Providing a definition of inactivity is not straightforward as the health benefits of exercise vary according to the amount of exercise taken, and have been considered to be dose responsive (Irwin, 2003). There is, however, clear guidance as to a recommended level of activity from Heath Development Agency (2000) who suggest 30 minutes of moderate exercise five times a week for adults. The Centre for Disease Control and Prevention (2003) agree with this but also suggests that inactivity is "not engaging in any regular pattern of physical activity beyond daily functioning" (Centre for Disease Control and Prevention, 2003, p1). Clearly there is agreement about how much activity is desirable, but little notion as to when a person might be considered inactive, for example, it would seem nonsensical that if a person only manages 149 minutes of moderate exercise in a week they are sedentary. Suggesting that an inactive person is one who does no more activity than through their general daily functioning takes no account of people who have built moderate activity into their routine, for example if daily life requires a cycle ride to work, the person is clearly not sedentary. It would, therefore, seem appropriate to look at levels of activity on a fairly individual level, rather than as time spent in a gym.
The evidence to suggest that moderate exercise gives health benefits is compelling. Rutter (2003), on behalf of the Public Health Observatory, suggests the risk of coronary heart disease (CHD), stroke, hypertension, cancers, diabetes, depression and cognitive functioning all benefit from moderate exercise, and the Health Development Agency (2002) add a reduction in obesity and osteoporosis to the list. Rutter (2003) goes on to suggest that preventable deaths from CHD alone that can be attributed to a sedentary lifestyle are around 85,000 per year in the UK . Although there are no estimates as to the preventable deaths by other causes due to sedentary lifestyles, as the increased risk of stroke is threefold, compared to twofold for CHD, and stroke being the UK's third biggest killer, it is likely to be of a significant size. Estimates from the US are of a smaller magnitude with Jones et al (1997) suggesting 250,000 deaths per annum. The 1998 Health Survey for England (Department of Heath, 1998) found that only 37% of men and 25% of women were exercising to the recommended levels and that this level dropped with age and in Black and minority groups.
There has been a multitude of studies looking at the relative risks and benefits of exercise. Irwin (2003) examined the effects of 90 minutes exercise per week on women aged 50 - 70 years and found significant weight loss and reductions in body fat. Hu et al (2003) looked at inactivity by US women over a six year period, and found that for each 2 hours per day of watching television increased the risk of obesity by 23% and diabetes type II by 14%. Hu et al (2003) also found that an hour per day of brisk walking reduced the risk of obesity by 24% and diabetes by 30%. Ebbeling (2002) suggested that television watching and obesity is associated by both the inactivity and through increases food consumption during this period. The Ahmed et al (2003) reported that rises in childhood obesity has meant a fall in life expectancy for the first time in 140 years and although extent of causes of this increase in obesity are not clear, they obviously involve exercise levels as well as food consumption.
The Department of Health (1999) aimed to save 300,000 lives through health improvements, and the evidence suggests that exercise levels have a huge impact in mortality as well as morbidity (Rutter, 2003), however the Department of Health seems keen to raise the profile of other public health issues above that of exercise in its performance indicators for public health (Commission for Health Improvement, 2003). In light of the lack of emphasis put on inactivity, it must therefore be considered what impacts can be made on the levels of exercise by public health practitioners.
Beattie (1991) proposed two continuums to health promotion, working with from an individual level to a community level, and from the initiative for change coming from people, "negotiated" or from the state, "authoritative". This model leads to four areas that public health practitioners can be involved in, traditional health education persuasion techniques, personal counselling with clients to health them develop their own health choices, through to working with communities to help them make changes to their health and finally to legislative action centrally. These four areas seem to encompass the variety of roles the public health practitioners can be involved in.
Lawlor et al (1999) studied primary care professional's attitudes to health promotion, and reported that only 33% of general practitioners (GPs) felt there was strong evidence linking sedentary lifestyles with early death. They also found that 30% of GPs did not feel knowledgeable enough to give advice and only 8% gave opportunistic advice to patients. Steptoe (1999) compared GPs with practice nurses and found that only 20% of GPs felt that personal counselling for lifestyle advice was effective compared with 54% of practice nurses, and that 70% of GPs did not think that targeting health promotion to patients with low exercise levels was important. Schemes to enable primary care practitioners to enable patients to access exercise, typically through local leisure centres have been in existence for some time (Health Development Agency, 1998a), but whilst practice nurses see health promotion as part of their role, and feel that it is effective, GPs do not. There is little evidence on the effectiveness of a one to one health promotion approach to exercise, with most schemes, especially those involving gyms, show little sustainable lifestyle change with participation falling after the initial enthusiasm; the exception to this are those schemes that promote walking, particularly brisk walking (Health Development Agency, 2001). There is seems to be little research on how effective public health practitioners can be in persuading GPs to understand the importance of exercise, or even to what extent this is happening, but clearly there is a need for this. With front line health professionals not accepting the importance of exercise or the effectiveness of health promotion, there is little chance of this knowledge being imparted to patients. There appears to be very little evidence as to the cost effectiveness of this approach, although given the problems with sustainability, the cost of leisure centre admission and the time involved counselling by health professionals, the relative costs are likely to be high. There is a further issue with the elderly, as traditional forms of exercise promotion does not suit them (Drewnowski, 2001).
