13th world sport for all congress — jyväskylä, …...13th world sport for all congress —...

1

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010

2

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010


3


XIII World Sport for All Congress

14-17 June, 2010 — Jyväskylä, Finland

Proceedings, Plenary Sessions

Promo�ng Sport for All

Benefits and Strategies for the 21st Century

Editors:Wendy J. Brown, Eino Havas, Paavo V. Komi

Technical Editor:Olli-Pekka Kärkkäinen

Hosted by:LIKES Research Center for Sport and Health Sciences

Neuromuscular Research Center, Department of Biology of Physical Ac�vity,University of Jyväskylä

4


Proceedings, plenary sessions: 13th World Sport for All Congress — 14-17 June 2010, Jyväskylä, Finland

Editors: Wendy J. Brown, Eino Havas, Paavo V. Komi

Technical editor: Olli-Pekka Kärkkäinen

Cover: Irene Manninen-Mäkelä

LIKES Research Reports on Sport and Health 235

Distribu�on:LIKES Research CenterViitaniemen�e 15FI-40720 JyväskyläFinlandEmail: �[email protected]

ISBN 978-951-790-284-7ISSN 0357-2498

Copyright © 2010, 13th World Sport for All Congress and LIKES Research Center

Printed by: Keuruskopio Oy, Keuruu, Finland (2010)


5


Promo�ng Sport for AllBenefits and Strategies for the 21st Century

Page Contents

I INTRODUCTION

9 Wolfgang Baumann (GER) The Global Sport for All Movement: From Vision to Reality

II COUNTERACTING THE SPREAD OF THE PHYSICAL INACTIVITY EPIDEMIC

21 Wendy J. Brown (AUS) Is Inac�vity a Global Phenomenon?

27 Nick Cavill (GBR) Sport for All – Is It a Reality?

33 Richard P. Troiano and William L. Haskell (USA) The Role of Physical Ac�vity Guidelines in Preven�ng Physical Inac�vity

III HEALTH AND ECONOMIC JUSTIFICATIONS FOR SPORT FOR ALL

43 Evert Verhagen and Willem van Mechelen (NED) Health Issues as Primary Reasons for Choosing Sport for All Programs

49 Pekka Oja (FIN) Sport for All for Health – Fact Or Fic�on?

61 Peter T. Katzmarzyk (CAN) Economic Considera�ons of Sport for All

IV STRATEGIES FOR PROMOTING SPORT FOR ALL

69 Victor K.R. Matsudo (BRA) Transla�ng Evidence into Effec�ve Programs and Prac�ce

79 Thierno Alassane Diack (SEN) Olympafrica: A Program of Social Development Through Sport

85 Tatsuo Araki (JPN) The Importance of Enjoyment: Recommenda�ons from Japan on “Gymnas�cs for All”

89 Paula Risikko (FIN) Mul�sectoral Approaches to Promo�ng Sport for All at the Government Level

93 Eddy L. Engelsman (NED) The World Health Organiza�on Global Recommenda�ons on Physical Ac�vity for Health and the Opportuni�es for the Sports World

6



7


I INTRODUCTION

8

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wolfgang Baumann


9

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wolfgang Baumann

The Global Sport for All Movement: From Vision to Reality

Wolfgang Baumann

TAFISA, The Associa�on For Interna�onal Sport for AllFrankfurt/Main, Germany

E-mail: [email protected]

Introduc�on

At the beginning of a new century we look back on one hundred years in which sport grew into one of the most conspicuous cultural phenomena. From a minority pas�me, and distant from the mainstream of social life, it developed into a significant segment of today’s world that at least concerns, and mostly ac�vely involves, our and future genera�ons. Sport is providing modern heroes and devils, lunch break topics, travel mo�ves, business booms, professional careers, na�onal iden��es and theatres of mass entertainment.

We have become used to this. It is a part of our daily life. It influences how we spend our money, select our idols, use our �me, enjoy public triumph and endure public despair. Modern sport was – together with the World Exhibi�ons of the outgoing 19th century – one of the first carriers of globaliza�on. Its concept and organiza�on spread throughout most of the world’s countries at a rate never seen before. Modern sport was the first form of culture that had the same appearance, principles, rules, terms and fashion around the world – long before global entertainment, tourism or informa�on technologies. Here, for the first �me ever, the world was conceived as one.

Half a century later, a new wave in the development of modern sport began to take shape. From the second half of the 20th century, sport grew further along an addi�onal, and also globally extending, branch. Translated into all major languages of the world, the concept, with its nucleus in Europe, has reached all corners of our globe within the last forty years. But what is seman�cally behind “Deporte para Todos”, “Sport pour Tous”, “Sport Mindenkinek”, “Sport für Alle”, “Kuntourheilu”, “Tautus Sports” to name only a few transla�ons?

The Vision of Sport For All

The three words SPORT FOR ALL stand for a vision that portrays an ideal condi�on in the future: it implies that the given status of sport is seen as insufficient. A vision is a synonym of hope, not of reality. But a vision may develop a dynamic drive in itself if it is nourished by human hope and ac�on. If a central human truth on one hand, and the power of social demands on the other, come together, than a vision may have a chance of at least par�al realiza�on. In our case the growing par�cipa�on of all kinds of people, under all kinds of circumstances, and in all kinds of ac�vi�es, being understood and shaped as Sport for All. From five percent of the popula�on to twenty, to thirty, to fi�y and seventy, who knows? We may never reach the one hundred. And we may have to start again with every genera�on. But the vision is worth every effort.

10

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wolfgang Baumann 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wolfgang Baumann

Under the name Sport for All, programs are developed which give everybody access to sport, independent of compe��ve performance: from the very young to the very old, according to the Life Stages Concept1, and under all economic condi�ons. Inclusion, in contrast to compe��on, has been the key word for this movement. The sport systems thus responded to changes in contemporary life condi�ons. Worldwide sport grew into a new dimension of par�cipa�on: more than one and a half billion people are es�mated to par�cipate in sport today. Sport for All, which started as an idea without pres�ge and publicity, has made remarkable progress and the term as a right to ci�zenship was formulated for the first �me in the resolu�on of the Council of Europe, 19662. Today, Sport is not yet for “All”, but it is for “more” than ever.

I am personally convinced that the visionary claim inherent in the term Sport for All has been important. According to the principle “imagining the impossible in order to obtain the possible”, we have together been very successful over the last decades in our a�empt to achieve our aims. In consequence, this Second Wave in the globaliza�on of sport gives Sport for All an extraordinary importance in today’s poli�cs, health, culture, community and economic development.

What Does “Sport for All” Mean Today?

From the point of view of TAFISA (The Associa�on For Interna�onal Sport for All), the Interna�onal Olympic Commi�ee, the World Health Organiza�on and others, Sport for All can be understood as the systema�c provision of physical ac�vi�es which are accessible for everybody. Sport for All is viewed as a process of social change which, to a considerable extent, can be planned and implemented on a large scale. The Sport for All movement is an intended devia�on from the tradi�onal sport system, as it renounces some tradi�ons and replaces them with others that promote greater accessibility of exercise and sport for everybody. Sport for All is therefore understood as a modern response to the basic human right, and necessity, of exercise and play3.

However, we have to ask ourselves the ques�on: Is Sport for All, as it appears now, sustainable? Will it stay among us in the forms and dimensions we have become used to? Twenty years from now, will sport have the same “face” as the one it had at the turn of the century? We can speculate about that and simply deduce from the shi�s and changes which occurred in the last century that there will be major changes to come in this century.

The Chronology

Before looking into the present and future of Sport for All, let us remember the history of our movement. The corner stones in the development of the global Sport for All movement are shown in the following table. Principally, it can be seen that in the last four decades, the Sport for All movement has grown more from prac�cal approaches than from theore�cal interpreta�ons4.


