreets/communitiestopromotephysicalactivity CDC/COMPASS/DCP2/ DPAS/NICE CDC/DCP2/DPAS/NICE CDC/NICE CDC/DPAS/NICE(together withPODprompts) CDC/NICE CDC/DPAS

Providephysicaleducation(60minutesormoreatleastfivetimesper week)forschoolchildren Createorenhanceaccesstoplacesforphysicalactivitycombinedwith informationaloutreachactivities Createstairwellsthataresafeandappealing Usepointofdecisionprompts Usenationalphysicalactivityguidelinesandencouragedevelopment andupdateguidelinesifnecessary

Institutionalisingtheencouragementofhealthylifestylebehaviour Providesupportgroupsforincreasingphysicalactivity Provideincentivestoencouragephysicalactivityinvarioussettingsvii Institutionalisetheidentificationofunhealthyriskbehaviourandsupportbehaviourchange Developprotocoltoaddressphysicalinactivity. Healthyscreeningreviseintakeassessmentforms Treatment Care CIHEvaluationTeam CDC(fortobacco)/NICE

Provideannualhealthscreeningthataddressphysicalactivity

Healtheducation/media Trainhealthcareprofessionalstoprescribeexercise DCP2

Providecommunitysponsoredprogrammeaddressingphysicalactivity CDC Providehealthscreeningsthataddressphysicalactivityandsecondary


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. Definitionofabbreviations: DPAS:theWHOGlobalStrategyonDietandPhysicalActivity Usehealtheducationmaterialswithclear,simplifiedmessages (increasephysicalactivity) UsemediaandcommunitywidecampaignsaimedatincreasingPA(in conjunctionwithotherstructuralchanges)

COMPASS/DCP2/DPAS CDC/COMPASS/DPAS

CDC:theUSCentersforDiseaseControlandPreventionsTheCommunityGuide COMPASS:theProtocolfortheWHOStudyoftheEffectivenessofCommunityBasedProgrammesfor NCDPreventionandControl DCP2:theWorldBanksDiseaseControlPrioritiesforDevelopingCountries

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Appendix3:Levelsofevidence
Mindthe(evidence)gap!
Thereareverymanyareasoftheimpactofphysicalactivityonhealththatwouldbenefitfrommore research.Theseinclude:thelinkswithmentalhealth(suchasdementiaanddepression),whichisafast growingareaofinvestigation;theimpactonhealthofexercisereferralschemes;theimpactofnew initiatives(suchastheuseofmobilephonesincludingindevelopingcountries,wheremobilephone ownershipismuchmorewidespreadthaninternetaccess112).Fromapolicyperspective,moreevidenceon theeconomicsandcostbenefitofimprovingphysicalactivitywouldbeavaluablespurtoaction.113 Inparticular,andasisstronglyemphasisedintherecentLancetseriesonphysicalactivity,thereisaglaring mismatchbetweenwherethestudiesonphysicalactivityinterventionshavebeendoneandwherethe potentialliesforpopulationleveleffectsthatcantrulyaffectglobalhealth.114Studiesofinterventionsin middleandlowincomecountriesareessentialifwhatworksindifferentculturesistobeassessed,and appropriateactiontaken.

Existingevidence
Despitetheextensivebodyofresearchlinkingphysicalactivityandhealthbenefits,thereisrelativelylittle scientificevidenceonspecifictypesofactivities(seeBox,below).TherearefarfewerLevel1andLevel2 studies(whicharecostlyandtimeconsuming),comparedtoLevel3studies.However,thisdoesnotcast doubtontheveracityoftheoverwhelmingevidenceonthebenefitsofphysicalactivity,whichiswhymajor nationalandinternationalauthoritiesresponsibleforhealthandwellbeinghaveunanimouslyendorsed thebenefitsofphysicalactivityinreducingriskfactorsassociatedwithNCDs.

Levelsofscientificevidence
Level1 Level2 Randomisedcontroltrialswithoutimportantlimitations Randomisedcontroltrialswithimportantlimitations Observationalstudies(nonrandomisedclinicaltrialsorcohort studies)withoverwhelmingevidence Otherobservationalstudies(prospectivecohortstudies,casecontrol studies,caseseries) Inadequateornodatainpopulationofinterest Anecdotalevidenceorclinicalexperience

Level3

Level4

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,eventhoughdataonspecifichealthbenefitsmaynothavebeenrigorouslygathered.

