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Let's get physical! Using law and policy to promote physical activity

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Image courtesy of Sport Manawatu

Image courtesy of Sport Manawatu

Each year, approximately 3.2 million people die due to physical inactivity. Physical inactivity can lead to obesity, and is a key risk factor for non-communicable diseases (NCDs), including heart disease, diabetes, and cancer.
Modern lifestyles, predominately in developed countries, but increasingly in less developed countries too, are sedentary. Watching television, playing video-games, elevators, escalators, and desk jobs, equate to less activity. Combined with high-caloric diets, we live in an increasingly obesogenic environment.
All around the world, governments are adopting innovative laws and policies to tackle the rising burden of physical inactivity, and resulting NCDs. Interventions take many different forms, including physical activity programs in primary care settings, institutions, and workplaces; zoning and planning laws to increase the accessibility and safety of parks and recreation facilities; mass media and public education campaigns; and economic measures such as tax incentives and financial rewards for engaging in physical activity, or achieving weight loss targets.
Alongside medical and scientific interventions, innovative laws and policies have great potential to counter sedentary lifestyles and their negative health consequences. As with all policy innovations, though, proponents face challenges, including building and assessing evidence, adapting policies for local contexts, ensuring equity, and fostering public and political support. This blog looks at three examples of innovative legal and policy approaches to promote physical activity, and some of the challenges they bring with them.
Physical activity on prescription
Medical professionals in New Zealand, Sweden, and Vietnam, are prescribing physical activity to prevent and treat symptoms and diseases. Under New Zealand’s Green Prescription (GRx) initiative, primary care doctors or nurses issue prescriptions to patients, setting out physical activity and nutrition plans to assist them to manage chronic conditions. Patients receive support and encouragement from their GRx Patient Support Person, through in person meetings, telephone calls, or group support in community settings. Patients’ progress is reported back to their health professional.
According to the New Zealand Ministry of Health’s 2014 survey of GRx patients, 63% reported remaining more active six to eight months after receiving their GRx than before receiving the prescription. Forty-six per cent of patients reported losing weight, and 63% reported having made changes to their diet. A 2003 randomized control trial by Elley et al found that the GRx program effectively increases physical activity, with the proportion of participants who achieved 2.5 hours of moderate or vigorous physical leisure activity per week increasing by 14.6% compared with 4.9% in the control group. Physical activity among male GRx patients increased by 68 minutes per week, and among female patients by 20 minutes per week. The study revealed a trend toward decreasing blood pressure among patients, though no significant change in the risk of coronary heart disease was observed.
Image courtesy of The Campaign for Physical Activity in the Prevention and Treatment of Non-communicable Diseases in Vietnam

Image courtesy of The Campaign for Physical Activity in the Prevention and Treatment of NCSs in Vietnam

A robust evidence basis is also being developed for the similar Physical Activity on Prescription initiative in Sweden. A randomized control trial by Kallings et al found that individualized prescriptions for physical activity improves cardio-metabolic risk factors and body composition in older, overweight adults. Eriksson et al found that interventions in primary care, including Physical Activity on Prescription, are highly cost-effective in relation to standard care.
Following the success of the Swedish initiative, the Swedish International Development Cooperation Agency is funding a 3-year joint initiative between Sweden’s Karolinska Institutet and the Hanoi Medical University, to train Vietnamese health providers in the use of physical activity to prevent and treat disease. Importantly, the Vietnamese program takes into account different country characteristics, incorporating evaluation of local practitioners’ learning and usage, and local patient adherence.
Another challenge for current initiatives and future rollouts is overcoming a lack of knowledge on the part of medical professionals worldwide, many of whom have not been trained on the use of physical activity to prevent and treat disease. To help address this concern, the Professional Associations for Physical Activity in Sweden has published a comprehensive handbook Physical Activity in the Prevention and Treatment of Disease. The handbook is available in Swedish, Norwegian, English, and Vietnamese.
Paying participants to lose weight
In 2009/10, the United Kingdom’s National Health Service (NHS) trialed offering financial rewards to residents who meet predetermined weight loss targets. The “Pounds for Pounds” pilot program in the Eastern and Costal Kent region allowed participants to choose a weight loss goal, with optional maintenance periods. Those who achieved their target weight in the specified time period received rewards valued between £70 and £425 per year.
Relton et al’s evaluation found that clinically significant weight loss occurred in 44.8% of participants. Estimated mean weight loss over 1 year was 4.0kg. Although the program yielded some positive results, the evaluation identified low completion rates (38%) as a challenge for these sorts of initiatives going forward, and the program’s cost-effectiveness and efficacy in maintaining weight loss over time were not evaluated. Proponents of providing people with financial rewards for modifying unhealthy behaviors also face the daunting challenge of convincing stakeholders, most notably the public and politicians, to spend public funds on what is often simplistically characterized as an individual’s problem based on poor decision-making.
Although the Pounds for Pounds pilot program was not rolled out, the NHS has foreshadowed similar programs to support employers to incentivize employees to improve health, including through weight loss, as part of its Five Year Forward View.
Tax incentives to enroll children in physical activity programs
Image courtesy of the Canadian government

Image courtesy of the Canadian government

In our final example, the Canadian government offers tax credits for enrolling children in physical activity programs. Canada’s Children’s Fitness Tax Credit allows parents to claim up to $500 in tax credits per child for fees paid to enroll children in approved physical activity programs. The government recently announced its intention to double the credit to a maximum of $1,000.
A study by Spence et al revealed about 16% of parents who had utilized the tax credit agreed that it had increased their child’s participation in physical activity, though this was much higher among low-income parents (37.5%). While the tax credit is most effective in increasing physical activity among children from low-income families, overall, the tax credit appears to offer greater financial benefits to wealthier families. Of concern, low-income parents were significantly less aware of and less likely to claim the credit than higher-income parents.
As with many economic-based health promotion initiatives, this tax credit raises issues of equity. Ensuring that low-socioeconomic populations have equal access to incentives, and are not overburdened by disincentives (such as taxes on unhealthy foods and beverages) is an important consideration for public health policy-makers going forward.
Emerging public health risks demand innovation, and alongside medical and scientific programs, legal and policy interventions have great potential to yield individual and population-level improvements. In order to achieve the best results we must build and assess evidence bases on an ongoing basis, adapt policies for local contexts, address equity concerns (in terms of access and application), and foster public support and political will.

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The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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