3 Physical activity—a key health
priority in its own right
61. As discussed in Chapter One, physical activity
in its own right has huge health benefits totally independent
of a person's weight, and it is vital that the importance of physical
activity for all the population—regardless of their weight,
age, health, or other factors—is clearly articulated and
understood. In its written evidence, the Department of Health
states that the Government has commissioned Public Health England
to develop a "5-a-day" style of message for physical
activity.[79] In oral
evidence to our inquiry, the Public Health Minister suggested
that messages about physical activity may not currently be very
well understood:
When you get off the bus a stop early, what percentage
of your recommended daily activity is the distance that you walk?
People do not have a sense of that".[80]
62. Dr Mike Knapton of the British Heart Foundation
provided his own simple slogan to increase physical activity—"just
do more".[81] Our
witnesses told us that even modest increases in activity levels
are beneficial to health, and for inactive people that may be
a more helpful starting place than immediately trying to meet
physical activity recommendations in full. CMO's guidelines have
now been updated to reflect this:
It was a subtle shift in the chief medical officer's
last guidance, which talked about achieving the guidelines that
you referred to but also said, "But more is better."
So, from whatever level people are at, they should be more physically
active. The public health benefits would probably be greatest
if we were to focus on that group who were sedentary in work and
in their recreation. Sometimes if we set a public health target
that is too far away from people's everyday reality, it can disincentivise
change. Telling people "The equivalent of a 20minute
walk a day extra"—which I think most people can achieve;
it is within the realms of possibility—"can have serious
health benefits," is a much more positive message.[82]
For some people, working on spending less time
watching the television may be a better place to start than thinking,
"I need to go out for a run three times a week." [83]
63. Julie Creffield, a grassroots physical activity
campaigner and blogger who supports overweight women in becoming
more active through running, also recognised that it may be helpful
to start slowly:
I have a campaign to get a million fat women
running … it is about a gradual introduction to the sport
of running, not going full whack and signing up to a marathon.
I have been developing a scale which could really help doctors.
It is a scale that goes from non-runner to contemplator to beginner…
[84]
64. Professor Nick Wareham also told us that a focus
on diminishing sedentary time is an important additional public
health target[85], a
point reinforced throughout our written evidence.
65. Our witnesses also gave us a very clear message
that physical activity can and should incorporate all forms of
activity, and that we should be promoting physical activity—the
totality—however people choose to do it. Physical activity
can include every day activities—such as walking, heavy
housework, gardening, and active or manual work: active travel,
including walking and cycling; sport; fitness training; and other
forms of active recreation such as dance, yoga or active play.
We also heard that it was important not to see active travel as
an "all-or-nothing" form of activity, and that for many
people mixed-modality transport—cycling to the railway station,
or walking to work from an off-site car park—might be a
more realistic way of engineering physical activity back into
their everyday lives.[86]
66. The recent report from the Academy of Medical
Royal Colleges reinforces the importance of promoting a broad
and inclusive range of physical activities, tailored to be appropriate
for an individual's preferences and lifestyle:
The actual activities are not important, as long
as they are moderately intense, can be fitted into the person's
schedule and are regular. There is no difference between "structured
exercise" and "lifestyle physical activity" in
the protective effect offered for the number of minutes of activity.
The choice of activity should be relevant, rational and routine.
The intensity may need to build up over several sessions. For
some, a sociable activity is more likely to be maintained. Young
people from deprived backgrounds find group activities, sport
and timetabled sessions more attractive when facilities are cheaper
and they are given encouragement. Fun activities are more likely
to be sustained. Many activities can be promoted; brisk walking,
cycling, climbing stairs, dog-walking, using outdoor gyms and
dancing—even sexual activity can bring some benefits. Basing
activities in communities leads to sustained acceptance.
Doctors should promote an active lifestyle. Although
the benefits of "150 minutes per week" are equivalent
to "5 times a week", there are problems with expecting
a sport to fulfil the physical activity requirements; the weather,
sporting injury and holidays can reduce the sustainability of
sporting activity. Furthermore, there are issues around taking
up sport for the first time, and maintaining sporting activity
throughout the life course. The Olympic legacy may have left some
with continuing sedentary behaviour, if they feel that sport is
for spectating and that the Olympic ideal is impossible to achieve.