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Endnotes

Acknowledgement:KatyCooperandChristineHancock(C3CollaboratingforHealth)wouldliketothankFionaWong andDeniseStevensatMATRIXPublicHealthSolutionsInc.fortheirassistanceinwritingandcompilingthefirstedition ofthisreport.C3alsothanksBupaforfundinganearlierversionofthisreview. Foracomprehensiveoverviewofthebenefitsofphysicalactivityonthebody,seeProfessionalAssociationsfor PhysicalActivity,PhysicalActivityinthePreventionandTreatmentofDisease(2010,2ndedition,SwedishNational InstituteofPublicHealth):http://www.fhi.se/en/Publications/Allpublicationsinenglish/PhysicalActivityinthe PreventionandTreatmentofDesease/,chapter1. Figure1isfromtheWorldHealthOrganizationslideset,GlobalHealthRisks:Selectedfiguresandtables: www.who.int/entity/healthinfo/global_burden_disease/global_health_risks_report_figures.ppt WorldHealthOrganization,GlobalRecommendationsonPhysicalActivityforHealth(WHO,2011): http://whqlibdoc.who.int/publications/2010/9789241599979_eng.pdf I.M.Leeetal.,Effectofphysicalactivityonmajornoncommunicablediseasesworldwide:ananalysisofburdenof diseaseandlifeexpectancy,TheLancet(2012)380:219:http://press.thelancet.com/physicalactivity.pdf,p.227. H.W.Kohletal.,Thepandemicofphysicalinactivity:globalactionforpublichealth,TheLancet(2012)380:294 305:http://www.thelancet.com/journals/lancet/article/PIIS01406736%2812%29608988/abstract J.Woodcocketal.,Nonvigorousphysicalactivityandallcausemortality:systematicreviewandmetaanalysisof cohortstudies,IntJEpidemiol(2011)40(1):12138:http://www.ncbi.nlm.nih.gov/pubmed/20630992 D.E.R.Warburtonetal.,AsystematicreviewoftheevidenceofCanadasPhysicalActivityGuidelinesforAdults,IntJ BehavNutrPhysAct(2010)7:39:http://www.biomedcentral.com/content/pdf/14795868739.pdf
8 9 7 6 5 4 3 2 1 *

Kohletal.,Thepandemicofphysicalinactivity.

WorldEconomicForum/HarvardSchoolofPublicHealth,TheGlobalEconomicBurdenofNonCommunicable Diseases(2011): http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf,p. 6. GlobalAdvocacyforPhysicalActivity,TorontoCharterforPhysicalActivity(2010): http://www.globalpa.org.uk/charter/ F.B.Huetal.,Walkingcomparedwithvigorousphysicalactivityandriskoftype2diabetesinwomen:aprospective study,JAMA(1999)282:14339:http://jama.amaassn.org/content/282/15/1433.abstract C3CollaboratingforHealth,Thebenefitsofregularwalkingforhealth,wellbeingandtheenvironment (September2012):http://www.c3health.org/c3activities/documents/


13 14 12 11 10

Warburtonetal.:Systematicreview.

R.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


15 16

ThisfollowstheWorldHealthOrganizationcategorisation.

WorldHealthOrganization,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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WorldHealthOrganization:GlobalHealthRisks:MortalityandBurdenofDiseaseattributabletoSelectedMajor Risks(Geneva,WorldHealthOrganization,2009): http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf
19 20 21 18

WHO,GlobalHealthRisks,ibid. InternationalDiabetesFederation,DiabetesAtlas(4thedition):http://www.diabetesatlas.org/map

I.M.Lee,Physicalactivityandcancerpreventiondatafromepidemiologicalstudies,MedSciSportsExerc(2003) 35:18237:http://www.ncbi.nlm.nih.gov/pubmed/14600545
22 23

Warburtonetal.,Systematicreview.

