House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

APPENDIX 8

Memorandum by Working for Cycling (OB 16)

INTRODUCTION

1. CTC the national cyclists' organisation, welcomes the opportunity to contribute to this inquiry. CTC has over 70,000 members and supporters, including both recreational and "utility" cycle users, who join for a wide range of benefits: information on all aspects of cycling, insurance, legal advice & support, organised rides tours and other local and national events, and to support our campaigns to promote better conditions for cycling, and to encourage more people to cycle more often.

2. Our submission details our knowledge and experience of the issue of obesity, discusses the role which cycling could play as part of the answer to the problem, and recommends actions to Government to maximise its potential benefits in this respect. We focus particularly on the role of cycle training as a uniquely powerful tool both for giving children the life skills of being able to cycle competently and safely (thereby reducing the risks of developing obesity), and as a means of gaining or regaining health and fitness for those in later life.

3. Throughout this submission the word "cycling" is used to mean use of a pedal cycle including bicycles, tricycles and tandems. It does not refer to the phenomenon of cyclical weight loss and gain.

4. We would be happy to give oral evidence to the Committee to expand further on the ideas contained in this submission. We are aware that a submission covering complementary issues is being prepared by the English Regional Cycling Development Team, with whom we work closely.

THE HEALTH IMPLICATIONS OF OBESITY

5. Obesity is considered to be a medical condition that causes significant morbidity and decreased life expectancy (1). At the upper extremes of body mass index, health risk increases significantly. Obesity is defined as having a body mass index (BMI) over 30 kg/m2(2), although significant risk of health begins at a BMI of about 27.3 kg/m2(3).

6. Body mass index, as an expression of fatness, is positively related to excess mortality. More specifically, obesity is associated with non-insulin-dependent diabetes mellitus, hypertension, hyperlipidaemia, osteoarthritis, psoriasis, respiratory insufficiency (including sleep apnea), gallstones, and biliary tract disease (4).

7. Although obesity is frequently associated with atherogenic factors such as diabetes, hypertension, and hyperlipedaemia, a direct relationship between obesity and cardiovascular disease is debated by some authorities (5). However obesity is known to contribute to other risk factors for coronary heart disease such as hypertension and inactivity and is therefore implicated as a risk.

8. For obese people, spending on hospital and outpatient care is 36% higher and medication costs are 77% higher than for people in the normal weight range, according to a study carried out in USA. People with high BMIs (>35) can experience lost years of life of nine to 13 years. White men in their 20s with a BMI of >45 had 13 years of life lost (YLL) compared to those with a BMI of 24. A white woman of the same age and BMI category lost eight years due to obesity. Among black people in USA there was not a consistent reduction in life expectancy until BMIs of 37 for women and 32 for men were reached (6).

9. A National Audit Office (NAO) report (7) estimates that obesity in England costs £ ½ billion a year in NHS treatment costs, and that the costs to the wider economy may exceed £2 billion.

TRENDS IN OBESITY

10. The previously-mentioned NAO report records over half of the adult population in England was overweight in 1998, and around one in five was obese (21% of men and 17%), following a doubling in the number of obese adults in the preceding 18 years (this was a much higher rate of increase than for other European countries, where growth rates were between 10% and 40%) (8). There are also signs of a growing epidemic of obesity among children—by 1997, 20% of four year olds in England were overweight and 8% obese (9).

What are the causes of the rise in obesity in recent decades?

11. Reduced physical activity has been identified as the dominant factor causing the trend of increasing obesity in Britain (10). A table in the recently published National Cycling Strategy advice note graphically illustrates the apparent relationship between cycling levels in different European countries and the levels of childhood obesity (11).

12. Recent decreases in physical activity among children are cause for concern. A report from Sport England claims that the emphasis on "back-to-basics" in primary schools means that children are not getting enough time for PE and games (12). In 1994, 32% of six to eight year olds were getting the recommended two hours of exercise a week. Last year, that figure was down to just 11%. For nine to 11 year olds, the report shows a fall from 46% to 21% in the same period.

13. The Scottish Health Survey of 1998 (13) revealed that young Scots, particularly girls, are taking less exercise than did previous generations. The amount of exercise taken by boys stays roughly steady through the childhood years, at 15 hours a week; girls only manage seven hours by the time they reach 14 or 15. Professor Marmot, an author of the survey report, said that the drop in exercise should be looked at in broad terms. "Taking the issue of obesity and exercise, it is not enough to say to people: `you must take more exercise'. There is also the whole question about where that fits into people's lives. Are there sports facilities available, is it safe for people to ride bikes?"