11


PHASE ACTION

Pioneer (1966 – 1985)

• Individuals as visionaries (Palm, Astrand, Conrad, Hauge-Moe, Wolanska, Dixon, Tröger, Chang, Oja etc.)• European origin• Volunteer movement• Informal biannual Trim and Fitness Conferences (since 1969)• Sport for All men�oned by Council of Europe (1966)

Consolida�on(1986 – 1999)

• 1st SfA Congress, Frankfurt (1986) ini�ated by IOC and DSB• Since then biannual Congresses • Establishment IOC SfA Commission (1983)• Founda�on of TAFISA (1991)• Interna�onal Conferences on SfA i.e. biannual TAFISA Congresses• Professionalisa�on • Launch of interna�onal SfA programs, e.g. Olympic Day Run (1987), World Walking Day (1991), Challenge Day (1993)• Expansion from Europe to the whole world• Establishment of na�onal SfA bodies

Globaliza�on(2000 – present)

• Involvement of addi�onal stakeholders e.g. WHO, UNESCO, UN• Targeted alliances established i.e. Healthy Ci�es (WHO)• Establishment of educa�onal schemes• Resolu�ons and policy papers• Social Marke�ng approach

The Reality

What are the specific characteris�cs of the global Sport for All Movement at present? As the leading interna�onal Sport for All organisa�on, TAFISA recognises seven key phrases that reflect not only the movement’s success, but also document the present standing of the global Sport for All movement. These are leanings from prac�cal, “on the ground” experiences. They also describe the specific challenges ahead. In general, however, the number one keyword in the processes described below is change. The last human genera�on has experienced more new developments in the field of sport than ever in modern history. A major part of this change has taken place in the area of recrea�onal sports or Sport for All.

The First Key Phrase is “Growth”

The Sport for All Movement is growing constantly. This is not only reflected in the growing numbers of par�cipants, but also in the increasing number and variety of na�onal Sport for All organiza�ons. TAFISA has accepted primarily those ins�tu�ons which are responsible for na�onal Sport for All programs. We do not insist on having only sport federa�ons or governmental ins�tu�ons. We take those organiza�ons which are actually doing the job, regardless of legal structure, as this meets the current trends in organiza�onal structures of Sport for All at the na�onal level.

12


In regard to the organiza�on of Sport for All on the na�onal level, an interes�ng phenomenon is observed. It appears that in those countries where tradi�onal sport systems are not prepared to integrate Sport for All as a legi�mate and deserving subsystem, there is a tendency for the establishment of independent na�onal Sport for All organiza�ons separate from the tradi�onal sport system. This tendency is also clearly reflected in the member structure of TAFISA, where more than 40% of the 200 member organiza�ons from 140 countries are independent na�onal Sport for All organiza�ons as the TAFISA member structure (2010) shows below. They are, of course, linked with the tradi�onal sport system of a country, but operate separately5. In those countries with an independent organiza�on, the condi�ons for an integra�ve solu�on in the tradi�onal sport structure were not seen to be as effec�ve as a separate structure. However, it is yet not clear whether this is for the advantage or disadvantage of the na�onal and interna�onal development of Sport for All.

Moreover, from a structural point there is an increasing establishment of interna�onally opera�ng Sport for All organiza�ons, very o�en origina�ng from a regional tradi�onal sport that is trying to spread globally5.

The Second Key Phrase is “Programs”

There is a great demand from countries for prac�cal Sport for All programs and events that can be easily applied to their na�onal market. This is in par�cular true of the Asian, La�n American and African regions. It appears that, due to a lack of experience and competence to develop their own na�onal promo�onal programs, members are searching for any sort of advice and programs that they can implement in their own country. The IOC Olympic Day Run is a fine example of how to meet this request.

Our organization is a ...

18%

8%

32%

42%

governmental organization

NOC

national sport confederation

special Sport for All organization


13


TAFISA has made responding to this demand one of its key priori�es in providing services for members. This demand explains to a large degree the success of our programs, including

• World Challenge Day, which is a friendly compe��on in Sport for All between ci�es of comparable size. It is always held on the last Wednesday of May, with 50 million par�cipants from 3.000 ci�es in more than 50 countries;

• World Walking Day, which takes place on the first weekend in October, with 70 countries par�cipa�ng every year;

• World Sport for All Games, which every four years bring together more than 100 countries presen�ng their tradi�onal games and sports, with the last Games held in Busan, Korea, 2008 under IOC and UNESCO patronage;

• Triple AC (Ac�ve City – Ac�ve Community – Ac�ve Ci�zen) program which focuses on the promo�on of Sport for All in the community se�ng and is being developed in partnership with the IOC.

In order to best serve the request of our members, TAFISA offers to par�cipa�ng members a tool box containing a complete set of professional standardized instruments for the organiza�on and marke�ng of the program on the na�onal or local level. For the success of these programs it is important to emphasize that, while they are conducted on a global scale, they have succeeded because they are community-based and low-cost in their implementa�on, with maximum flexibility at the local level6.

According to our findings7 the following trends in the development of na�onal Sport for All programs are apparent:

• Rediscovery of Tradi�onal Sports and Games;

• Use of Open / Public Spaces:

• Return to Simplicity;

• Focus on New Target Groups.

The further development of these individual programs and events demands that there is a comprehensive, targeted campaign, as a mul� na�onal or even global ini�a�ve, to use Sport for All and physical ac�vity to fight obesity and inac�vity amongst ci�zens of the world. This ini�a�ve would be in keeping with various statements of the IOC President, where he envisages a global campaign to fight obesity. Moreover, the issue was also referred to in the Final Recommenda�ons of the XIII Olympic Congress last year in Copenhagen8. TAFISA is prepared to serve as a coordinator in order to design and launch the campaign, with the help of interna�onal stakeholders and sponsors.

14


The Third Key Phrase is “Recogni�on”

Sport for All started in the 1960s as a concept without reputa�on or publicity. Very o�en in the shadow of elite sport, it has developed tremendously since then and is now well respected in the world of interna�onal and na�onal sports.

An example of the new poli�cal posi�on held by Sport for All is documented by:

• Acknowledgement of Sport for All by the IOC, including the signing of a contract between TAFISA and the IOC for the development of Sport for All programs;

• Signing of the “Busan Appeal for the Promo�on and Development of Tradi�onal Games” by UNESCO and TAFISA;

• Coopera�on between TAFISA and the WHO in regard to “Healthy Ci�es” and “Triple AC”.

On the na�onal level, there is a clear indica�on that Sport for All is increasingly considered by governments to be crucial for the development of society. The a�ached table7 reflects the significance governments are gran�ng to Sport for All on the poli�cal level:

Political Recognition of Sport for All

16

25

31

24

15

0

5

10

15

20

25

30

35

part of nationalconstitution

explicitly mentionedpart of a national

sport law

part of an off icialgovernmental

policy paper on thenational level

part of an off icialgovernmental

policy paper on theregional level

a nationalCharter/Resolutionfor the promotion ofSport for All exists

Figure 1. TAFISA Survey 2008, based on 70 countries responses.

Finally, from a poli�cal view, the future development of Sport for All globally will depend on how the exis�ng regional and interna�onal bodies working in Sport for All will succeed in joining forces to speak with one voice. With the increasing par�cipa�on in Sport for All worldwide, the movement needs a clear poli�cal iden�ty and mission that can only be achieved by the outspoken will and readiness of all stakeholders to follow the same general aims and objec�ves.


15


Presently an exci�ng process is under way in regard to the establishment of alliances and partnerships between various players in Sport for All on the regional and global level. For example, TAFISA has:

• As a result of our longstanding partnership, signed a contract with the IOC on the development of two joint projects in Sport for All, namely the TAFISA Cer�fied Leadership Course and the TAFISA Triple AC program;

• Integrated IANOS into its organisa�on and member base, signed an MoU with ENGSO in Europe;

• Started talks with FISpT to establish a closer coopera�on for the benefit of our members.

These and other examples strongly indicate that, on the global level, a process of consolida�on through coopera�on and amalgama�on has started. The ul�mate goal should be the shaping of one strong, global, independent Sport for All body in close coopera�on with the IOC, represen�ng the interests of the global Sport for All Movement in order to strengthen our posi�on and thus further increase recogni�on in the poli�cal, economic and social field.

The Fourth Key Phrase is “Extension of Perspec�ve”

The new image and significance of Sport for All correlates with a new understanding of its manifold benefits for the individual as well as for society. Sport for All is much more than leisure �me for the masses; it also has important social outcomes. The new and future message is that Sport for All is not only directed to the individual, but is also embedded into a social context9.