PhysicalActivityGuidelinesAdvisoryCommittee,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 V.Press,I.FreestoneandC.F.George,Physicalactivity:theevidenceofbenefitinthepreventionofcoronaryheart disease,QJM(2003)96:424551:http://qjmed.oxfordjournals.org/content/96/4/245.full.Thisstudystatesthatin menwithoutpreexistingCHDthoseparticipatinginmoderateormoderatelyvigorousactivitieshada50%reduction inrisk,comparedtothosewhowereinactive.


25 26 24

Leeetal.,Effectofphysicalinactivity,pp.2278.

See,inparticular,S.I.Mishraetal.,Exerciseinterventionsonhealthrelatedqualityoflifeforpeoplewithcancer duringactivetreatment(Review),CochraneLibrary(2012)8: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008465.pub2/abstract See,inparticular,S.I.Mishraetal.,Exerciseinterventionsonhealthrelatedqualityoflifeforcancersurvivors (Review),CochraneLibrary(2012)8:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007566.pub2/abstract D.Y.T.Fongetal.,Physicalactivityforcancersurvivors:metaanalysisofrandomisedcontrolledtrials,BMJ Research2012:344:370:http://www.bmj.com/content/344/bmj.e70andR.M.Specketal.,Anupdateofcontrolled physicalactivitytrialsincancersurvivors:asystematicreviewandmetaanalysis,JCancerSurviv(2010)4(2):87100: http://www.springerlink.com/content/p1500840qt11h157/ SeeMacmillanCancerSupport,Theimportanceofphysicalactivityforpeoplelivingwithcancerandbeyond:a conciseevidencereview(2012): http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Physicalactivityevidencereview.pdf,Table3,p.6. MacmillanCancerSupportpressrelease(16July2012): http://www.macmillan.org.uk/Aboutus/News/Latest_News/Fourinfivecancerpatientsstillnotbeingprescribedexercise.a spx
31 32 30 29 28 27

Formoreonmentalhealth,seetheWHOswebsite:http://www.who.int/mental_health/en/

A.TaylorandG.Faulkner,Inauguraleditorial,MentalHealthandPhysicalActivity(2008)1:18: http://www.sciencedirect.com/science/article/pii/S1755296607000026 B.Taylor,J.F.SallisandR.Needle,Therelationshipofphysicalactivityandexercisetomentalhealth,PubHealth Rpts(1985)100(2):195201:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424736/;M.Babyak,J.Blumenthaland S.Herman,Exercisetreatmentformajordepression:maintenanceoftherapeuticbenefitat10months,Psychosom Med(2000)62(5):6338:http://www.ncbi.nlm.nih.gov/pubmed/11020092;S.TokerandM.Biron,Jobburnoutand depression:Unravelingtheirtemporalrelationshipandconsideringtheroleofphysicalactivity,JournalofApplied Psychology(2012)97(3):699710:http://psycnet.apa.org/psycinfo/201200194001/


34 35 33

Tayloretal.,ibid.

A.L.Dunnetal.,Exercisetreatmentfordepression:efficacyanddoseresponse,AmJPrevMed(2005)28(1):18: http://www.ncbi.nlm.nih.gov/pubmed/15626549
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R.Motletal.,Naturallyoccurringchangesinphysicalactivityareinverselyrelatedtodepressivesymptomsduring earlyadolescence,PsychosomMed(2004)66(3):33642:http://www.ncbi.nlm.nih.gov/pubmed/15184692
37 38 36

Deslandesetal.,Exerciseandmentalhealth.

J.Weuveetal.,Physicalactivity,includingwalking,andcognitivefunctioninolderwomen,JAMA(2004)292(12): 145461:http://www.ncbi.nlm.nih.gov/pubmed/15383516
39 40 41

AlzheimersDiseaseInternational,WorldAlzheimersReport2009:http://www.alz.co.uk/research/worldreport/ Deslandesetal.,Exerciseandmentalhealth.

