Impact of physical activity and diet on health - Health Contents

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.

79   Department of Health (IDH0078) para 56 Back

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87   Academy of Medical Royal Colleges, Exercise: the miracle cure and the role of the doctor in promoting it ,(February 2015), p28, p34 Back

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95   Diabetes UK (IDH0076) p4 Back

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106   Sustrans news release, "Cycling and walking investment strategy now law", 13 February 2015, accessed 18 March 2015 Back

107   Sport England, Active People Survey 8, 2014  Back

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113   Public Health England (IDH0063) p23 Back

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Prepared 25 March 2015