It may be easier and better to kick a football around for fun,
than to sign up for a football team. In addition, for increasing
numbers of people, signing up for a future charity challenge is
an excellent way of obtaining regular training sessions in the
weeks leading up to the event.[87]
67. Dr William Bird gave the Committee a clear and
memorable illustration of how re-building physical activity into
daily life is easier if physical activity is a means to an end
rather than an additional extra that needs to be fitted in on
top of other pressures:
Can I use the example of Bob? Bob is a 42-year-old
diabetic, depressed and living on the 14th floor of a tower block
with two unruly teenage children. He is the kind of person that
I will see as a doctor. To give Bob a badminton racket and tell
him to go off and do some sport is not going to be the key thing.
He is depressed and stressed; he has loads of problems. The kinds
of ideas we have gone through before are to get off the bus a
stop early and to use the stairs. These are complete anathema
to Bob. He has too many problems in his life to go off on a rainy
day to do that extra walk. What he does do is walk to Anfield—he
is from Liverpool—two miles there and two miles back. He
does not call that exercise at all. That to him is not exercise;
that is going to Anfield as a supporter.
We have to find in everybody, in your constituents
and my patients, the "Anfield" part, which would mean
that physical activity is secondary to the end; it is a means
to an end rather than the end in itself. There are those of us—and
probably in this House—who are very keen on being physically
active and wanting to cycle and do all those things, and we have
all sorts of gadgets on us, but that is a very small proportion
of the country's population. Most people see physical activity
as work and they will be prepared to do that work if there is
a reward at the end. So it is a means to an end, rather than the
end in itself.[88]
68. Professor Dame Sue Bailey gave a further example
highlighting the importance of building physical activity into
daily activities:
Pragmatically, it is doing what you do but doing
it slightly differently. My example would be my daughter taking
children to school pushing the buggy. There will be several of
them doing that and on the way back they will come back at a quicker
pace; they will go more rapidly; they will meet the criteria of
this. Actually, they will have the socialisation and will physically
feel better for it. That is almost without cost, I would say.
So it is actually looking at the routine in people's lives and
how they can alter their routine slightly each week on a regular
basis. Taking children to school five days a week, here is the
opportunity to do this. It is about having that conversation with
people in the community and/or if you are the doctor in the surgery
thinking of ways that it would be possible within the surgery.
The practice nurses have meetings with young mothers and mothers-to-be,
so there are opportunities right across the surgery to start having
these conversations. The other thing is that health professionals
themselves are going to have to join in and embrace this.[89]
69. We have heard the hugely positive
message that increasing physical activity has significant health
benefits and does not necessarily mean playing organised competitive
sport three times a week—it encompasses a diverse range
of activities, including everyday activities such as walking.
The point was made that raising heartrate was the most important
thing, but any increase in activity is beneficial.
70. For some people it can be easier
to fit physical activity in if it is "a means to an end"
rather than an end in itself. The key message from witnesses was
to "just do more", in a way that fits with your lifestyle.
Promoting physical activity in
clinical encounters
71. Despite the overwhelming evidence to support
the promotion of physical activity, doctors and other clinical
professionals are not yet playing an active enough role in promoting
this and, in some circumstances, may be adding to the problem.
Julie Creffield described at first hand the negative attitude
she faced from doctors as an overweight person undertaking physical
activity:
I went to my doctor in 2013 with some lower back
pain which was caused by picking my daughter up. When I mentioned
that I was due to run a marathon, he said I couldn't run a marathon—I
was too fat. That really spurred me on to take what was a bit
of a hobby—this kind of blog—to being a real campaign.