Sport for All has taken on a new responsibility. To fully exploit the opportuni�es prevailing in Sport for All means to fully unfold its cultural, social, integra�ve, health and economic quali�es. What we need is an extension of perspec�ve, with the result of presen�ng Sport for All as beneficial for the individual and also for society; as an individual and also a social process, and as a medium to change society. This adapta�on is not yet fully explored, and not completely understood and applied either in sport clubs, sport organiza�ons, sport departments of ci�es and states, in the sports media, or in the spor�ng goods industry.

Sport for All now aims for more. It gains a new dimension and strengthens its poli�cal and social significance. It offers its services for health and integra�on, for peace and solidarity. It aims for an ac�ve world. It aims for making the world a be�er place! Of course, Sport for All cannot solve all the serious problems the world is facing. However, it can help to make the world be�er. The significance, recogni�on and visibility of Sport for All will increase to the degree we, as leaders, succeed to present Sport for All as a major means to improve society. I personally believe, due to its manifold social and health benefits, that Sport for All should play a much stronger role in our social lives.

16


The Fi�h Key Phrase is “Networking and Exchange”

The major success factor for our future development is, quite simply, the exchange and sharing of experiences, knowledge and good prac�ces between Sport for All organiza�ons. Especially under limited financial condi�ons, it is important not to duplicate effort among organiza�ons. What has been developed successfully in one country should be available to all other interested par�es. A new solidarity in Sport for All as an integra�ve, not compe��ve, system is required10.

In order to facilitate a systema�c and demand oriented transfer of knowledge between all of us, we need professional tools, including making use of modern informa�on technology11. TAFISA is presently re-launching its website, above all in order to establish and provide a pla�orm to our members for the exchange and sharing of experience. We would be pleased to extend our responsibility beyond our member structure and establish a global “clearing house” for the benefit of the global Sport for All movement and its stakeholders.

The Sixth Key Phrase is “Educa�on”

One of the most frequently asked ques�ons of TAFISA refers to educa�onal schemes for the training and qualifica�on of Sport for All leaders. It deals with the transfer of knowledge and informa�on beyond the na�onal level to the local and regional level of Sport for All leaders. So far in the last 30 years, we have served the na�onal directors of Sport for All. We invited and received them at conferences. We have reached a hundred or two hundred persons this way each �me. But there are many thousands of leaders responsible for Sport for All programs on the sub-na�onal level. In city municipali�es, sport ministries, sport federa�ons, clubs, resorts, companies etc. However, there are few adequate programs on a sub con�nental or regional level that incorporate the specific management skills and competencies required for the development of Sport for All.

One of our answers has been the establishment of the “TAFISA Cer�fied Leadership Course in Sport for All” (CLC) which is a five day course to qualify young Sport for All leaders. TAFISA is proud to state that the IOC recently became a partner of the program with the special objec�ve of invi�ng delegates from NOCs to par�cipate. So far CLCs have been organized in Iran, Macau, Tanzania, Nigeria, Australia and Malaysia, with further courses planned this year in Turkey and Argen�na. Altogether 40 countries have sent representa�ves to a�end the CLCs so far. Apparently we have filled a gap.

At its last board mee�ng in Tel Aviv in March, the TAFISA Board decided to develop and establish a six month, semi virtual “Interna�onal Sport for All Management Course” as an advanced program. TAFISA aims to launch this at the end of this year in conjunc�on with a group of private universi�es from Austria and Germany. Using the internet we can reach the target group today and can offer specific ongoing and accessible educa�on in Sport for All management. Another approach to meet the lack of educa�onal schemes in Sport for All could be given by a “Sports Volunteers Corps” modelled for instance on the South African SCORE program, but supplemented by specially experienced, or re�red sport administrators from countries with a extensive Sport for All experience.


17


The Seventh Key Phrase is “Targeted Approach”

In order to ul�mately reach “All” (the whole popula�on), a targeted approach is increasingly applied in many countries. This includes the iden�fica�on of large and significant groups of the popula�on, such as families, women or immigrants that are reached by using specific and targeted marke�ng instruments and tools. The underlying strategy is referred to as the Life Stages Concept, e.g. children, young adults, mid-age and older people etc. in order to assure lifelong physical ac�vity for all. The ques�on of how to manage this diversity of target groups in Sport for All appears to mark one of our major challenges for the future.

Conclusion

There is a clear indica�on that we are willing to cope with the contemporary and future challenges in Sport for All. However, we have to ask ourselves, as na�onal Sport for All leaders: is the job done? No, the job is not yet done. The world of the 21st century knocks at our doors with new challenges. Sport is confronted with the challenges of a changing world. There are challenges ahead of us that will require concerted efforts to improve the success of Sport for All.

The 20th century was the first saeculum of Olympic sport; the 21st century will see the rise of Sport for All. Couber�n’s brilliant idea of crea�ng an elite for li�ing the level of par�cipa�on in the general popula�on, by ac�ng as role models for us average humans, will have to be complemented by a redirected focus, not only on the elite but on humankind as a whole. The tasks are there. The solu�ons have to be found. The work may last long. But it is worth every effort!

Prac�cal Implica�ons

• The ins�tu�ons of Sport for All can become more effec�ve through coopera�on and shared capacity building. By working together they can become more visible in the arena of interna�onal sport, be taken more seriously by elite sport, and be be�er supported by governments and the business world. The Sport for All movement must react flexibly to the varying social, poli�cal and economic condi�ons around the world, and strive to reduce inequali�es in sports par�cipa�on for all in both developed and developing countries.

• The IOC, with its Sport for All Commission has assisted the development of Sport for All remarkably since the nineteen eigh�es. The IOC and SportAccord (formerly GAISF) should support the global Sport for all movement by encouraging effec�ve involvement in both elite and grass roots sport.

• The poten�al of Sport for All could be be�er recognized by UNESCO as a tool for the socializa�on of humans into a culture of peace. This might involve further recogni�on and promo�on of tradi�onal games and sports, as well as physical educa�on for all children. The social and cultural aspects of Sport for All could also be a focus of research by the World Leisure and Recrea�on Associa�on.

• The Sport for All movement could contribute to a new understanding and prac�ce of healthy behavior, by working with professionals in the health sector, including the World Health Organiza�on, at the local, na�onal and global level.

18

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wolfgang Baumann 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010

Abbrevia�ons

ENGSO European Non Governmental Sport Organiza�ons

FISpT Federa�on Interna�onal Sport pour Tous

IANOS Interna�onal Assembly Non Governmental Organiza�ons of Sport

GAISF General Assembly of Interna�onal Sports Federa�on

References

1. Tröger W (2008). 10th ASFAA Congress, Paper “Health, Educa�on and Culture through Physical Ac�vity and Games”.

2. Hartmann-Tews I (1996), Schorndorf, Hofmann. “Sport für alle!?“ (p.40).

3. Palm J (1991), Schorndorf, Hofmann. Sport for All – Approaches from Utopia to Reality.

4. Da Costa L, Miragaya A (2002), Oxford, Meyer & Meyer. Worldwide Experiences and Trends in Sport for All (page 20).

5. Dixon B (2008). TAFISA Business Strategy Development.

6. Andreasen A (1995), Washington, Jossey-Bass. Marke�ng Social Change (page 3).

7. Baumann W (2008). 4th TAFISA Sport for All Survey.

8. XIII Olympic Congress (2009). “The Recommenda�ons”.

9. Baumann W (2009). 21st TAFISA World Congress, Paper “Aiming for An Ac�ve World”.

10. Baumann W (2006). TAFISA Magazin, Current Status of Sport for All Globally.

11. 12th World Sport for All Congress. “Sport for All – for Life”, Final Declara�on, Gen�ng Highlands, Malaysia (2008).


19


II COUNTERACTING THE SPREAD OF THE PHYSICAL INACTIVITY EPIDEMIC

20

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wendy J. Brown


21

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wendy J. Brown

Is Inac�vity a Global Phenomenon?