14. In 1997, only 55% of boys and 39% of girls in England were doing the 60 minutes of at least moderate activity (eg feeling warm and slightly out of breath) as recommended by the Department of Health (14). Activity levels have been declining, partly due to a fall in the levels of walking and cycling, particularly for the journey to and from school. Data on school travel show that the proportion of five to 10 year olds being driven to school has increased from 22% in 1985-86 to 39 % in 1999-2001, with corresponding decreases in the proportions walking and cycling. The number of 11-16 year olds cycling to school has declined from 6% to 2% in the same period (15).

WHAT CAN BE DONE ABOUT IT?

The role of physical activity in tackling obesity

15. There is evidence that physical activity, with the aim of increasing calorie expenditure, is an important part of the solution to the current rise in obesity. In two studies in 1976 (16) (17) researchers compared changes in body composition between three groups of study participants; the first group reduced their dietary intake, the second increased their calorie expenditure, and the third did a bit of both. The three groups achieved comparable reductions in body weight, but the first group (diet only) did so by loosing muscle mass, whereas the other two did so by loosing body fat whilst gaining in muscle mass.

16. A multifaceted weight reduction program, including diet, exercise and behaviour modification, has been shown to be more effective than other weight reduction programs (18). The balance between intensity and duration should be struck to give a high total caloric expenditure. Approximately, 300 to 500 Calories each period of exercise and 1,000 to 2,000 Calories per week for adults is recommended. Since many obese individuals are at an increased risk for injury to joints and soft tissues, non-weight-bearing activities may be recommended. An intensity of 60% or less of maximal heart rate may be maintained to improve cardiorespiratory endurance (19).

17. It has been found that obese people could loose a considerable amount of weight by walking or cycling for a mile or two each day for a year (20). Moreover, obese people who exercise regularly have been found to reduce their risks of suffering heart attacks or other related illnesses even if they remain overweight. The risk of heart attacks for obese people who exercise regularly are no higher than the norm for those who take exercise, whereas for sedentary obese people the risk is five times higher than the equivalent norm (21).

The role of cycling in tackling obesity

18. Cycling is close to being an ideal form of exercise for the following reasons:

— It is aerobic—it uses major muscle groups (in the legs) and causes the heart rate and respiration to increase in order to supply the muscles.

— It is low weight bearing—because the cycle takes the weight of the body off the legs, much less pressure is exerted on the joints than in running for example. Cycling is therefore a good form of exercise for people with joint problems.

— It is a low skill activity (by contrast with ballet for example)—although navigating today's roads may sometimes seem very skilled, it is essentially a skill that can be once acquired and never forgotten.

— Those who eschew sports orientated recreational activity, such as women, may find, commuter cycling acceptable (22). Cycling can take people out into green space and the countryside which has in itself been shown to have health benefits (23).

19. A UK study found that people who took up cycling as a new activity gained the greatest benefits at the outset of the trial, but fitness continued to improve as they increased their cycle use. Reduced body fat was also noted, particularly among those who were overweight or obese at the outset of the trial (24).

Cycling is healthy, not dangerous

20. Proposals to encourage increased cycle use on health grounds sometimes prompt the concern that this could increase the number of cyclist casualties. We do not accept that this is a valid concern, for a number of reasons:

— The risks of cycling are easily overestimated. It takes around 21,000 years of average cycling to suffer a fatal injury (25).

— The number of cyclists killed in road traffic crashes in 2000 was 125. Deaths from heart disease attributable to physical inactivity that year were 46,250 (26). One could reasonably argue that the risks of cycling are dwarfed by the risks of not doing so.

"Even in the current hostile traffic environment, the benefits gained from regular cycling are likely to outweigh the loss of life through cycling accidents for the current population of regular cyclists."

— There is some evidence to suggest that the risk per kilometre cycled goes down as cycle use goes up at the population level. It has been estimated that a doubling of cycle use would result in only a 25-30% increase in cycle fatalities, representing a 35-40% reduction in risk per cyclist (29). It is assumed that this is partly because drivers become more "cycle aware" with more cyclists on the road, and partly because a greater proportion of the driving population would themselves be sometime cycle users. Improving cycle facilities and/or reducing traffic speeds can achieve even better results—London and York are both among several European towns and cities which has increased cycle use while at the same time reducing casualties in absolute terms.