I was so angry that that doctor, who wasn't my doctor but a locum,
didn't want to hear that just the week before I had done 18 miles
around Hyde Park and that I had been running for a long period
of time; this wasn't just something I had in my head. I was determined
to run in that marathon to prove him wrong but also then to use
that catch phrase "Too Fat to Run?" as a way of starting
these debates with parliamentarians, the people who can make changes,
because, ultimately, the people who were reading my blog were
the people who needed help. I have struggled over the last few
years to get my voice heard and to have discussions about health
and what I have learned and experienced.[90]
72. She went on to describe her delight when she
first heard a doctor say it was possible to be "fit and fat":
When I heard that out of the mouth of a doctor,
I almost exploded—just that phrase alone—for doctors
to accept that that is a possibility—would be helpful.[91]
73. Professor Nick Wareham was amongst many to highlight
that more needs to be done to promote physical activity within
clinical encounters:
One of the areas where we can do more is in the
promotion of physical activity in a clinical encounter. That sometimes
gets given lesser importance than dietary change or obesity. I
know from my clinical work where we are treating people with diabetes
that, if we want to focus on the behaviour, even the provision
of a pedometer to people in a diabetes clinic is extremely difficult,
and yet we know from trials that providing a pedometer and making
people aware of their own level of physical activity does promote
beneficial change. There are things we can do in a clinical encounter
as well as, more broadly, in a public health arena.[92]
74. Dr William Bird agreed that:
…the GPs particularly need to have their
knowledge increased. Physical activity should be part of being
a good doctor. It is not quite there yet. The evidence is there
but it needs to be put in the hearts and minds of doctors.[93]
75. Professor Dame Sue Bailey agreed:
You may ask why we have not done this before—that
this was something that seemed obvious—but doctors, as part
of society, have forgotten what it takes to stay healthy as we
are leading increasingly sedentary lives. Doctors have a unique
role to play in this because we are trusted and we are in a position
beyond primary care to have the critical conversation with patients
about the need for physical activity and the benefits it can bring
to them, particularly in primary care.[94]
76. Offering brief advice promoting physical activity
in a primary care setting has been found to be a cost effective
intervention by NICE. The Department of Health and Public Health
England raise the NHS Health Check as an intervention which offers
potential to promote physical activity, but Public Health England
said that they "still have work to do on maximising that
opportunity". Diabetes UK argue that in their view not enough
of the target population of 40-75 year olds have had an NHS Health
Check—they state that less than half of the eligible population
have received an NHS Health Check and only 70 out of 152 local
authorities are on course to achieve a Public Health England target
of 66% uptake by March 2015.[95]
77. Beyond the issue of how many people are receiving
a health check, many giving evidence to us also argued that even
those receiving a health check may not then be being offered effective
support to change their behaviour. Professor Wareham argued that
whilst health checks may identify individuals at risk, there may
be a "disconnect between that and clinicians then being able
to help people to actually do something about increasing their
activity levels."[96]
Dr William Bird also described this:
The health checks have been a way of getting
people aware of what their risk factors are. In the evidence that
I have seen, it has actually reduced blood pressure; it has reduced
some of the areas, though not smoking so much. I have not seen
any evidence that it reduces mortality from it, but, as a way
of getting physical activity into a conversation for a patient,
the health check is a very good way as long as the provider of
that health check has a connection to understand about what they
should be talking about on physical activity. Unfortunately—and
I quote someone who is a very avid supporter of this—a GP
went to his own health check in the practice and the nurse said,
"I am meant to be talking about something to do with physical
activity, but I am not quite sure what it is." That almost
summarises, in effect, that there was a tick box to talk about
physical activity, but it did not mean much to that nurse because
she had never been told what physical activity was about. There
is a massive gap there, and the report comes through very strongly
that doctors and nurses need to be upskilled in the knowledge
of physical activity, which would make the health check much more
effective on physical activity promotion.[97]
78. Dr Bird also described the difficulties doctors
face in promoting physical activity when patients may have been
expecting, and attach greater value to, more high-tech interventions:
The biggest problem with the patient, going back
to the example of the stent or physical activity, is that patients
often were not ready to be told they had to go for a walk in the
park when there was a nice shiny stent in a lovely brand new hospital
down the road. They felt they were much more worthy to have that
because that is where science and technology was at its ultimate
and they were just being told to go for a walk. So the patients'
expectations were not met and the doctor felt uncomfortable very
often in promoting that because it was not what we had been taught
to do and we had not got the confidence to do it. Finally, the
patients have a fear of physical activity. Most of them have never
been out of breath because they have never exerted themselves
to the point where they are actually going at 70% of their VO2
max, which is a three-mile-an-hour
walk. They are walking incredibly slowly, so to get to the point
of being out of breath is quite scary. That is another aspect,
when they come back to the doctor saying they cannot do this because
it is too dangerous.[98]
