In January this year, the World Health Organization (WHO) renewed its focus on physical inactivity, a key risk factor for the worldwide epidemic of non-communicable diseases (NCDs). Encouraging and creating universal opportunities for physical activity is a complex, potentially costly exercise for governments, involving a wide range of public and private actors. Fresh global attention presents both opportunities and challenges for all stakeholders, and an opportunity for WHO to provide leadership on this often-neglected NCD risk factor.
Physical inactivity is a leading risk factor for premature death
Physical inactivity is one of the leading risk factors for premature death worldwide. Lack of physical activity increases the risk of NCDs including heart disease, cancer, and type 2 diabetes. Lee et al. estimate that by reducing rates of physical inactivity by 25%, more than 1.3 million deaths could be avoided each year. Additional benefits of physical activity include improved mental health, better cognitive function, and enhanced bone health.
High rates of physical inactivity
Globally, 23% of adults do not meet WHO’s recommended levels of physical activity. Of even greater concern, more that 80% of adolescents (11-17 years) are not sufficiently physically active.
Economic growth and urbanization, manifesting in sedentary jobs, leisure activities, and modes of transportation, often correspond with decreases in levels of physical activity. Other factors contributing to high rates of physical inactivity include air pollution and lack of safe, accessible places for recreation.
A lack of global attention (and progress) on physical inactivity
As compared to other key modifiable risk factors for NCDs (tobacco, alcohol, and unhealthy diets), physical inactivity has tended to receive less dedicated attention from the WHO, governments, and civil society.
During the first decade of the 21st century, WHO developed a range of strategies and recommendations to promote physical activity, including the Global Strategy on Diet, Physical Activity and Health (2004), a Guide for Population-Based Approaches to Increasing Levels of Physical Activity (2007), and the Global Recommendations on Physical Activity for Health (2010). More recently, global action on physical activity has been in the context of NCDs more broadly, including as part of the United Nations Political Declaration on the Prevention and Control of NCDs (2012), the Global Action Plan for the Prevention and Control of NCDs (2013), and the Sustainable Development Goals (2015).
For the most part, these global efforts to address physical inactivity have not translated into impactful national action or reductions in persistently high or increasing rates. For example, although around 80% of WHO Member States have polices and plans to address physical inactivity, only 56% of these plans are operational. The International Congress on Physical Activity and Public Health’s 2016 Bangkok Declaration on Physical Activity for Global Health and Sustainable Development identifies the “urgent need to strengthen… the development, prioritisation, financing and implementation of evidence-informed national plans to enable all countries to achieve the WHO global target for reducing physical inactivity… by 10% by 2025.” WHO’s renewed focus on physical inactivity: challenges and opportunities
Following leadership from Thailand, WHO’s South-East Asia Regional Office, and the International Congress on Physical Activity and Public Health, the WHO’s Executive Board has set the agenda for the development of a Global Action Plan on Physical Activity by May 2018. WHO’s renewed focus on physical inactivity brings both challenges and opportunities for international organizations, governments, non-government organizations and academia.
Multi-sectoral causes and solutions
Physical inactivity has a range of interrelated causes, from sedentary leisure activities and transport options to lack of access to safe recreation spaces. The causes (and solutions) involve a range of sectors including urban planning, transport, environmental protection, and education. Health departments leading the development and implementation of physical activity policy therefore need to work with and drive progress in agencies that may be less familiar with health promotion. For example, a partnership between the Ministry of Health and the Ministry of Education in Sri Lanka has facilitated three periods of physical education per week in schools and inclusion of physical education as part of assessment from grade six.
WHO, with the support of relevant stakeholders, should promote multi-sectoral collaboration on and accountability for promotion of physical activity. Governance structures and legislative frameworks, for example, would assist to mainstream collaboration, consultation, and integration of promotion of physical activity across a wide range of sectors.
Financing challenges
Many strategies to promote physical activity, such as cycling infrastructure and public transport options, can be costly and involve long-term infrastructure investments. When compared to other NCD interventions, such as smoke-free place laws (relatively inexpensive) and product taxes (typically revenue-generating), it may be difficult to generate political will and financing for more costly interventions.
In addition to identifying and leveraging public and private funding opportunities to drive reductions in physical inactivity, WHO, with the support of civil society, should research and share information on innovative, cost-effective opportunities. Shared-use agreements, for example, are a means of increasing access to existing recreation spaces and repurposing obsolete infrastructure may be more cost-effective than new construction. Planning laws requiring larger scale developers to provide or share the costs of public recreation spaces may also help reduce costs for governments.
Protecting physical activity policies from negative corporate influence
While renewed focus on physical activity is a positive development in NCD prevention, proponents should be aware of the potential for exploitation by companies whose products contribute to the NCD pandemic. Tobacco, alcohol, and food and beverage companies have a long history of advertising and promoting their products through sponsorship arrangements with professional, amateur, and local sports leagues. Manufacturers of unhealthy foods and sugary drinks have funded scientists who shift blame for overweight and obesity away from unhealthy eating and onto lack of exercise. Promotional materials such as “BalanceUs.org” and “Mixify,” initiatives of the American Beverage Association, encourage consumption of sugary drinks as part of a “balanced mix of foods, drinks and physical activities.”
To ensure that physical activity promotion does not detract from efforts to reduce other NCD risk factors, WHO should provide leadership on protecting NCD policies from commercial interests of the tobacco, alcohol, and unhealthy food and beverage industries. Guidance is particularly needed in relation to government interaction with the food and beverage industry, which presents a complex challenge. As compared to the tobacco and alcohol industries, which produce largely uniform and harmful products, the food and beverage industry produces a wide range of products from sugary beverages to staple products essential to sustaining life. Food and beverage manufacturers are therefore part of the problem and potentially part of the solution, but governments need advice on how to regulate and interact with the industry so as to prevent negative interference with public health policy and outcomes.
In relation to physical activity promotion, WHO should also encourage governments to avoid in-kind or monetary contributions from companies whose products contribute to the NCD pandemic. Governments should also consider banning or restricting advertising, promotion, and sponsorship activities associating sport and recreation with unhealthy food and beverage products.
Translating high-level policies into feasible and effective interventions
An ongoing challenge across all NCD risk factors is translating high-level policies into feasible and effective interventions. In the field of tobacco control, tools such as MPOWER and the Framework Convention on Tobacco Control (FCTC) Implementation Guidelines provide practical guidelines on the successful development and implementation of key tobacco control measures. More recently, similar guidance is emerging in respect of measures to promote healthier diets, such as SHAKE the Salt Habit, a technical package for salt reduction.
In relation to promoting physical activity, WHO, with the support of civil society and academia, should take steps to develop similar evidence-based practical guidance for governments. There are many steps WHO can take to this end, including:
- promote research on rates and health impacts of physical inactivity, and associated health care and other costs;
- facilitate policy evaluation assessing the impact of physical inactivity interventions, with an emphasis on identifying cost-effective, affordable, impactful measures;
- disseminate information about successful interventions; and
- provide technical guidance and assistance to help governments, particularly in low- and middle-income countries, to develop, implement, and monitor interventions.
Despite the importance of physical activity to public health, too little attention has been paid to creating communities in which everyone can enjoy recreation and lead physically active lives. Although there are challenges, WHO, with the support of academia, civil society, and public health advocates, can provide much needed leadership to help governments create more active, healthier societies.