Wendy J. Brown

School of Human Movement StudiesUniversity of QueenslandSt Lucia, Australia


Introduc�on: the Difficul�es of Defining Inac�vity

In thinking about how pa�erns of inac�vity have changed over the last several hundred years, it is evident that the industrial revolu�on, with the introduc�on of machines for transport, mining and manufacturing, significantly changed the way that people around the world lived and worked. As a result, in western developed countries today, ac�vity has been almost en�rely engineered out of our lives. In countries with widespread use of motor vehicles there is li�le need to expend energy for transport, even less need to expend energy in associa�on with food produc�on, and machines are used to assist with all kinds of household work. In the last 25 years, since the advent of the internet, people working in business and commerce have become increasingly sedentary. At the same �me leisure �me physical ac�vity (LTPA) may have given way to more sedentary pas�mes such as watching television, playing computer games and social networking via the internet. In some socie�es, it would appear that there is no need to move at all. But is this inac�vity a global phenomenon? In some parts of the world people s�ll �ll the soil by hand (or with the help of animals); they grow most of their own food, and rely on human muscle power to construct shelter and to move from place to place. Presumably because of the high daily energy expenditure in everyday life, ac�vity in leisure �me is limited.

So how do we define “inac�vity”? Even if we confine our thinking to the last 50 years, this is a difficult ques�on to answer. Since 1948, when Jeremy Morris began his studies of the so called “epidemic” of heart disease, epidemiologists have been interested in the no�on of physical ac�vity at work. He showed differences in risk factors for, and incidence of heart disease in London bus drivers (who sat all day) and conductors (who climbed the stairs all day to sell �ckets). Later he showed that English postmen, who walked, cycled, li�ed and carried to deliver the mail, had be�er health outcomes than government office staff 1. Clearly occupa�onal physical ac�vity was important for health. It was not un�l the 1970s that the results of the early cohort studies, [which had been established earlier by Morris in London (Bri�sh civil servants) and Ralph Paffenbarger in the USA (Harvard Alumni and San Francisco dock workers)] found that aerobic leisure �me ac�vity was also associated with protec�on against the development of heart disease1. The results of the Harvard alumni study, which collected informa�on on stairs climbed, city blocks walked and par�cipa�on in spor�ng ac�vi�es, provided the first indica�on that it might be important to consider both occupa�onal and leisure �me ac�vity when assessing the health risks of inac�vity.

22

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wendy J. Brown 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wendy J. Brown

Measuring Inac�vity in Different Countries

In the last decade of the last century progress was made towards the assessment of ques�onnaires for assessing popula�on levels of ac�vity (and inac�vity) in different countries. One of the earliest studies, which focussed mainly on sports par�cipa�on, found that there was a north-south gradient in physical ac�vity in the (then) 15 countries of the EU, with Sweden and Finland more ac�ve than Italy, Spain and Portugal in 1997. However, when the same countries were surveyed using the Interna�onal Physical Ac�vity Ques�onnaire (IPAQ), a different picture emerged. This is because the IPAQ was designed to capture physical ac�vity in the domains of work, leisure and transport, rather than focusing solely on sport, as the earlier survey had done. The results showed that Sweden, which was near the top of the ac�vity list in the 1997 survey, had one of the lowest physical ac�vity scores on the IPAQ, presumably because of low levels of transport and work-related ac�vity. Overall, in the total sample, the prevalence of “being sedentary” was 31%, and the lowest levels of sedentariness were observed in the Netherlands (19%) where there is a high prevalence of bicycling for transport2. Clearly it is important in these studies to use the same measure if comparisons between countries are to be valid.

The IPAQ was later used by researchers from the World Health Organiza�on (WHO) to assess physical ac�vity levels in 51 low-middle income countries outside Europe. Only 18% of the pooled sample was found to be inac�ve, compared with 31% in the EU countries. Levels of inac�vity were consistently low in parts of Africa, Eastern Europe, Southeast Asia and the Western Pacific, especially among people living in rural areas. These results seem to suggest that inac�vity is not a global phenomenon, and this finding is confirmed in another WHO report, in which data from several different surveys were carefully compared. Levels of inac�vity (no ac�vity in work, transport or leisure) were lowest (about 12%) in Ethiopia and South Africa, and highest (about 28%) in Peru3. Taken together, these es�mates suggest that about 20% of people in developing countries, and 30% of people in the EU do not do any physical ac�vity for work, transport or leisure. Moreover, according to a recent WHO report, only 40% of the world’s popula�on currently meets the widely accepted guideline of 30 minutes of moderate intensity ac�vity daily. Hence 30-40% of the world’s popula�on probably do some ac�vity, but insufficient to meet the guidelines4.

Are There Any Trends over Time in Physical Ac�vity?

So is inac�vity a global phenomenon and is it ge�ng worse? Are physical ac�vity levels around the world falling? So far I have said li�le about the USA, Canada or Australia, as their na�onal measures cannot easily be compared with the IPAQ. However, even if countries use different measures, surveillance data can be used to assess trends over �me within countries, provided the same measure is used for each survey.

A systema�c review of worldwide trends in physical ac�vity published in 2009 located 41 papers which included data on temporal trends in adults or children. In this review, Knuth and Hallal concluded that leisure �me physical ac�vity levels in adults tend to be increasing, while occupa�onal ac�vity is decreasing. They also found that both physical ac�vity and fitness appear to be declining in youth5.


23


Some of the strongest evidence of an increase in leisure �me physical ac�vity in adults comes from Finland. The North Karelia project found that LTPA increased from 13 to 25% in men and from 10 to 18% in women, from 1972 to 1997. A report from other long term studies, including the Minnesota Heart Survey and the Mul�ple Risk Factor Interven�on Trial (MRFIT) has also reported that energy expenditure in leisure �me increased over the period from 1957 to 1987, from 97 to 196 kcal/day in men and from 111 to 124 kcal/day in women. The increases in these studies, par�cularly in men, are remarkable, and probably reflect the success of the early interven�on trials which were conducted in these areas. There is however also evidence of an increase in LTPA in the 1980s and 1990s in both Scotland (from 1987 to 1991) and New Zealand (from 1982 to 1994), where, to my knowledge, no large interven�on studies were conducted5. Trends in the USA during the 1990s and early 2000s are however less clear, with one CDC report documen�ng a very small increase (from 24 to 25%) in the propor�on of people mee�ng physical ac�vity guidelines from 1990-1998, and another repor�ng a decrease from 30% to 24% from 1994 to 20045. Changes to the wording of the BRFSS survey in 2001 may account for this confusion. Changes to the ques�ons used in na�onal monitoring also make it difficult to draw conclusions about trends in Australia and the England. The Australian Na�onal Health Survey (NHS) data show an increase in walking (8%) and moderate ac�vity (4%) between 1989 and 2000, while par�cipa�on in vigorous ac�vity remained stable over this period6. The NHS focuses mainly on recrea�onal physical ac�vity. In contrast, the Ac�ve Australia survey, which includes ques�ons about physical ac�vity for transport as well as recrea�onal ac�vity, found a decrease in physical ac�vity from 51% mee�ng guidelines in 1997 to 46% in 20007. An interes�ng recent paper from Australia determined whether age, birth cohort and period of survey had independent effects on energy expended in LTPA by Australian adults from 1990 to 2005. The results show that declines in energy expenditure over this period were most marked in young adults (under 35, especially men) and older people (over 65)8. More recent Ac�ve Australia surveys, conducted by separate State jurisdic�ons from 2002 to 2009, show that physical ac�vity levels are now increasing in Australia, with recent es�mates showing that almost 60% of people in Victoria and Western Australia now meet the na�onal guidelines.

Similar trends have been reported in Canada, where there was an increase in LTPA from 1995 (54% mee�ng guidelines) to 2007 (65%)9. Na�onal monitoring in Finland also confirms that their upward trend con�nued through to 20035. The most recent data from the USA suggest a 2% increase in the propor�on of people who par�cipated in regular physical ac�vity in 2009 (35.4%), compared with the average over the previous ten years10. Finally, the Health Survey for England also showed that par�cipa�on in ac�vi�es such as cycling, swimming, gym and fitness club ac�vi�es increased between 1999 and 2004, with the propor�on of adults mee�ng the physical ac�vity recommenda�ons increasing from 46.8% to 48.5%11. As was the case in Australia, the increases were not apparent in the 16-34 and over 65 year age groups .