M.HamerandY.Chida,Physicalactivityandriskofneurodegenerativedisease:asystematicreviewofprospective evidence,PsycholMed(2009)39(1):311:http://www.ncbi.nlm.nih.gov/pubmed/18570697;J.Burnsetal., CardiorespiratoryfitnessandbrainatrophyinearlyAlzheimerdisease,Neurology(2008)71:21016: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657657/ K.I.Eriksonetal.,Physicalactivitypredictsgraymattervolumeinlateadulthood,Neurology(2010)75:141522: http://www.ncbi.nlm.nih.gov/pubmed/20944075 E.B.Larsonetal.,Exerciseisassociatedwithreducedriskforincidentdementiaamongpersons65yearsofageand older,AnnInternMed(2006)144(2):7381:http://annals.org/article.aspx?volume=144&issue=2&page=73


44 45 43 42

Deslandesetal.,Exerciseandmentalhealth.

MIND,Ecotherapy:TheGreenAgendaforMentalHealth(2007): http://www.mind.org.uk/campaigns_and_issues/report_and_resources/835_ecotherapy HealthSurveyforEngland2008:Volume1PhysicalActivityandFitness: http://www.ic.nhs.uk/webfiles/publications/HSE/HSE08/Volume_1_Physical_activity_and_fitness_revised.pdf,pp. 11718. PanAmericanHealthOrganization,PromotingphysicalactivityamongyouthinNicaragua:agenderandhuman rightsbasedapproach(2011): http://new.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=14905&Itemid= B.L.Willisetal.,Midlifefitnessandthedevelopmentofchronicconditionsinlaterlife,ArchInternMed(2012) 172(17):18:http://archinte.jamanetwork.com/article.aspx?articleid=1352789 A.D.Dangouretal.,Effectofanutritionsupplementandphysicalactivityprogramonpneumoniaandwalking capacityinChileanolderpeople:afactorialclusterrandomizedtrial,PLoSMedicine(2011)8(4): http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001023 M.Hameretal.,Physicalactivityandinflammatorymarkersover10years:followupinmenandwomenfromthe WhitehallIICohortStudy,Circulation(2012): http://circ.ahajournals.org/content/early/2012/06/28/CIRCULATIONAHA.112.103879.abstract J.E.Ahlskogetal.,Physicalexerciseasapreventiveordiseasemodifyingtreatmentofdementiaandbrainaging, MayoClinicProceedings(2011)86(9):87684:http://www.mayoclinicproceedings.org/article/S0025 6196%2811%29652191/fulltext;E.B.Larsonetal.,Exerciseisassociatedwithreducedriskforincidentdementia amongpersons65yearsofageandolder,AnnInternMed(2006)144(2):7381: http://annals.org/article.aspx?volume=144&issue=2&page=73 Table2.1,Selfreportedsummaryactivitylevels(participationinatleastmoderateintensityactivity),byageand sex,fromtheHealthSurveyforEngland2008:Volume1. A.E.Baumanetal.,Correlatesofphysicalactivity:whyaresomepeoplephysicallyactiveandothersnot?,The Lancet(2012)380:25871:http://www.thelancet.com/journals/lancet/article/PIIS01406736%2812%2960735 1/abstract,p.264. J.H.RimmerandA.C.Marques,Physicalactivityforpeoplewithdisabilities,TheLancet(2012),380:1935: http://www.thelancet.com/journals/lancet/article/PIIS01406736%2812%29610289/fulltext
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W.L.Haskelletal.,Physicalactivityandpublichealth:updatedrecommendationforadultsfromAmericanCollege ofSportsMedicineandtheAmericanHeartAssociation,MedSciSportsExercise(2007)39(8):142334: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185649v1.SeealsoWHO,Global RecommendationsonPhysicalActivityforHealth. Forolderadults,see http://www.acsm.org/AM/Template.cfm?Section=Home_Page&TEMPLATE=CM/HTMLDisplay.cfm&CONTENTID=7764 andforchildrenseehttp://www.cdc.gov/physicalactivity/everyone/guidelines/children.html C.P.Wen,Minimumamountofphysicalactivityforreducedmortalityandextendedlifeexpectancy:aprospective cohortstudy,TheLancet(2011)378:124453:http://www.thelancet.com/journals/lancet/article/PIIS0140 6736%2811%29607496/abstract H.P.vanderPloegetal.,Sittingtimeandallcausemortalityriskin222,497Australianadults,ArchInternMed. (2012)172(6):494500:http://archinte.jamanetwork.com/article.aspx?articleid=1108810
59 60 61 58 57 56 55

C3CollaboratingforHealth,Thebenefitsofregularwalkingforhealth. Kohletal.,Thepandemicofphysicalinactivity.

