Let's Make Scotland More Active: A strategy for physical activity
'We do not cease to play because we grow old we grow old because we cease to play.'
George Bernard Shaw
1 For centuries, people in Scotland lived active lives - but not any more. As a nation, Scotland is inactive, unfit and increasingly overweight (obese). The health of two-thirds of the Scottish adult population is now at risk from physical inactivity, making it the most common risk factor for coronary heart disease in Scotland today. Perhaps most worryingly, this trend starts before young people have left school. Tackling this is now crucial.
2 The health effects of an inactive life are serious. Inactivity accounts for over a third of deaths from heart disease and threatens the progress made in this area over many years. Added to this is the disease, disability and poor mental health that come from growing levels of obesity and a lack of physical strength. Physical inactivity has been called the 'silent killer of our time'.
3 The National Strategy for Physical Activity aims to change this. This Strategy sets out the vision that:
4 This needs changes in both policy and culture. However, as the World Health Organisation (WHO) has noted:
"There is insufficient action and limited policy orientation for encouraging the adoption and maintenance of physically active lifestyles within supportive political, social and physical environments... political leaders and decision-makers need to be convinced of the importance of physical activity for health."
5 Scottish ministers set up the National Physical Activity Task Force in June 2001. This followed a commitment in the Government's White Paper 'Towards A Healthier Scotland'. We recognise that being set up by ministers is a positive sign of commitment to developing a national strategy for physical activity. However, we also support the view of WHO. It is clear that there are no comprehensive strategies, policies or programmes that have long-term funding to deal with the problem of inactivity in Scotland. Where good practice exists, it is not available throughout Scotland. Also, many examples of good practice are short-term projects.
6 For this reason, we are aiming this report at Scottish ministers, the Scottish Executive and its agencies. We are asking them to provide leadership, co-ordination and resources for a strategic approach to physical activity. Without this, we do not believe it is possible for those at a local level to develop comprehensive programmes to deal with the crisis of inactivity.
7 We acknowledge that there is no simple solution to change a national culture of inactivity. However, there is now solid research evidence about effective approaches using many strategies. These strategies are consistent with WHO policy and the five main strategies of the 'Ottawa Charter for Health Promotion' (1996).
Building healthy public policy.
Creating supportive environments.
Strengthening community action.
Developing personal skills.
Directing health services at the people who need them most.
8 The recommendations of this report are entirely consistent with this approach to promoting health.
9 Given the scale of inactivity that we face, we believe that reaching the target levels for physical activity (described in the next section) in this strategy will take 20 years. However, a commitment from Scottish ministers, the Scottish Executive and its agencies is needed urgently. It will only be possible to develop co-ordinated action plans for taking forward the priority areas when there is a clear planning and co-ordination framework in place nationally and resources have been identified.
10 The benefits will be reduced healthcare costs through the reduction of chronic disease and the potential contribution of physical activity to support the delivery of major social, economic, environmental and community policies is enormous. Our recommendations reflect a belief that investment to achieve these targets is "one of the best buys in public health", as stated by Professor Jeremy Morris, one of the UK's leading researchers in this area.
Physical activity and health
What is physical activity?
11 Physical activity is a broad term to describe movement of the body that uses energy. It can be as simple as walking. Some people think about getting active as getting fit and assume that it means vigorous physical activity. It doesn't.
12 We do get fitter as we get more active. But, the goal for good health is to increase the amount of physical activity that we do. In doing more physical activity, we will develop the health-related areas of our fitness. These are cardiovascular fitness (our heart, lungs and circulatory systems), muscle strength and stamina, flexibility and body composition (percentage of body fat). There are also skill-related areas of fitness - power, speed, agility, co-ordination, balance and reaction time. These are not vital for good health but are important for sports performance.
13 The First International Consensus Statement on physical activity, fitness and health recognised that physical activity is a general term. There are many types of physical activity: exercise, sport, play, dance and active living such as walking, housework and gardening.
14 Given this very broad range of ways in which we can be active, there is no single department, agency or organisation that currently develops and promotes and delivers all areas of physical activity.
How much physical activity is enough?