The situa�on is not so encouraging for children and youth. A 2003 analysis of secular trends in the fitness of 129 882 children and adolescents from 11 countries found a decline in fitness of about 1% per annum over the 20 year period from 1980 to 200012. This decline mirrors several reports of falling levels of par�cipa�on in physical educa�on and leisure �me ac�vity in the US (1991-2003), Switzerland (1993-2002), Canada (1997-2001) and Australia (1985-2001). The only increase has been reported in Sweden, where sports par�cipa�on increased from 53% to 61% in girls and from 68% to 72% in boys from 1974 to 19955. A 2005 narra�ve review of trend data by Dollman and colleagues found that physical ac�vity in clearly defined contexts such as ac�ve transport, school physical educa�on and organised sport is declining in many countries13.

24

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wendy J. Brown 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wendy J. Brown

The authors note that recent es�mates point to total use of electronic media (TV, videos, DVDs and games) of about five hours a day in western adolescents, and it is likely that these ac�vi�es may now be taking up �me that was once dedicated to par�cipa�on in more ac�ve leisure and outdoor play. However, a study of children in the same ten South Australian Schools in 1985 and 2004 found no differences in club or school sports par�cipa�on, or walking to school, and PE classes were more frequent in 2004 than in 198514. However, fewer children cycled to school in 2004, and more children sat and talked during school breaks. Overall, there was an increase in leisure �me physical ac�vity in the boys, but not in the girls. These results suggest that while physical ac�vity has declined in some contexts, in others it is the same, or higher in 2004 than in 1985.

What about Sport – Is Par�cipa�on Decreasing?

There is very li�le informa�on specifically on sports par�cipa�on around the world, especially in developing countries. Data from Canada suggest that the propor�on of people par�cipa�ng in sport (defined as physical ac�vi�es that involve compe��on and rules and develop specific skills) fell from 35% in 2004 to 30% in 2008. The decline was most notable in those aged 45-64 years, in some middle-income Canadians, in those with post-school educa�on and in re�rees. The five most common sports were ice hockey, soccer, golf, baseball or so�ball and racquet sports such as tennis and badminton15. However, in Australia, regular (three �mes per week) par�cipa�on in “organised” physical ac�vity (defined as physical ac�vity for exercise, recrea�on or sport that was organised by a club or centre) increased from 9% of the adult popula�on in 2001 to 12% in 2008. In contrast with the spor�ng image of Australians that is o�en portrayed by the media, only about half of these par�cipants (6.3%) were members of a spor�ng club. In Australia the most common ac�vi�es were aerobics/fitness, golf, football, netball and tennis16. This increase in par�cipa�on in sport in Australia occurred at a �me when overall physical ac�vity par�cipa�on (par�cularly walking, either to get to and from places – or for recrea�on) also increased6.

The narra�ve review of children’s physical ac�vity levels could find no consistent trends in organised sport par�cipa�on in children in different countries13. For example, in contrast with the data for adults, par�cipa�on by Australian children in organised sport declined over two decades from 1986-2006 by about 2%. In Sweden, par�cipa�on by children in tradi�onal team sports also seems to be declining, as less structured ac�vi�es become more popular, with no overall change in par�cipa�on levels. However, in England, there appears to have been an increase in sports par�cipa�on between 1994 and 2002, par�cularly in girls13.

Can Par�cipa�on in Sport Be Increased?

Australian na�onal physical ac�vity surveys in November 1999 and 2000 could find no immediate effects on popula�on physical ac�vity levels of having the Olympic Games in Sydney in 200017. However, in the lead-up to the Summer Olympic Games in 2012, Sport England has developed a strategy which aims to increase the number of people playing sport by 1 million in the period 2005/2006 to 2012/2013. In the baseline survey for this strategy (Ac�ve People Survey 1) in 2006, 15.5% of adults reported par�cipa�ng in sport at least three �mes a week for 30 minutes at moderate intensity. By 2008/2009 this propor�on had increased to 16.4%. The increase was most marked in men, and in those aged under 5418.


25


Conclusion

Is inac�vity a global phenomenon? Certainly, if we consider physical ac�vity at work, then the answer would appear to be “yes”. Although the data are scarce, occupa�onal physical ac�vity in developing countries is declining as countries adopt more automated prac�ces in agriculture and manufacturing, and as motor vehicles become more widespread. In western developed countries there are data to show that occupa�onal physical ac�vity has declined significantly, especially since the registra�on of the first three “dotcoms” in 1985 and the first publically available dial-up internet access in 1989.

However, during the last 20 years of the 20th century, although we might have expected to see a decline in LTPA with the increase in screen based ac�vi�es, there were no clear interna�onal downward trends in LTPA in adults. Indeed, since the turn of the century, it would appear that most western developed countries are experiencing increases in LTPA. This upturn appears to be the result of adop�on of the moderate ac�vity message, with more adults now walking for transport or recrea�on, rather than because of an increase in par�cipa�on in organised sport and recrea�on. This increase in physical ac�vity, is not however apparent in children and youth, or in younger (<35) or older (>65) adults. If the Sport For All movement is serious about ge�ng ALL involved in sport, then it will be necessary to focus on people of all ages, across the en�re lifespan, but with a par�cular focus on these age groups.


• Occupa�onal physical ac�vity levels are falling. To counteract this there is a need for more physical ac�vity in leisure �me.

• This is especially important for “Gen Y” (young adults) as their levels of physical ac�vity appear to be falling as �me in sedentary leisure (e.g. screen �me) increases.

• With the ageing of the popula�on, and a decline in physical ac�vity among older people, there is also a need to focus on people over 60 years old.

• Sport for All could be an important strategy for increasing leisure �me ac�vity, especially in younger and older adults, who appear to be most at risk of declining physical ac�vity levels.

26

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Wendy J. Brown 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Nick Cavill

References

1. Blair SN, Morris JN (2009). Healthy Hearts – and the Universal Benefits of Being Physically Ac�ve: Physical Ac�vity and Health. Annals of Epidemiology, 19 (4), 253 – 256.

2. Brown WJ (2010). Global Prevalence of Adult Physical Inac�vity. In Bouchard C, Katzmarzyk PT (Eds.). Physical Ac�vity and Obesity (2nd Hearts Edi�on). Champaign, USA: Human Kine�cs.

3. Bull F, Armstrong T, Dixon T, Ham S, Neiman A, Pra� M (2004). Physical Inac�vity. In: Ezza� M, Lopez A, Rodgers A, Murray C (eds.). Compara�ve quan�fica�on of health risks: global and regional burden of disease a�ributable to selected major risk factors. World Health Organiza�on: Geneva, 2004, 729-881.

4. World Health Organiza�on. Physical Ac�vity. Available online at: h�p://www.who.int/dietphysicalac�vity/publica�ons/facts/pa/en.

5. Knuth AG, Hallal PC (2009). Temporal Trends in Physical Ac�vity: A Systema�c Review. Journal of Physical Ac�vity and Health, 6, 548 – 559.

6. Merom D, Phongsavan P, Chey T, Bauman A (2006). Long-term changes in leisure �me walking, moderate and vigorous exercise: Were they influenced by the na�onal physical ac�vity guidelines? Journal of Science and Medicine in Sport, 9, 199-208.

7. Bauman A, Ford I, Armstrong T (2001). Trends in popula�on levels of reported physical ac�vity in Australia, 1997, 1999 and 2000. Canberra: Australian Sports Commission.

8. Allman-Farinelli MA, Chey T, Merom D, Bowles H, Bauman AE (2009). The effects of age, birth cohort and survey period on leisure-�me physical ac�vity by Australian adults: 1990 – 2005. The Bri�sh Journal of Nutri�on, 101 (4), 609 – 617.

9. Bryan SN, Katzmarzyk PT (2009). Are Canadians mee�ng the guidelines for moderate and vigorous leisure-�me physical ac�vity? Applied Physiology, Nutri�on and Metabolism, 34 (4), 707- 715.

10. Centers for Disease Control and Preven�on. Early Release of Selected Estimates Based on Data from the January-September 2009 National Health Interview Survey: Leisure �me physical ac�vity. Available online at: h�p://www.cdc.gov/nchs/nhisreleased201003.htm.

