How inactivity can be a silent killer: How to improve basic physical activity in individuals with a high BMI and/or other co-morbidities.
Introduction
In 2018, internationally a quarter of adults and three quarters of young people (11-17) do not meet the World Health Organisation guidelines for physical activity. WHO (2018). This sedentary behaviour can be associated with the early onset on numerous chronic non-communicable diseases such as diabetes, some cancers, heart disease, COPD and others.
In addition to this when an individual is overweight or obese this lack of movement can lead to further weight gain and thus making activity even more challenging which then becomes a vicious circle that becomes harder to break.
These issues together can add additional barriers to accessing physical activity, such as having limited mobility, fatigue, pain and even the fear of judgement which can make exercise even less likely.
There are ways to build up physical activity without making this overwhelming and can provide further health benefits.
Lived experience of these issues and involvement within local Integrated neighbourhood board projects around this topic have developed a keen interest in the topic and wanting to support others with their journey to physical activity.
Inactivity: A silent killer?
Inactivity is a problem that is seen across the globe, not just in the developed world, prompting the World Health Organisation(WHO) in 2018 to develop their Global action plan on physical activity 2018–2030: more active people for a healthier world, with the target being a 15% reduction in physical inactivity in adults & adolescents by 2030. WHO (2018)
WHO recommends that adults should do a minimum of 150 minutes of moderate intensity physical activity though out the week, or 75 minutes of vigorous activity to gain substantial health benefits, however even doing a small amount rather than zero has some benefits to health.
This small amount of physical activity can be shown on a dose response curve to highlight how just getting moving can be beneficial to health and can be low risk.
The results of this inactivity can be seen in higher incidences across those of a lower socio-economic status, and this should be a higher focus area for the development of any interventions/promotions. WHO have identified this as a potential barrier and explicitly state that consideration of this should be taken across the life course of an individual to reduce inequalities. WHO (2020)
Ekelund Et al (2019) concluded in their analysis of several scientific studies that an increase in activity at any intensity, and a decrease of sedentary time are associated with a substantial reduction in the risk of premature mortality and this increases as the time spent active increases.
In Public Health England’s evidence based Everybody Active Everyday Framework they advise that physical inactivity has the same number of deaths attributed to it as smoking does, which is one in six deaths, (Public Health England, 2014) so on that basis it should be treated as far more important than most people see it.
In figures from 2022/2023, 22.6% of adults 19+ were physically inactive, this has remained generally the same since 2015 with a slight increase during the pandemic when outside movement was restricted. (Office for Health Improvement & Disparities, 2024)
There has also been a marked increase in the mean weight of adults since 1993 (when it was 72.4kg) to the most recent data in 2022 when it was 79.3kg, (NHS Digital, 2022) this cannot be dismissed as a consequence of the physical inactivity of people.
What can cause people to be inactive
There are a myriad of reasons why someone may not be physically active, these can include, illness, ability, cost and fear. There are also human evolutionary reasons why we are now more inactive then our ancestors.
Fear may seem an abnormal reason for not being active, but the fear of judgement can be an extremely restrictive feeling for people who have a high BMI, photos of people in gyms being laughed at have been posted on Social Media and this can have a severe effect on body image and confidence.
The physical fear of exercising alone or outside can be very real, especially for women and girls, even more so in countries where being female is seen as being subservient. In many countries, even those without the governmental or cultural restrictions on movement by females, the fear of being out alone, walking, jogging or running can be a huge barrier to women being able to exercise freely. Recently in the UK an event was held to highlight this exact issue by This Girl Can, part of Sport England. The campaign found 72% of women change their behaviour when exercising during winter (Ivey 2024)
The cost of what is perceived to be needed to be physically active, can also be a major barrier to people, cost of equipment, travel or membership of sports clubs.
Cheval & Boisgontier (2021) discussed the Theory of Effort Minimisation in Physical Activity or TEMRA where they theorised the evolution of humans had over the last two million years adapted to the hunting strategies of our ancestors where they would track and chase prey into exhaustion, Due to human anatomy, we were able to sweat and work more efficiently and cool quicker.
Increasing physical activity during food scarcity was a survival instinct, humans no longer have this trigger for physical activity as there is no longer a need to hunt to survive. The current abundance of available food has caused intake to increase and expenditure to decrease, leading to the global increase in obesity. Humans are literally designed to be physically active.
Why might there be inequalities?
Reviewing the WHO social determinants framework, you can clearly see where inequalities in social determinants can be shown for the physical activity,
Looking at the higher structural determinants such as public, and governance policies especially in global situations, things such as lack of education come into play, in some countries females are not allowed to attain a high education or be allowed to leave the house without a male accompanying them, this can have a huge effect on being able to take part in physical activity to protect their health. This links into the cultural and societal values of countries as well.