It is often more difficult to promote something
simple, and walking is almost too simple. The reason I set up
Intelligent Health was to add technology to walking so that everyone
can do it, and then suddenly everyone finds walking is attractive
and they put money into it. But when you have walking on its own
it is almost too simple, and the mentality of health is that you
need treatments and you need packages to help. So there is a kind
of psychology of the way that we deal with health which we have
to work with. As doctors, we have the responsibility to change
the expectations of patients. We should not be giving antibiotics
at every consultation. We have managed to win that and it is starting
to take effect. We can do the same with physical activity.[99]
79. Professor Dame Sue Bailey told us that improvements
were required to medical education:
Maybe it needs to be recognised as an entity
rather than just appearing in separate parts of different parts
of medical curricula, but I can certainly come back to you on
that.[100]
Doctors will accept that physical activity is
not just prevention but treatment as well, so we have to explain
that almost every condition can be treated. There is a gap that
we have probably not been very good at filling in getting that
knowledge to GPs and all doctors, which is there, and I think
they will accept it when it has been put in the right way.[101]
80. Dr Bird described his approach to engaging GPs
by focusing on the medical benefits in a detailed way, rather
than taking a public health approach:
…when I started teaching GPs about physical
activity, I got it all wrong. I talked in a public health language—I
am a GP—and it was about prevention, statistics and tables
and things. It was only when I started talking about the actual
physiology—when I talked about the cellular level—that
it started to reconcile in their minds with a medical problem.[102]
81. NICE has clearly recommended
that offering brief advice in a primary care setting is a cost
effective way of getting people to increase their levels of physical
activity. It is clear that clinicians have a crucial role to play
in promoting physical activity. Better undergraduate and postgraduate
education is now required, both to ensure clinicians' understanding
of the medical benefits of physical activity, and to teach them
how to promote physical activity to their patients in an effective
way, particularly when some patients may be sceptical of such
a "low tech" approach. We recommend that the next Government
works with the royal colleges and Health Education England to
achieve this.
82. In relation to NHS Health Checks,
we heard of a "tick box" approach to physical activity,
with clinicians carrying out Health Checks lacking the skills
to support people in actually changing their behaviour. We recommend
that, given the considerable investment of public resources in
NHS Health Checks, NICE should be tasked with assessing their
clinical and cost effectiveness.
An environment that promotes
physical activity
83. Dr Bird told us that "the problem is that
we do not have environments at the moment that encourage people
to walk."[103]
Professor Wareham also highlighted the importance of infrastructure
and environmental factors in promoting physical activity, pointing
to international examples:
If you want to make comparisons between cities,
or between the Netherlands and Britain, it is about the infrastructure
and making it conducive to physical activity. There is a major
win here. If we could only get people here to be as physically
active as people in Copenhagen, for example, in terms of walking
and cycling, colleagues have estimated that over a 20year
horizon the benefits, in terms of health care costs averted, would
be of the order of about £19 billion. So it is possible,
because we are talking about near neighbours in Europe, but the
solution does not lie in only encouraging people not to be lazy;
we have to be more radical and think about structural changes
to the wider environment.[104]
84. Professor Susan Jebb argued that while infrastructure
change may be costly, our environment is not static, and change
is happening constantly, providing opportunities to redesign environments
in order to promote physical activity:
People often raise the cost of making change
as being a barrier when we talk about anything that involves infrastructure.
Of course that is a very legitimate issue, but we need to remember
that change is happening all the time; schools are being refurbished
all the time and work places are being reconfigured. We are building
whole new towns and we have a real opportunity to build this in
from the start. It would be unrealistic to imagine that we were
going to sweep across the country and retrofit some of these changes,
but we can start to do things differently because we now understand
that the environment—whether it is the micro-environment
in your school or your home or the macro-environment in the towns
and places we live—has a real impact on the way we live
our lives. We need to be planning for that and planning for health
as we rebuild.[105]
85. Under the Infrastructure Act 2015, the Secretary
of State for Transport will be required by law to set out a strategy
for cycling and walking infrastructure and importantly the funding
provided to meet it. The Infrastructure Act sets out the Government's
ambitions to build a better transport system. Although initially
focusing on a Roads Investment Strategy, with a number of transport
groups and health organisations campaigned for a Cycling and Walking
Investment Strategy to also be included in the Act to ensure that
active travel is considered as a priority area for investment.
This means that for the first time there is a legal obligation
on the government to set targets and investment for cycling and
walking.[106]
86. We have heard that the physical
environment can have a significant impact on activity. Open spaces
are needed for recreation and play, and the built environment,
including road infrastructure and speed limits, all impact on
how easy or attractive it is to walk or cycle. We call on the
next Government to make a clear commitment, together with appropriate
long term funding, to significantly increase the levels of cycling
and walking.