11. Stamatakis E, Chaudhury M (2010). Temporal trends in adults’ sports par�cipa�on pa�erns in England between 1997 and 2006: the Health Survey for England. Bri�sh Journal of Sports Medicine, 42, 901 – 908.

12. Tomkinson GR, Leger L, Olds T, Cazorla G (2003). Secular trends in the fitness of children and adolescents 1980-2000 – an analysis of 20m shu�le run studies. Sports Medicine, 33 (4), 385-400.

13. Dollman J, Norton K, Norton L (2005). Evidence for secular trends in children’s physical ac�vity behaviour. Bri�sh Journal of Sports Medicine, 39, 892 – 897.

14. Lewis N, Dollman J, Dale M (2007). Trends in physical ac�vity behaviours and a�tudes among South Australian youth between 1985 and 2004. Journal of Science and Medicine in Sport, 10, 418-427.

15. Canadian Fitness & Lifestyle Research Ins�tute (2009). Lets get ac�ve: Planning effec�ve communica�on strategies: 2008 Physical ac�vity monitor: facts and figures: Sport par�cipa�on in Canada. Available online at: h�p://www.cflri.ca/eng/sta�s�cs/surveys/documents/PAM2008FactsFigures_Bulle�n03_Sport_Par�cipa�onEN.pdf.

16. Australian Sports Commission (2008). Par�cipa�on in exercise, recrea�on and sport: Annual report 2008. Belconnen, ACT.

17. Murphy NM, Bauman A (2007). Mass Spor�ng and Physical Ac�vity Events – Are They “Bread & Circuses” or Public Health Interven�ons to Increase Popula�on Levels of Physical Ac�vity. Journal of Physical Ac�vity and Health, 4, 193 – 202.

18. Sport England. Ac�ve People Survey 2008/09. Available online at: h�p://www.sportengland.org/research/ac�ve_people_survey/ac�ve_people_survey_4/aps4_quarter_1.aspx.


27

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Nick Cavill

Sport for All – Is It a Reality?

Nick Cavill

University of Oxford Oxford, United Kingdom


Introduc�on

The promo�on of sport is one of the issues that bothers governments across the world. A great deal of na�onal and interna�onal-level effort (and taxpayers’ money) is put into s�mula�ng the provision for, and playing of, sport, defined as any form of physical ac�vity involving effort and skill in which an individual or team competes against another or others1. Sport has even recently become one of the European Union’s suppor�ng, coordina�ng and supplemen�ng competences with the ra�fica�on of the Lisbon Treaty in late 2009. This means that individual Member States will be encouraged to “implement evidence-based policies in order to improve their provision of spor�ng facili�es and opportuni�es”2. So for the first �me the EU is ac�vely aiming to promote sport and physical ac�vity at the policy level. It seems that the Sport for All movement has become an important social phenomenon in contemporary society, becoming government policy under many different �tles3.

Why does sport ma�er so much? Why do governments feel the need to intervene in our leisure �me compe��ve ac�vity? The answer comes principally from the health benefits of sport – outlined by Verhagen and van Mechelen in Chapter III (pp. 43-47). It is clear that sport – as part of total physical ac�vity - has an enormous role to play in promo�ng health and well being, reducing obesity, and preven�ng mortality and morbidity from condi�ons such as cardiovascular disease, cancer, and diabetes. But sport is also seen to offer numerous benefits to broader society, to jus�fy “sport for all” becoming an interna�onal ins�tu�on.

There are many claims made for the social benefits of sport, and these have different relevance across the lifespan. For children, sport can be an important part of growing up: helping to develop core skills such as throwing and catching4, as well as broader no�ons of team play and fairness. Sport may also help to improve academic performance and reduce truancy and disaffec�on. But perhaps the most compelling argument for involving children in sport and physical ac�vity is the considera�on that it might be possible to establish a life�me habit in physical ac�vity through posi�ve par�cipa�on experiences as a child. Unfortunately, there is s�ll only limited evidence to support the idea that physical ac�vity “tracks” from childhood to adulthood5. Sport can help young people to become part of their local communi�es and may help to reduce crime and an�-social behaviour, although the evidence for this is also s�ll limited6. For adults, sport can be a route back into physical ac�vity a�er a period of abs�nence, and some recent reports suggest that in the UK at least there is a surge in some sports, as middle-aged men seek ways to regain some fitness and lose weight7. For older people, sport can offer significant social benefits (alongside the well-established health benefits) through helping to increase social capital and reduce isola�on. In a review of qualita�ve studies8, older people iden�fied the importance of physical ac�vity such as dance in staving off the effects of ageing, helping to challenge tradi�onal expecta�ons of older people being physically infirm.

28

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Nick Cavill 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Nick Cavill

The evidence for these benefits of sport is variable: a review of the evidence has suggested that, while there are some areas for which there is a considerable amount of evidence in favour of a posi�ve rela�onship with par�cipa�on (such as physical and mental health), there remain issues for which further research remains necessary, such as cogni�ve and academic development, crime reduc�on, truancy and disaffec�on6.

The Sport for All movement has taken on this posi�ve evidence for the benefits of sport, and focused on the spreading of the sport message to the widest sec�ons of society: the “All” in the �tle. But what does this mean in reality, and where has this been achieved?

To be a truly inclusive movement, Sport for All should mean equal levels of sport par�cipa�on (or at least equality of opportunity) irrespec�ve of sex; age; ethnic origin; income; or social class. Data from the latest Eurobarometer survey2 show that this is far from the current picture. While 65% of EU ci�zens get some form of physical exercise at least once a week, a quarter of all respondents declare that they are completely or almost physically inac�ve. Clearly the no�on of “Sport for All” has not yet reached important segments of the EU popula�on. There are large varia�ons in par�cipa�on according to social class, educa�on and income. Sport for all: if you can afford it.

Figure 1 shows that there are some fascina�ng varia�ons in this simple indicator of the propor�on of the popula�on that does no sport or exercise once a week. There is a dis�nct north-south distribu�on across the EU region, with more countries in the southern part of the region having greater than 50% of the popula�on repor�ng no sport or exercise in the past week.


29


Figure 1. Propor�on of na�onal popula�ons who never par�cipate in exercise or sport.

Clearly there could be many reasons for these vast varia�ons in par�cipa�on, including climate; topography; or varia�ons in the extent to which the physical built or natural environment support physical ac�vity9. Or there may be differences in na�onal cultures and norms around physical ac�vity, and the extent to which they are reflected in provision for sport by both government and non-government sectors. The best example of this is the rates of membership of sports and fitness clubs in EU countries. Figure 2 shows the wide varia�ons in rates of membership. In Germany and Austria – well known for their approach to sports membership10, the majority of the popula�on are members of a sports, fitness or social club with some link to physical ac�vity. This compares with the EU average of one in three adults being members, or countries such as Greece, Lithuania or Hungary, where the figure is around one in ten.

30

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Nick Cavill 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Nick Cavill

Figure 2. Propor� on of na� onal popula� ons who are members of a sport, fi tness or socio-cultural club in European countries.

This is likely to have a strong infl uence on sport and physical ac� vity par� cipa� on, as evidence shows that social support is a strong determinant of behaviour. So why don’t people in some countries join sports clubs? The answer may lie in the image of sport that is promoted, and the barriers that this presents. In the UK, surveys show one of the frequently quoted barriers to physical ac� vity is being “not the sporty type”11. If sport is seen as being about physical prowess and winning compe� � ons, then no wonder that many people are put off par� cipa� ng in a public forum and joining a sports or fi tness club. But in countries where sports club membership is high, more emphasis has been put on de-mys� fying sport and making it accessible to all. Contrast that with countries such as the UK where Sport For All some� mes seems to mean sports viewing for all: in the UK even Bri� sh Cycling is sponsored by a TV channel and all par� cipants in mass par� cipa� on bike rides are made to wear the sponsors’ vests promo� ng a sedentary pas� me. This is pandering to a na� onal sedentary culture. To achieve true societal benefi ts from sport we must have signifi cant reach into the popula� on, and sport needs to become a way of life, and part of the na� onal par� cipa� on culture. In many countries we seem to be more interested in seeing sport as compe� � ve and focused on winning at all costs.