DepartmentofHealthandHumanServices,HealthUnitedStates2010: http://www.cdc.gov/nchs/data/hus/hus10.pdf#070,Table70,p.258. TheInformationCentre,StatisticsonObesity,PhysicalActivityandDiet:England,2011(2011): http://www.ic.nhs.uk/webfiles/publications/003_Health_Lifestyles/opad11/Statistics_on_Obesity_Physical_Activity_a nd_Diet_England_2011_revised_Aug11.pdf,p.28. Table2.3,Selfreportedsummaryactivitylevels(agestandardised),byequivalisedhouseholdincomeandsex,from HealthSurveyforEngland2008:Volume1. L.M.Powell,S.SlaterandF.J.Chaloupka,Therelationshipbetweencommunityphysicalactivitysettingsandrace, ethnicityandsocioeconomicstatus,EvidenceBasedPreventiveMedicine(2004)1(2):13544: http://www.rwjf.org/pr/product.jsp?id=14654 L.M.Powelletal.,Availabilityofphysicalactivityrelatedfacilitiesandneighbourhooddemographicand socioeconomiccharacteristics:anationalstudy,AmericanPublicHealthAssoc(2006)96(9):167680: http://www.ncbi.nlm.nih.gov/pubmed/16873753 S.CapewellandH.Graham,Willcardiovasculardiseasepreventionwidenhealthinequalities?,PLoSMed(2010) 7(8):http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000320 P.EdwardsandA.Tsouros,PromotingPhysicalActivityandActiveLivinginUrbanEnvironments:TheRoleofLocal Governments(Copenhagen,WHORegionalOfficeforEurope,2006): http://www.euro.who.int/__data/assets/pdf_file/0009/98424/E89498.pdf E.ShaandG.D.Smith,Exportingfailures?Coronaryheartdisesaseandstrokeindevelopingcountries,International JournalofEpidemiology(2001)30:2015:http://www.ncbi.nlm.nih.gov/pubmed/11369713 M.B.Katan,Weightlossdietsforthepreventionandtreatmentofobesity,NEnglJMed(2009)360(9):9235: http://dcscience.net/kataneditorialonsacks2009nejm.pdf
70 71 69 68 67 66 65 64 63 62

Kohletal.,Thepandemicofphysicalactivity,pp.299300.

G.W.Heath,etal.,Evidencebasedinterventioninphysicalactivity:lessonsfromaroundtheworld,TheLancet (2012)380:27281:http://www.thelancet.com/journals/lancet/article/PIIS01406736%2812%29608162/abstract,p. 276.


72 73

SeealsoC3,Thebenefitsofregularwalkingforhealth,CaseStudy8,p.28. http://www.cicloviasrecreativas.org/en/

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O.Sarmientoetal.,TheCiclovaRecreativa:amassrecreationalprogramwithpublichealthpotential,Journalof PhysicalActivityandHealth(2010)7(Suppl2):S16380: http://cicloviarecreativa.uniandes.edu.co/english/advocacy/anexos/The_CicloviaRecreativa_A_Mass Recreational_Program.pdf
75 76 77 74

Ibid. WHO,GlobalStatusReportonNCDs2010,chapter2,NCDsanddevelopment.

StatisticsfromDeloitte,HealthoftheNation:AnIndepthReportintoUKConsumerAttitudestoPhysicalExercise (2006):http://www.deloitte.com/assets/Dcom UnitedKingdom/Local%20Assets/Documents/UK_HealthofNationReport_ExecSummary_March06.pdf A.R.Webeletal.,Systematicreviewoftheeffectivenessofpeerbasedinterventionsonhealthrelatedbehaviorin adults,AmJPubHealth(2010)100(2):24753:http://www.ncbi.nlm.nih.gov/pubmed/20019321 Forexample,D.N.Lombardetal.,Walkingtomeethealthguidelines:theeffectofpromptingfrequencyand promptstructure,HealthPsychol.(1995)14(2):16470:http://www.ncbi.nlm.nih.gov/pubmed/7789352


80 81 79 78

Change4Life:http://www.nhs.uk/change4life. Bauman,Correlatesofphysicalactivity,p.266.