WHO stated that cultural values influence physical activity, particularly for girls, women, those in underprivileged groups, older people, and those with chronic diseases or disabilities, they have less access to safe affordable and in some cases appropriate activities. WHO (2020)
Socio-economic determinants also play a huge part in whether people feel able to take part in physical activity, gym memberships can be extremely expensive, membership of sports groups, subs for weekly sessions and specialised equipment can count many out of being able to take part.
Cheval et al (2019) highlighted that a recent review pointed to a link between socio- economic position and physical activity being related to childhood, with those from a disadvantaged background less likely to have high levels of physical activity in adulthood.
Environmental factors also play a role in people being able to exercise, from global issues such as living in a warzone, to weather conditions, to living in an area with no outside green space. This includes where exercising near to road traffic could cause the risk to health to be greater due to the pollution.
The Marmot Review (2010) highlighted that the burden of disease does fall on those living in deprived conditions in a disproportionate way and this increases for certain ethnic groups. He also found that physical activity in adults increases as the socioeconomic group increases, this is likely due to the increased amount of disposable income and free time available to them.
Current interventions?
WHO have a global action plan (Global action plan on physical activity 2018–2030: more active people for a healthier world) that member nations have signed up for and are implementing within their own nations in ways that are appropriate for them to achieve the global goal. (WHO 2018)
Their mission statement is
“To ensure that all people have access to safe and enabling environments and to diverse opportunities to be physically active in their daily lives, as a means of improving individual and community health and contributing to the social, cultural and economic development of all nations.” (WHO, 2018, p8)
This forms part of their SDG’s (Sustainable Development Goals) which were agreed across all United Nations members in 2015.
Within the UK, Klenk & Kerse(2019) have stated that prescribing of activity as opposed to medicine is both cheaper and more effective in improving quality and length of life.
The role of social prescribers and health coaches have been easing this load on GPs and these roles have been seen to be very effective.
The UK government has set out their own physical activity guidelines document by the chief medical officer, UK Government (2019), this highlights that the minimum 10 minutes at a time is no longer required and any length of time is a benefit.
Some of the initiatives that have been implemented in the UK include “Active 10” which is a walking monitoring app and “Couch to 5 k”, which is an app to get people up and running, these are free to download, but require the person to have a smart phone and time to complete the activity. Which can exclude some of a low socio-economic background, where they cannot pay for childcare or have time in their day due to work shifts. This also links back to the fear of women and girls to be out in winter doing these types of exercise.
Walking and running apps are also excluding those who have some chronic illnesses and disabilities, however there is the website https://weareundefeatable.co.uk which provides online exercise programmes for those with disabilities or illness, however this again could be restrictive in that you need a suitable device and either data or broadband connectivity to be able to view the site.
What is my proposed intervention
Going even lower tech than We are Undefeatable – exercise whilst doing other things – so it doesn’t feel like exercise. This can be provided as a paper booklet by health professionals, available in libraries or for those with access as a download from a website.
Making physical activity a part of a normal day, adding little things in to activities that are already being completed. Giving people the ability to start small and achieve something, rather than feel they can’t do anything and give up early. To overcome the barrier some have to starting to exercise – the “I can’t do that because…………….” Even something as simple as walking on the spot for 3 minutes whilst the kettle boils can be seen as an increase in physical activity, doing this 10 times a day adds up to 210 minutes a week.
Geidl et al (2020) state that their findings can reinforce recommendations for low dose physical activity and that a volume significantly below the 150 minutes a week can have an effect on health and longevity. They also advise that this minimum can be seen as overwhelming and unachievable and by encouraging smaller low dose physical activity you could actually increase the activity levels of those with non-communicable diseases and high BMI with more chance of success
Summary
Increasing the level of physical activity can be seen as more than just improving fitness levels, but can be a way of preventing a range of health issues, this can be especially beneficial for those with a high BMI or with current co-morbid conditions. It’s been shown that small consistent changes can have long term health gains and have significant health prevention benefits.
Providing accessible information to people in health promotion initiatives empowers them to increase activity levels, especially those who lack confidence or access.
Even minor increases in activity levels can protect against worsening health conditions and can protect against future complications. This can reduce the burden on the NHS and improve the quality of life.
By encouraging an increase in physical activity, as well as having health benefits, can provide a more holistic approach that builds healthier, more active communities, with higher mental and physical resilience.