Consider the Olympics: the next Games are to be in London in 2012, and one of the cornerstones of London’s Olympic bid was a promise that the Games would have a number of legacies, notably the promise that it would have a measurable impact on levels of physical ac� vity. Yet this promise appears to have been made based on li� le or no understanding of how this would happen. The bid documents for the London Games claimed that “moun� ng excitement in the seven years leading up to the Games in London will inspire a new genera� on of youth to greater


31


spor�ng ac�vity”12. Is this an empty promise? It is certainly not supported by research evidence: no previous Games appears to have achieved this Herculean feat13 despite numerous a�empts at a las�ng health legacy. And even the mechanism for this legacy is unclear: is it due to [1] the increasing investment in facili�es (focused on one part of the capital city and already massively over-budget); [2] the “trickle-down effect” as investment at elite level has an impact on everyday par�cipants, or [3] some form of inspira�on, in which everyday joggers and cyclists try to emulate the performance of their heroes in the stadium or velodrome?

When the public were asked about the legacy of the Games, the long-term benefits were considered more important by more respondents to a survey than medal achievements, and respondents believed benefits should be felt most a�er the Games rather than during. Around three in four (78%) respondents agreed the long-term benefits of the Games should be wider than just sport14. Yet this does not appear to be the way that the funding is being priori�sed. Shortly a�er the Games were agreed for London, the Government appeared to switch emphasis away from par�cipa�on, and towards elite performance and winning medals15. The remit for Sport England has been radically reformed so they no longer have responsibility for broader physical ac�vity, and the na�onal targets have been le� in a mess. Now, UK physical ac�vity promo�on professionals are faced with the almost ridiculous situa�on that someone cycling around a park at a leisurely pace on a Sunday a�ernoon is deemed to be exercising, whereas someone commu�ng to work on their bike every day will not count towards the na�onal indicator targets: because what they are doing is “Not Sport”.

These barriers have to be broken down. We have to remove the ar�ficial dis�nc�ons between what is sport and what is not; between compe��on and par�cipa�on. If we are to be successful in gaining the social and health benefits of sport, we need to really focus on Sport for All. This means All types of Sport (and ac�vity) for all types of people. And in par�cular this means re-focusing on ac�vi�es that people can integrate easily into their daily lives, notably walking and cycling. We should start to focus more on the All and less on the Sport. Nothing less is needed to lead to the sort of culture shi�s that are essen�al to make sport and physical ac�vity a normal part of everyday life for most people.


• Sport for All programmes should be aimed at the broadest possible range of people in society, with a principal aim of recrui�ng new people into sport and physical ac�vity (not offering more sport to the same people).

• Sport for All programmes should promote sports and physical ac�vi�es that will be taken up by people across the lifespan and sustained throughout life. This is more likely to be through ac�vi�es such as walking and cycling rather than compe��ve sport.

• Sport for All programmes should emphasise the health, social and environmental benefits of sport over those connected to compe��on or na�onal pres�ge.

32

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Nick Cavill 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Richard P. Troiano and William L. Haskell

References

1. Oxford University Press, Oxford English Dic�onary. 2007.

2. TNS Opinion and Social Eurobarometer 72.3: Sport and Physical Ac�vity; Brussels, 2010.

3. de Knop P, Oja P, Sport for All. Sports Science Studies 1994, 8 (Current Issues of Sports Science).

4. Na�onal Ins�tute for Health and Clinical Excellence Promo�ng physical ac�vity for children and young people; London, 2008.

5. Biddle SJ, Gorely T, Stensel DJ. Health-enhancing physical ac�vity and sedentary behaviour in children and adolescents. Journal of Sports Sciences 2004, 22(8), 679 - 701.

6. Bailey R. Evalua�ng the Rela�onship between Physical Educa�on, Sport and Social Inclusion. Educa�onal Review 2005, 57(1), 71-90.

7. Gibson O. Not so lonely for the long-distance runner now, as city marathons boom in popularity. Guardian 2010.

8. Foster C, Hillsdon M, Cavill N, Allender S, Cowburn G. Understanding Par�cipa�on in Sport – a Systema�c Review; London, 2005.

9. Na�onal Ins�tute for Health and Clinical Excellence Promo�ng and crea�ng built or natural environments that encourage and support physical ac�vity; NICE: London, 2008.

10. Naul R, Hardman K. Sport and Physical Educa�on in Germany. Routledge: London, 2002.

11. Joint Health Surveys Unit Health Survey for England 2007. Healthy lifestyles: knowledge, a�tudes and behaviour; London, 2008.

12. Armstrong G, Stamatakis E, Campbell N. The Spor�ng Legacy of Olympic Games and Major Spor�ng Events: Reality Reconsidered. In Design for Sport, Roibas A; Stamatakis E; K, B., Eds. Gower: London, 2010.

13. Murphy N, Bauman A. Mass spor�ng and physical ac�vity events--are they “bread and circuses” or public health interven�ons to increase popula�on levels of physical ac�vity? Journal of Physical Ac�vity and Health 2007, 4(2), 193-202.

14. Central Office of informa�on London 2012 Legacy Research Wave 3, 2009: Quan�ta�ve Report; London, 2009.

15. Revill J. Observer, 2007.


33

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Richard P. Troiano and William L. Haskell

The Role of Physical Ac�vity Guidelines in Preven�ng Physical Inac�vity

Richard P. Troiano1 and William L. Haskell2

1 Risk Factor Monitoring and Methods Branch, Applied Research ProgramDivision of Cancer Control and Popula�on SciencesNa�onal Cancer Ins�tuteNa�onal Ins�tutes of HealthBethesda, Maryland, USA

2 Department of Medicine, Stanford University School of Medicine Stanford UniversityPalo Alto, California, USA


Introduc�on

As the link between physical ac�vity and health benefits has become stronger and more clearly established, professional organiza�ons and government agencies have developed physical ac�vity guidelines or recommenda�ons that prescribe recommended amounts, intensi�es and types of physical ac�vity. In general, these guidelines aim to encourage individuals to change their behavior to increase physical ac�vity. The objec�ve of this paper is to consider the role of such guidelines in promo�ng increased physical ac�vity and decreased inac�vity, par�cularly in popula�ons. The case will be made that although there is li�le evidence that physical ac�vity guidelines alone lead to changes in individual behavior, they are an essen�al founda�on for poten�ally beneficial changes in policy and environment that can lead to the maintenance of a physically ac�ve lifestyle.

Physical Ac�vity Guidelines in the United States

Promulga�on of physical ac�vity guidelines or recommenda�ons to promote health has a long history in the United States1. Although the need to provide guidance on recommended types, intensi�es, and amounts of physical ac�vity was recognized as early as the 1960s-1970s, terms such as “epidemic of inac�vity” were not used. Ini�ally, the approach was primarily clinical and therapeu�c, with a focus on exercise prescrip�on based on rela�ve intensity (e.g., percent of maximal heart rate) and considerable a�en�on given to reducing the risk of exercise among those at high risk of or with exis�ng coronary heart disease. Recommenda�ons were disseminated through posi�on stands and statements by professional organiza�ons, such as the American College of Sports Medicine and the American Heart Associa�on.

34

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Richard P. Troiano and William L. Haskell 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Richard P. Troiano and William L. Haskell

In the mid-1980s, a paradigm shi� began from a clinical to a public health approach for the promo�on of physical ac�vity. Data from epidemiologic studies showed significant benefits in chronic disease risk reduc�on from moderate- and vigorous-intensity physical ac�vi�es that were o�en carried out during ac�vi�es of daily living (as compared to exercise training sessions) and in short episodes, such as climbing the stairs. The chronic disease risk model contrasted with the exercise prescrip�on/training model that emphasized more extended bouts of higher intensity physical ac�vity to increase aerobic capacity. The paradigm shi� was exemplified by the addi�on of sedentary lifestyle to the American Heart Associa�on list of major coronary heart disease risk factors2. This new public health perspec�ve culminated in the 1995 publica�on of Physical Ac�vity and Public Health: A Recommenda�on from the Centers for Disease Control and Preven�on and the American College of Sports Medicine3, followed quickly by Physical Ac�vity and Cardiovascular Health from the NIH Consensus Development Panel on Physical Ac�vity and Cardiovascular Health4, Exercise for Health from the WHO/FIMS Commi�ee on Physical Ac�vity for Health5, and Physical Ac�vity and Health: A Report of the Surgeon General6. These publica�ons from 1995 and 1996 all sought to foster health benefits through accumula�on of moderate-intensity physical ac�vity with a target of at least 30 minutes per day on most days of the week. Brisk walking became the iconic example for recommending moderate-intensity physical ac�vity. In contrast to the focus on exercise in the 1960s and 70s, scien�sts recognized that sedentary behavior was becoming more prevalent and cons�tuted a significant health risk.