Engaging different groups in
physical activity
87. We have also been struck during the course of
this inquiry by the inequalities apparent in rates of physical
activity. Particularly pronounced is the gender difference, with
only 16% of girls aged 5-16 achieving the recommended levels of
physical activity compared with 21% of boys, and 32% of women
achieving the recommended levels compared with 43% of men. Looking
specifically at participation in sport, 31% of females engage
in sport once a week compared to 40.1% of men.[107]
Discussing the possible reasons for this difference, Kay Thompson
told us that Sport England's work had identified "fear of
judgement" as a key factor:
Three quarters of women want to become more active
but something is stopping them…fear of judgement…judgement
about appearance when exercising, ability to be active, confidence
to turn up to a session, or feeling guilty about going to be physically
active or doing something when you should have been spending more
time with your family.[108]
88. Julie Creffield described the difficulties she
faced in a frank and insightful way:
When I looked online for information, there was
lots about weight loss and running but nothing about running just
as an overweight person, the psychological aspects of that and
how tough it is when you are constantly shouted at, laughed at
and clothes in fitness stores don't fit you. It feels like the
whole sport is not geared up for you.[109]
89. Ms Creffield mentioned the fear of being ridiculed
as a barrier to becoming more active, and also fear of being too
slow a runner and not wanting to be the one "struggling at
the back".[110]
She stated that the virtual runs she organises are designed to
ensure that people know they won't be comparing speeds, and that
they are for all abilities. She went on to say:
You do not see a lot of overweight people exercising
because they do it in secret. I have women who tell me they run
on a treadmill in their shed because they just don't want to be
seen in public, but that is part of the problem. Because we don't
see many overweight women exercising in public, other women don't
think that exercise is for them. They think it is for all the
slim people that they always see out in the parks. So "Be
invisible." I get a lot of feedback saying, "I bought
your T-shirt because I want to support what you are doing, but
I always thought I wouldn't be very confident to go out wearing
a T-shirt that says 'Too Fat to Run?' But I did and I felt so
empowered, and when people looked at me I didn't care because
I am on my own fitness journey." So there is something about
reversing that kind of psychology stuff and getting people to
feel like it is their right to be in public and exercising, and
they should not have to make apologies for themselves.[111]
90. Ms Creffield also raised the simple but important
issue of larger people not being able to find exercise kit that
fits:
In the UK it is nigh-on impossible to get technical
running gear in anything larger than a size 18, and even to get
a size 18 in some items like a running jacket is impossible. That
is a real barrier because no woman wants to dress in men's clothing
to go out for a run when there is already the risk of being laughed
at. That is a real problem. Initiatives like parkrun and Jantastic
and all of these kinds of running things that are there to get
more people active themselves don't provide T-shirts in anything
larger than a size 16. So it is really hypocritical that the Government
pump money into initiatives, but at the end of the line somebody
goes to sign up and says, "I'm not going to sign up for that
because I can't get a T-shirt in my size. So why should I?"[112]
91. The number of children who are obese doubles
in primary school, and as the table below shows, child obesity
prevalence is closely associated with socioeconomic status:
[Source - National Child Measurement Programme 2013/14-Public
Health England]
92. Children fare worse than adults in meeting recommended
levels of physical activity, with only 16% of girls and 21% of
boys achieving the recommended levels of physical activity.[113]
Witnesses also gave us views on children's and young people's
physical activity levels: while Dr Dagmar Zeuner argued that it
was "quite astounding how little PE is in the curriculum"[114]
, Professor Nick Wareham emphasised the need to also consider
activity levels outside school:
The natural assumption is to think that it is
all about what goes on in school, about PE and the school environment,
but much of that decline is actually happening out of school hours
and at weekends…30% of children who live within 2 km of school
are driven to school.[115]
93. Physical activity must be seen
in its totality, and a flexible and inclusive approach is needed
to enable individuals to choose a way to increase physical activity
that is right for them. Nowhere is this more important than in
promoting physical activity amongst groups of people who seldom
take part. The most obvious is the disparity between men and women,
but inequalities in physical activity levels exist between other
sectors of society too, and children fare worse than adults in
terms of meeting physical activity recommendations.
94. Fear of judgement is a key barrier
preventing women from being more active. Some barriers may be
quite simple such as the lack of availability of sports clothes
in larger sizes or mixed changing rooms. The Government-wide programme
on diet and physical activity should include a specific workstream
focused on identifying and tackling inequalities in relation to
physical activity, and it should begin with work to examine how
women, those with disabilities and overweight people, can be encouraged
and supported to be more active.
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Sport England, Active People Survey 8, 2014 Back
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