15 Physical activity does not need to be strenuous to have significant effects on people's health, general wellbeing and productivity. Reviews have led to two well-accepted health messages:
Adults should accumulate (build up) at least 30 minutes of moderate activity on most days of the week.
Children should accumulate (build up) at least one hour of moderate activity on most days of the week.
('Moderate activity' is using about five to seven calories a minute - the equivalent of brisk walking.)
16 Evidence shows that this is a complicated message to get across. It has three parts - time, intensity and frequency. Also, the time part is different for adults and children. A recent international physical activity conference (Whistler 2001) decided that, in order of priority, the emphasis should be on:
17 As this is a complicated message, we need to put it across to the public and policy-makers as simply as possible. There is evidence from the Health Education Population Survey (1998) that only 34% of the population are aware of this message.
18 There is strong evidence that the greatest health benefits happen when the least active people become moderately active. In a 20-year study of men and women in the United States, Professor Stephen Blair and his colleagues at the Cooper Institute for Aerobics Research in Dallas found that the risk of dying (at any age) of someone with low fitness was at least twice that of someone of moderate fitness.
19 People can become physically active in many ways. However, evidence suggests that moderate activities are the most appropriate and effective for inactive people. It is important to keep the strategic focus and priority on getting inactive people to be active and on preventing people from reducing the amount of activity they do. It is not the main goal of this strategy to get people who are already physically active to do more physical activity. If our efforts were focused on these people, this would result in wider health inequalities.
Who is inactive?
20 The Scottish Health Survey shows that most people in Scotland are not active enough. The numbers are large and the implications are immense. For example:
72% of women and 59% of men are not active enough for health;
this scale of physical inactivity makes it the most common risk factor for coronary heart disease in Scotland (more so than smoking or obesity); and
even among children, 27% of boys and 40% of girls are not active enough to meet the guidelines.
21 A closer look at the table shows that activity levels vary by age, stage of life and sex. For women, activity drops sharply at 12 to 13 years, levels off from 14 to 35 years and then goes down throughout later life. For men, there is a more gradual decline in activity starting at age 10 to 11 years and continuing for life.
22 Within this general picture of inactivity is a major issue of health inequality. The proportion of sedentary adults (doing 30 minutes or less of physical activity on one day a week or not at all) in the lowest socio-economic groups is double that among those from the highest socio-economic groups. However, any actions to deal with this inequality need to be very carefully targeted as people from the lowest socio-economic groups are also among the most active (largely accounted for by more manual work and lack of access to private motorised transport).
23 The lack of research makes it difficult to comment on differences in activity levels for people with disabilities, people from ethnic-minority groups, people over 74 and people with specific health conditions. However, research from elsewhere suggests that they are likely to be less active than the general population.
What are the risks of inactivity?
24 Inactive people (those who do not meet levels set out in the guidelines) face serious health risks. For example, research shows that inactive people have:
twice the risk of coronary heart disease that active people have;
higher blood pressure - which in itself is a major risk factor for coronary heart disease;
a higher risk of colon cancer - 3.6 times more at risk than active people;
a higher risk of developing Type II diabetes - regular activity can reduce risks of Type II diabetes by 50%;
lower bone density leading to a higher risk of osteoporosis leading to fractures - up to 50% of hip fractures could be avoided with regular physical activity;
a greater risk of being overweight or obese - which also increases risks of other types of cancer as well as osteoarthritis and back problems; and
more injuries and accidents.
These are serious health problems with serious consequences. Although the social and economic costs of inactivity are not often stated, they are no less severe.
Inactive children are at risk of poorer self-esteem, higher anxiety and higher stress levels. They are also more likely to smoke and use alcohol and illegal drugs than active children are.
Among working adults, inactive employees have double the number of days off work compared with active employees.
In later life, inactive people lose the basic strength and flexibility for daily activities and so many lose independence and have poor mental health.
What are the benefits of physical activity?
26 Evidence shows that active people have:
a longer life;
less risk of developing many diseases;
fewer symptoms of depression;
lower rates of smoking and substance misuse; and
more ability to function better at work and home.