"More cycling would almost certainly reduce road deaths", to quote one author

A policy framework to promote cycling

21. This is not the place for a full discussion of the range of policies and initiatives that are necessary or desirable to promote increased cycle use. Nevertheless, we feel it is useful to provide a brief overview of some key points in the paragraph below, before proceeding to discuss specifically how to promote cycling among children and young people (in order to prevent the onset of weight problems), and how the health sector could promote projects to assist people in tackling obesity.

22. A strategy to promote cycling would include the following features:

Tackling traffic growth.

reduce the need to travel

Tackling vehicle speeds and other forms of dangerous driving.

Cycle facilities, including cycle parking.

Land use policies to promote local travel.

Integration of cycling with public transport.

Integration of cycling with other policy areas.

Promoting cycle use for children and teenagers

23. Sport England also asked young people what they do most in their leisure time (40) and 48% of them reported cycling. Yet other evidence suggests that few of them do so for travel. One survey found that, although 90% of junior school pupils and 67% of senior school pupils owned cycles, three quarters of the juniors and a quarter of seniors were not allowed to cycle on roads. Very few of the seniors cycled to school even though about three in five of the cycle owners had journeys of less than 2 km, an easily cyclable distance (41).

24. There is already a wealth of advice from Government and other sources about encouraging cycle use for school journeys (42), (43), and many examples of good practice and success stories (44). Yet most of these best practice examples rest on the enthusiasm and commitment of individual teachers/head-teachers, parents or governors—the encouragement of cycling for school travel is far from universal and many schools still actively discourage it, often due to fears about road danger.

25. Moreover, there is a lack of effort to promote cycling activities for children and young people for purposes other than the school journey. More needs to be done to provide children and teenagers with spaces where they can develop their cycling skills in a safe environment, and enjoy cycling as a free-time activity. For instance, properly funded and managed Kids Cycling Clubs, based in local parks, could offer cycle training and excursions in the neighbourhood, nearby rural areas or further afield. The provision of facilities such as BMX parks can encourage participation in a healthy activity among teenagers, and can often be provided inexpensively on otherwise underused land—this is particularly true in deprived areas, where there is often a lack facilities and activities to engage teenagers' interest.

The importance of cycle training

26. We have already argued that the risks of cycling are a good deal lower than is widely realised. Nevertheless, the perception that "cycling is dangerous" is a significant barrier to realising the benefits of increasing cycle use. We would undoubtedly argue that action is needed to improve cycling conditions—both by improving the physical infrastructure and by improving driver awareness of the need to respect the vulnerability of pedestrians and cyclists. However, we have also argued that there are overwhelming health benefits to be gained from encouraging greater cycle use even in existing conditions. Moreover, the presence of more cyclists will of itself affect driver attitudes and awareness.

27. So the question is one of how to start this "cycle of benefits". We believe that cycle training has a large part to play in the solution.

28. All unfamiliar activities with an element of risk are "too dangerous" for people who have not gained the confidence and skill to undertake them safely. In this respect, cycling is no different from canoeing, horse-riding or indeed driving. Yet most young people in Britain never have the opportunity to learn how to handle real traffic conditions confidently, competently and safely, and many do not gain cycle training at all. Those cycle training schemes which do exist typically give young children the skill to balance, signal and make basic turning movements, often in playground conditions only. As they progress through teenage years and into adulthood, they are unlikely to encounter any opportunity to develop their cycling skills further, and particularly to develop the confidence and skills necessary to handle real traffic conditions. A recent survey of cycle training provision found that:

— Fewer than 30% of children receive some form of training before primary school and only 25% learn mostly on-road;

— Less than 20% receive professional instruction and only 10% are definitely trained by instructors who are experienced cyclists;

— Only 4% receive on-road training carried out by professional instructors who are cyclists and have been trained on a structured instructor training course;

— Only 1% of secondary school pupils receive any cycle training (45).

29. It is unsurprising then that, by adulthood, people often use the shorthand "it's too dangerous" to explain why they do not cycle. It is an understandable statement, however its true explanation is more complex, and yet at the same time it is a totally surmountable problem. 99% of men and 87% of women aged over 15 say they can cycle (46). With adequate training, they could be cycling for regular day-to-day local journeys, thereby gaining health and fitness benefits without needing to set any special time aside to undertake physical exercise for its own sake (eg visit a gym).

30. CTC has been working with the Department for Transport and the Department of Health to develop national frameworks and standards for cycle training schemes and their providers. The aim of this project is to raise standards of cycle training schemes, by:

— defining various levels of cycle training to meet varying needs, from beginners through to competent cyclists who need to gain roadcraft skills; and

— supporting providers in delivering cycle training courses which meet best practice standards.