References
Cheval, B. and Boisgontier, M.P. (2021) ‘The Theory of Effort Minimization in Physical Activity’, Exercise and sport sciences reviews, 49(3), pp. 168–178 Available at: https://doi.org/10.1249/JES.0000000000000252.
Cheval, B., Sieber, S., Guessous, I., Orsholits, D., Courvoisier, D.S., Kliegel, M., Stringhini, S., Swinnen, S.P., Burton-Jeangros, C., Cullati, S. and Boisgontier, M.P. (2018) ‘Effect of Early- and Adult-Life Socioeconomic Circumstances on Physical Inactivity’, Medicine & Science in Sports & Exercise, 50(3), pp. 476–485 Available at: https://doi.org/10.1249/MSS.0000000000001472.
Ekelund, U., Tarp, J., Steene-Johannessen, J., Hansen, B.H., Jefferis, B., Fagerland, M.W., Whincup, P., Diaz, K.M., Hooker, S.P., Chernofsky, A., Larson, M.G., Spartano, N., Vasan, R.S., Dohrn, I., Hagströmer, M., Edwardson, C., Yates, T., Shiroma, E., Anderssen, S.A. and Lee, I. (2019) ‘Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis’, BMJ, 366, pp. l4570 Available at: https://doi.org/10.1136/bmj.l4570.
Geidl, W., Schlesinger, S., Mino, E., Miranda, L. and Pfeifer, K. (2020) ‘Dose–response relationship between physical activity and mortality in adults with noncommunicable diseases: a systematic review and meta-analysis of prospective observational studies’, The international journal of behavioral nutrition and physical activity, 17(1), pp. 109 Available at: https://doi.org/10.1186/s12966-020-01007-5.
Ivey, E. (2024) Campaign highlights women’s winter exercise fears. Available at: https://www.bbc.co.uk/news/articles/cz7wq2ny10vo (Accessed: 09/11/2024).
Klenk, J. and Kerse, N. (2019) ‘Every step you take’, BMJ, 366, pp. l5051 Available at: https://doi.org/10.1136/bmj.l5051.
Marmot, M. (2010) Marmot Review – Fair Society, Healthy Lives. United Kingdom: The Marmot Review. Available at: https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review (Accessed: 23/09/2024).
NHS Digital, 2022. Health Survey for England 2022: Part 2. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2022-part-2 [Accessed 11/11/2024].
Office for Health Improvement & Disparities. Public Health Profiles. [11/11/2024] https://fingertips.phe.org.uk © Crown copyright [2024]. (Accessed 11/11/2024)
UK Government. (2019) UK Chief medical officers’ physical activity guidelines. United Kingdom: UK Government. Available at: https://www.gov.uk/government/publications/physical-activity-guidelines-uk-chief-medical-officers-report (Accessed: 10/11/2024).
Ulf Ekelund, Jakob Tarp, Jostein Steene-Johannessen, Bjørge H Hansen, Barbara Jefferis, Morten W Fagerland, Peter Whincup, Keith M Diaz, Steven P Hooker, Ariel Chernofsky, Martin G Larson, Nicole Spartano, Ramachandran S Vasan, Ing-Mari Dohrn, Maria Hagströmer, Charlotte Edwardson, Thomas Yates, Eric Shiroma, Sigmund A Anderssen and I-Min Lee (2019) ‘Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis’, BMJ, 366, pp. l4570 Available at: https://doi.org/10.1136/bmj.l4570.
Varney, J., Brannan, M. and Aaltonen, G. (2014) Everybody active, every day: an evidence-based approach to physical activity. London: Public Health England. Available at: https://www.gov.uk/government/publications/everybody-active-every-day-a-framework-to-embed-physical-activity-into-daily-life (Accessed: 11/11/2024).
World Health Organisation (2020) WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organisation. Available at: https://www.who.int/publications/i/item/9789240015128 (Accessed: 10/11/2024).
World Health Organization (2018) More active people for a healthier world : global action plan on physical activity 2018-2030. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789241514187 (Accessed: 04/11/2024).
World Health Organization (2010) A conceptual framework for action on the social determinants of health. Geneva: World Health Organisation. Available at: https://www.who.int/publications/i/item/9789241500852 (Accessed: 10/11/2024).
Images
Fig 1
World Health Organisation (2020) WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organisation. P35 (Dose response Curve)
Available at: https://www.who.int/publications/i/item/9789240015128 (Accessed: 10/11/2024).
Fig 2
World Health Organization (2010) A conceptual framework for action on the social determinants of health. Geneva: World Health Organisation. P (conceptual framework for action on the social determinants of health)
Available at: https://www.who.int/publications/i/item/9789241500852 (Accessed: 10/11/2024).