27 Showing what the possible cost benefits would be to the economy is also becoming recognised worldwide for making decisions in healthcare. Measuring the economic burden on public funds arising from physical inactivity on morbidity (disease) and mortality (death) is developing. Studies in Canada, Australia, the United States and Northern Ireland have tried to estimate the cost of savings to the economy if physical inactivity is reduced. The Physical Activity Task Force has joined in this discussion by carrying out a study. This study applied a similar model used by previous studies and focused on Scottish data for coronary heart disease, colon cancer and stroke.
28 The study estimated the economic effects based on a goal of reducing the level of inactive Scots by 1% each year for the next five years. The study found that 2,447 people in Scotland die prematurely each year due to physical inactivity. This is made up of 2,162 deaths from coronary heart disease (42% of total coronary heart disease deaths each year), 168 deaths from stroke (25% of total stroke deaths each year), and 117 deaths from colon cancer (25% of total colon cancer deaths each year). If the goal for reducing inactivity levels over the next five years is achieved (that is, only a 1% change a year), the number of deaths due to inactivity will fall by 157. The economic benefit associated with the number of life years saved due to preventing these deaths is estimated to be 85.2 million. Yearly hospital admissions for coronary heart disease, colon cancer and stroke would also fall by around 2,231 cases and the possible yearly cost savings to the NHS as a result is estimated at 3.5 million. These estimates, although cautious, are consistent with other economic benefit studies of physical activity.
29 It is widely accepted that these figures present the tip of the iceberg in terms of possible economic benefits if the population became more active. There are many other benefits of increased physical activity that were not considered in this study. Reduced medical costs from treating other conditions such as depression, fractures due to falling, hypertension and diabetes can also be seen. Measuring the cost benefits due to improved wellbeing and other areas of quality of life is complicated and difficult at the moment. So too is the effect on workplace productivity due to fewer employees being off sick. The Physical Activity Task Force recommends that this study is extended so that the true cost benefits of an active nation are known.
30 We are asking Scottish ministers to adopt a 'spend to save' (spend extra money now to save healthcare costs later) approach to resourcing the work needed to develop action plans to deal with the priorities in this strategy.
What are the barriers?
31 Given the scale of both risks from inactivity and benefits from being more active, it is difficult to understand why so many of us are inactive. Studies such as the Health Education Population Survey provide a broad picture of the barriers to being more physically active.
Barriers to being more physically active, by age
Preferring to do other things
Feeling too fat or overweight
Do not enjoy exercise
Being too old
Lack of time due to other commitments
Ill health, injury or disability
Lack of suitable local facilities
Lack of money
Lack of transport
Nobody to go with
Put off by traffic, road safety or the environment
Put off by the weather
Don't have the skills or confidence to do it
Source: Health Education Population Survey 1997, Health Education Board for Scotland (HEBS)
32 This chart shows that there are a wide range of personal, social and environmental barriers and that these differ depending on our age and stage of life. For people in later life, poor health and bad weather are greater barriers than lack of time or money. For young people, the attraction of other activities and other time commitments are barriers to being more physically active.
33 Fortunately, many of these barriers can be tackled. Research shows the things that help people to change their behaviour are high levels of belief in their ability (self-efficacy), a strong intention and readiness to change, and supportive social networks and environments with no barriers. We have taken account of these in our strategic priorities and objectives.
34 The Task Force commissioned further research to look in greater detail at the barriers for children under five and their parents, teenage girls and men in their mid years, as well as the effectiveness of reducing charges as a way to encourage people to take part. This provides further evidence of issues that we will need to consider in our action plans. This data is available on the Task Force website.
The National Strategy for Physical Activity
35 The National Strategy for Physical Activity is not a one-off report. This is about supporting long-term change.
36 This report presents the conclusions and recommendations from the first stage of the process. In this stage, we looked at:
research about active and inactive people in Scotland;
the links between physical activity and health;
the social and economic effects of inactivity; and
evidence about the best ways to bring about change.
37 This report also states our vision, goals, strategic objectives and priorities. We have deliberately provided only a broad framework of objectives and priorities for developing physical activity in Scotland. We recognise that Scottish ministers, the Scottish Executive and its agencies and community planning partnerships now need to consider how they can best put physical activity objectives and priorities into practice nationally and locally.