D.M.Williamsetal.,Interventionstoincreasewalkingbehavior,MedSciSportExercise(2008)40(S7):S56773: http://www.ncbi.nlm.nih.gov/pubmed/18562974 SeeProfessionalAssociationsforPhysicalActivity,PhysicalActivityinthePreventionandTreatmentofDisease,pp. 51ff. R.Weileretal.,PhysicalactivityeducationintheundergraduatecurriculaofallUKmedicalschools.Aretomorrow's doctorsequippedtofollowclinicalguidelines?,BrJSportsMed(2012): http://bjsm.bmj.com/content/early/2012/07/20/bjsports2012091380.abstract?sid=6c1bc8e7caeb4c93a4f4 d79bd394d460


85 86 84 83

82

www.moveeattreat.org.

P.TruemanandN.K.Anokye,Applyingeconomicevaluationtopublichealthinterventions:thecaseof interventionstopromotephysicalactivity,JournalofPublicHealth(2012), http://jpubhealth.oxfordjournals.org/content/early/2012/07/01/pubmed.fds050.full T.Paveyetal.,Effectofexercisereferralschemesinprimarycareonphysicalactivityandimprovinghealth outcomes:systematicreviewandmetaanalysis,BMJ(2011)343:http://www.bmj.com/content/343/bmj.d6462 J.F.Sallis,Measuringphysicalactivityenvironments:abriefhistory,AmericanJournalofPreventativeMedicine (2009)36(S4):S8692:http://www.ncbi.nlm.nih.gov/pubmed/19285214;AFrameworktoMonitorandEvaluate Implementation:WHOGlobalStrategyonDiet,PhysicalActivityandHealth.Guideline(Geneva:WHOPress,2008): http://www.who.int/dietphysicalactivity/Indicators%20English.pdf;S.L.Merceretal.,Possiblelessonsfromtobacco experienceforobesitycontrol,AmericanJournalofClinicalNutrition(2003)(77Supplemental):1073S82S: http://www.ncbi.nlm.nih.gov/pubmed/12663321;S.A.French,M.StoryandR.W.Jeffery,Environmentalinfluenceon eatingandphysicalactivity,AnnualReviewsPublicHealth(2001)22:30935: http://www.ncbi.nlm.nih.gov/pubmed/11274524;P.Jamesetal.,Theobesityepidemic,metabolicsyndromeand futurepreventionstrategies,EuropeanJournalofCardiovascularPrevention&Rehabilitation(2004)11(1):38: http://www.ncbi.nlm.nih.gov/pubmed/15167200 J.Twissetal.,Communitygardens:lessonslearnedfromCaliforniaHealthyCitiesandCommunities,AJPH(2003) 93(9):14358:http://www.ncbi.nlm.nih.gov/pubmed/12948958 A.K.Yancey,M.G.OryandS.M.Davis,Disseminationofphysicalactivitypromotioninterventionsinunderserved populations,AmJPrevMed(2006)31(4S):http://www.ncbi.nlm.nih.gov/pubmed/16979472
90 89 88 87

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J.Prettyetal.,Acountrysideforhealthandwellbeing:thephysicalandmentalhealthbenefitsofgreenexercise (CountrysideRecreationNetwork,Sheffield,2005): http://www.countrysiderecreation.org.uk/pdf/CRN%20exec%20summary.pdf W.Bird,NaturalFit:CanGreenSpaceandBiodiversityIncreaseLevelsofPhysicalActivity?(2004): http://www.rspb.org.uk/Images/natural_fit_full_version_tcm9133055.pdf;seep.15(above)forGreenGyms.
93 94 92 91

http://muckin4life.direct.gov.uk/index.html.