Beattie's (1991) continuums suggest that health improvements can be effected at a community level, which can be from either a "top down", authoritative approach or led by the community to make changes. There seem to be two aspects to improving the physical activity levels within communities, promoting exercise as an addition to day-to-day living, such as visiting gyms and encouraging sports, but also ensuring that aspects of daily life are changed to incorporate exercise. Transport is the most obvious area of this second aspect, increasing car usage is associated with reduced physical activity levels (Turbin et al, 2002) and clearly one option to improve exercise levels would be to reverse this trend.
Fergusson (1999) felt that a range of measures is needed to change behaviour in relation to travel. The Health Development Agency (2001) agrees with this and suggests that local authorities need to be deeply involved with this. There is a need to ensure that people have the ability to make journeys by foot or cycle, and this means that when local authorities plan for services they need to take this into account. Out of town shopping centres and hospitals may allow little opportunity for travel other that by car or bus, which increases inactivity, aside from the knock-on effects of social exclusion, pollution and the decline in community (Rutter, 2003). Van Diepan (2000) found that car usage was associated with lower population densities, i.e urban sprawling, and walking increases as the density of the population rises. It seems obvious that in order to encourage shorter travel distances, local authorities need to understand health, through working with public health professionals, in order to consider impacts to health when making planning decisions. Ensuring that partnerships between health and local authorities are fundamental, allowing health impact assessments to inform planning decisions and for health needs assessments to assist in the local authority's strategic plans.
Whilst it seems essential that local planning is required to ensure that it becomes possible to access services without reliance on cars, this in itself would need to be augmented by other measures to encourage healthy travel. There have been concerns about how safe it is for children to walk to school or for cycling in general. This perception clearly needs addressing and can be managed with the introduction of cycle lanes and traffic calming measures (Mackie and Wells, 2003). Again, these are areas that are under the control of local authorities, but if the highways departments are not working in partnership with planning and health then getting schemes to aid the promotion of healthy travel to work and schools will prove difficult. It is also necessary to involve employers in these schemes. Ensuring that the workplace has opportunities for showering and changing, may well be a crucial factor in an individual's decision to cycle to work (Health Development Agency, 1998b), clearly no one would want to remain in sweaty clothes!
The promotion of cycling and walking to work and school has been shown to be an effective way of increasing exercise levels ( Department for Transport, 2000). Clearly there needs to be a drive by health promoters and primary care professionals, including those in occupational health, to encourage people to adopt alternative, sustainable, forms of exercise. The public health professionals who span health and social services have very clear roles in ensuring that the elements of this form of exercise are in place.
It may be that a community lead impetus to make the changes required for healthy alternatives to travel would be unlikely, given the public's passion for the car (Hathaway, 2000). Those being socially excluded, through lack of access and transport, may not have the political power to motivate communities into action to provide for some of the wide ranging changes required. It seems important to ensure that the clear and pragmatic alternatives to travel are lead by the authoritative corner of Beattie's (1991) model, allowing for individuals and communities to adopt these changes. Seedhouse (1997) in his discussions on health promotion, suggests that health promotion is concerned with societal values and driven by politics to encourage social order and cohesion rather that trying to ensure that individuals are somehow saved from unhealthy habits. Perhaps in the case of sustainable exercise through travel, it needs to be acknowledged that a top down lead is required.
To conclude, it has been shown that there is a good consensus as to the optimal level of activity, and to the vast benefits to both mortality and morbidity that it confers, but there is no agreement as to at which point inactivity is defined. With estimates in excess of 85000 early death due to inactivity and the majority of the population not taking the recommended level of exercise, there is the potential to clear health improvements to be made. There is a great deal of work to be done in raising the level of knowledge in health professionals, as their own understanding of this area is poor. Schemes to encourage exercise, based on education and encouragement to use local leisure centres, have not been shown to be cost effective and do not give a sustainable approach to lifestyle change. Encouraging brisk walking and cycling are the areas that have been shown to provide long term lifestyle change and it has been shown that one way of doing this is through promoting alternative modes of transport to work and school. This requires a partnership approach involving, planning, highways, health professionals and employers, to ensure that the barriers to this are removed and that this form of exercise is encouraged. Whilst there are opportunities for health promotion within each of Beattie's (1991) areas, perhaps encouraging exercise needs to be led politically to ensure that the partnership working removes the barriers appropriately.
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