Cycle training: maintaining children's health

31. One respect in which British patterns of cycle use are crucially different from countries such as Holland are the degree to which cycle use in Britain drops off markedly after passing the mid-teenage years (earlier for girls), whereas Dutch males and females alike maintain healthy levels of cycle use throughout adulthood and into old age (47). Cycle training for children and teenagers therefore has a valuable role to play in ensuring that children not only learn the basic skills of handling their cycles, but continue to develop their skills as seek and gain increasing freedom and independence to travel more extensively on their own. Creating the habits of healthy travel—or overcoming the habits of physical inactivity—could play a significant role in addressing the health effects of obesity, as well as other conditions related to physical inactivity. It is also an ideal form of exercise for children who already have weight problems. The efficiency of cycling makes it attractive to children who might be deterred by the difficulties they encounter with other forms of exercise.

Cycle training: overcoming weight problems

32. There is growing recognition in the health sector of the value of exercise on referral schemes as a means to tackle a range of health problems, including obesity. We have referred already to a project in which overweight adults were found to loose weight and gain fitness rapidly through participation in cycling (see paragraph 19). Despite this finding, we are not aware of any projects that have been run specifically to enable overweight or obese adults to gain these benefits. Nevertheless, there have now been a number of "cycling on prescription" projects run for people with a range of health and fitness problems. For instance, CycleWest is providing cycling on prescription for PCTs in Bristol and mid-Devon, while Cycle Project for the North West is running a specific project for rehabilitation of post-cardiac arrest patients run in conjunction with Stockport PCT. We believe that similar projects could prove valuable in enabling overweight people to loose weight in a way that can be maintained and which will give them increasing confidence and quality of life benefits over time.

33. The Department of Health's national quality assurance framework for exercise referral schemes says

"Many patients entering a referral scheme will not find leisure facilities such as gyms desirable or convenient for maintaining an increased level of physical activity. It is therefore imperative that exercise referral schemes are individualised to provide an educational experience that motivates patients for long-term change. Walking and cycling in the community may well be the most popular options, particularly if they are convenient, safe, affordable and can be sociable" (48).

Cycle training: tackling health inequalities

34. The recent report Social Exclusion Unit on Transport identified clearly how socially excluded individuals and communities tend to suffer disproportionately from the poor transport services and from other adverse effects of transport (eg air pollution and danger from road traffic) (49). However it was very disappointing in failing to identify the potential role of cycling in enabling people to gain improved access to schools and colleges, job interviews and employment opportunities, healthcare facilities etc. Socially excluded communities are generally more likely than the norm to suffer from deficiencies in public transport services. Encouraging people in these communities to cycle would not only enable them to break out of the sense of powerlessness that exclusion can create, and give people in those communities a sense of independence. At the same time, projects to provide spaces in those communities where children and teenagers can cycle would help to overcome the health risks that some children in those communities face due to parental pressure to remain indoors, for fear of the disproportionate dangers they face from road traffic in their areas.

RECOMMENDATIONS FOR NATIONAL AND LOCAL STRATEGY

35. Responsibility for physical activity and active transport in young people should be shared between the education, health and transport sectors. We have already outlined (in paragraph 22) the transport and land use policy framework needed to foster a higher level of cycle use, in order to realise its various health and other benefits. We would add specific recommendations as follows:

Health

— Primary Care Trusts should work with highway authorities to ensure that the provision of cycle training schemes for people of all ages is an integral part of and Local Transport Plans and cycling strategies. Health promotion units should work with those authorities to promote such schemes.

— PCTs should work with local authorities and/or independent cycle training providers to make cycling on prescription available as part of all exercise on prescription schemes.

Education

— Cycle training courses, provided by accredited cycle training providers and including tuition in on-road riding skills, should be made available for all children. Training should be made available for teenagers as well as younger children.

Recreation (with links to social inclusion/regeneration where appropriate)

— Funding should be allocated to each local authority area, without competition, for children's cycling clubs. These should be run by trained and qualified adults and could take place in local parks, schools and leisure centres where a tarmac cycle track and additional hard surfaced area has been provided.

— Funding should be allocated to each local authority area, without competition, for provision of sufficient tarmac cycle tracks and additional hard surfaced areas in schools with large grounds to meet the demand for children's cycling clubs.

— The National Cycle Network should be completed, enhanced and maintained by local authorities through dedicated funding.

April 2003

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