J.PrettyandJ.Barton,Whatisthebestdoseofnatureandgreenexerciseforimprovingmentalhealth?Amulti studyanalysis,EnvironmentalScienceandTechnology(2010)44(10):394755: http://www.ncbi.nlm.nih.gov/pubmed/20337470


95 96

Williamsetal.,Interventionstoincreasewalkingbehavior. Ibid.

D.M.Brevataetal.,UsingpedometerstoIncreasephysicalactivityandimprovehealth:asystematicreview,JAMA (2007)298(19):2296304:http://www.ncbi.nlm.nih.gov/pubmed/18029834
98 99

97

Williamsetal.,Interventionstoincreasewalkingbehavior.

Forthebenefitsofsocialinteractionduringphysicalactivity,seemanyexamplesinPrettyetal.,Acountrysidefor healthandwellbeing. ForapresentationbyProfessorVictorMatsudo(AgitaMundoandChairmanofthePhysicalActivityNetworkfor theAmericas)detailingallthesebenefits,seehttp://www.3four50.com/v2/?page=summit10vid4 HealthyLives,HealthyPeopleWhitePaper:OurStrategyforPublicHealthinEngland(DepartmentofHealth,2010): http://www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm,para3.32. TransportforLondonstatisticsseealsoTravelinLondon:Report3(2011): http://www.tfl.gov.uk/assets/downloads/corporate/travelinlondonreport3.pdf,chapteronSpotlightontheyear ofcycling. StatisticsdrawnfromSustrans,MovingForward:AYearofDeliveringSmarterTravelChoice(2010): http://www.sustrans.org.uk/assets/files/rmu/Moving%20forward%20Sustrans%20Monitoring%20Report%20to%20en d%202009%20September%202010.pdf. TheWorldHealthOrganization,withSustransandothers,hasdevelopedaHealthEconomicsAssessmentTool, HEAT,toestimatetheeconomicsavingsfromreducedmortality:http://www.euro.who.int/en/whatwedo/health topics/environmentalhealth/Transportandhealth/activities/promotionofsafewalkingandcyclinginurban areas/quantifyingthepositivehealtheffectsofcyclingandwalking/healtheconomicassessmenttoolheatfor cycling.SeealsoN.CavillandA.Davis(forCyclingEngland),CyclingandHealth:WhatstheEvidence?(2007) http://www.dft.gov.uk/cyclingengland/healthfitness/healthbenefitsofcycling/.
105 106 104 103 102 101 100

http://www.gccjunior.org

Evaluationofafourmonthlowimpactphysicalactivityworkplaceintervention2008: http://chronicdiseaseprevention.org/research/monash.html. A.K.Yanceyetal.,TheLosAngelesLiftOff:asocioculturalenvironmentalchangeinterventiontointegratephysical activityintotheworkplace,Prev.Med.(2004)38(6):84856:http://www.ncbi.nlm.nih.gov/pubmed/15193908 A.Laraetal.,PausaparatuSalud:reductionofweightandwaistlinesbyintegratingexercisebreaksintoworkplace organisationalroutine,PreventingChronicDisease(2008)5(1):http://www.ncbi.nlm.nih.gov/pubmed/18082001 C.Blattman,SWAYResearchBrief1:Theabductionandreturnexperiencesofyouth,inTheSurveyofWar AffectedYouth(SWAY)(2006):http://chrisblattman.com/documents/policy/sway/SWAY.RB1.pdf.


110 109 108 107

http://oaprojects.org/

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Seehttp://www2.btcv.org.uk/GreenPrescriptions.pdf.ThereisalsoashortvideoabouttheBourneprojectat: http://www.youtube.com/watch?v=9F9fcn7Tmpw&feature=related. See,forexample,M.Prattetal.,Theimplicationsofmegatrendsininformationandcommunicationtechnology andtransportationforchangesinglobalphysicalactivity,TheLancet(2010)380:28293: http://www.thelancet.com/journals/lancet/article/PIIS01406736%2812%29607363/abstract,pp.283,285.
113 114 112 111

Kohletal.,Thepandemicofphysicalinactivity,p.294. Prattetal.,Theimplicationsofmegatrends,p.288.

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