Most recently, the US Department of Health and Human Services issued the 2008 Physical Ac�vity Guidelines for Americans7. These guidelines, based on a systema�c review of the scien�fic evidence linking physical ac�vity to health, con�nue to focus on the health benefits of moderate-intensity physical ac�vity. They go even further than the 1995-96 publica�ons in recognizing the problem of an increasingly sedentary lifestyle and include a recommenda�on to “Avoid inac�vity,” and note that “Some ac�vity is be�er than none.” Acknowledging the presumed current low levels of physical ac�vity and fitness in the US popula�on, the Physical Ac�vity Guidelines state that it is acceptable, and in some cases, desirable to use rela�ve intensity rather than absolute intensity to determine the appropriate degree of effort.

Defini�on of Guidelines

Many countries have physical ac�vity “guides,” “guidelines,” or “recommenda�ons.” The interpreta�on of these labels varies. In some instances, the documents are behavioral or programma�c guides for how to make choices that will increase physical ac�vity levels (e.g., Canada8). In others, the documents represent a synthesis of the available science linking physical ac�vity to health and prescribe recommended amounts and types of physical ac�vity7. Also some guidelines/recommenda�ons are intended for exercise or health professionals to guide them in assis�ng individuals in the design and implementa�on of an appropriate exercise regimen2, while others are intended for the general public8. For the purpose of this presenta�on, the term “guidelines” refers to documents that prescribe par�cular amounts, intensi�es and types of physical ac�vity based on scien�fic evidence. An implicit assump�on is that provision of such science-based informa�on will encourage behavior change among individuals throughout the target popula�on.


35


Trends in Physical Ac� vity

Having presented a brief history of physical ac� vity guidelines in the United States, it should be informa� ve to present data on trends in physical ac� vity over a similar � me frame. Figure 1 presents data from the Behavioral Risk Factor Surveillance System9 from 1986-2000 showing the propor� ons of men and women in the popula� on repor� ng that they performed the recommended amounts of physical ac� vity (30 min/day on at least 5 days per week).

Figure 1. Trend in Mee� ng Physical Ac� vity Recommended Levels (Behavioral Risk Factor Surveillance System).

Although a slight upward trend occurs across the 15 years and a possible temporary increase is seen in 1995, the prevalence of repor� ng the recommended amount of physical ac� vity is quite low and remarkably stable. The data presenta� on in Figure 1 stops at 2000 because a change in the ques� on wording in subsequent years led to higher prevalence, which increased from 45.3% in 2001 to 48.4% in 2007 for men and women combined. A related measure, the propor� on of the popula� on repor� ng no leisure � me physical ac� vity from the Na� onal Health Interview Survey, has also remained quite stable between 1997 and 200710, fl uctua� ng around 38-40% of the adult popula� on over the decade. Thus, these two sources of surveillance data do not indicate any major or extended increase in reported leisure-� me physical ac� vity by adults in the US in response to three major sets of recommenda� ons published in the US during 1995 and 1996.

36


Others have examined secular trends in physical ac�vity data and a�empted to relate these trends to physical ac�vity guidelines or recommenda�ons. The studies generally find li�le or no change over �me, and no clear effect of physical ac�vity guidelines. Talbot et al.11 examined secular trends in reported leisure-�me physical ac�vity in the Bal�more Longitudinal Study of Aging cohort from the 1960s to 1990s for men and the 1970s to 1990s for women. Among this generally well-educated and health conscious adult cohort, they found essen�ally no changes for women, but a decrease in the propor�on of sedentary men and an increase in the reported minutes of vigorous-intensity physical ac�vity, mostly between the 1960s and 1970s. Steffen et al.12 evaluated trends in lifestyle and leisure-�me physical ac�vity in the Minnesota Heart Survey from 1980-2000. The series of five cross-sec�onal surveys of residents of Minneapolis-St. Paul indicated that daily energy expenditure from lifestyle and leisure-�me physical ac�vity increased in both genders with the major change in reported vigorous-intensity physical ac�vity, but the propor�on of men and women repor�ng par�cipa�on in 30 or more minutes of physical ac�vity at least 5 �mes per week did not change over �me. Data from three of the surveys also indicated a decrease in physical ac�vity occurring in occupa�on over the same 20 years. The cohort and na�onal survey data in the United States do not indicate any drama�c improvement in reported physical ac�vity behavior that can be a�ributed to the promulga�on of physical ac�vity recommenda�ons.

Although no substan�al increase in physical ac�vity appears to have occurred over the period of �me that physical ac�vity recommenda�ons were being promoted, it is possible that the guidelines prevented or a�enuated a decline in physical ac�vity levels that may have occurred in their absence. Unfortunately, we can only speculate on this possibility, as the available data cannot answer the ques�on. Another way to explore the apparent lack of effect of guideline crea�on and dissemina�on is to examine the assump�on that informa�on alone provided in guidelines will produce any measureable behavior change. This approach postulates that crea�on and dissemina�on of physical ac�vity guidelines may be necessary, but is not sufficient to lead to behavior change. Policy and environmental changes to decrease barriers and facilitate individual behavior change are likely to be essen�al in addi�on to the provision of informa�on.

Example of Dietary Guidelines and Diet Quality

The history of dietary guidance and trends in dietary quality provide a parallel to the situa�on for physical ac�vity, with greater consistency in message and messenger. Since 1980, the US Department of Health and Human Services and the US Department of Agriculture have issued the Dietary Guidelines for Americans. The Dietary Guidelines are updated every 5 years. In addi�on to se�ng government policy and standards for food programs, the Dietary Guidelines are the basis of nutri�on educa�on and informa�on to influence consumer choices. Across the six itera�ons since 1980, the Dietary Guidelines have been very consistent in recommending: increase intake of fruits, vegetables, and whole grains; restrict energy, sodium, solid fats, and added sugars; consume alcohol in modera�on13.


37


Krebs-Smith et al.13 examined trends in the healthfulness of the food supply, as indicated by the Healthy Ea�ng Index-2005 (HEI-2005) of the United States from 1970-2007. Food supply data are collected with consistent methods and can be adjusted for losses due to waste and spoilage. The HEI-2005 was developed to evaluate the quality of diets rela�ve to the 2005 Dietary Guidelines. It is density-based, meaning it rates how well the diet or a defined set of foods provides recommended food or nutrient components per 1000 calories, and includes component scores reflec�ng dis�nct aspects of dietary guidance (e.g., whole grains, fruits, vegetables, sodium, calories from solid fats, etc.).

Similar to the trends observed for physical ac�vity, Krebs-Smith et al.13 found that there were some posi�ve changes in the quality of the US food supply. However, not all components improved, and even those that did were s�ll far from reaching recommended levels. This is comparable to seeing an improvement in the propor�on of the popula�on repor�ng mee�ng physical ac�vity recommenda�ons from 23% to 27%. Although such a change may be presented as a 20% improvement, it is not a major success.

Need for Policy and Environmental Change

Environmental changes in addi�on to informa�on programs may be necessary for sustained changes in health-related behaviors. In the United States, the an�-smoking campaign made li�le headway when the only focus was on individual behavior change emphasizing the health risks of smoking. Major reduc�ons in smoking prevalence occurred when tax policies were established that substan�ally increased the cost of cigare�es and community regula�ons and other policies at various levels shi�ed smoking from a norma�ve behavior to being socially undesirable. In the dietary context, Krebs-Smith et al.13 make the case that the federal nutri�on policy focus on helping consumers to make informed food choices to improve their health is not sufficient to lead to improved diets. Rather, changes are needed across the socio-ecologic spectrum. For diet, a major focus would be on agricultural policy and food industry choices to shi� the food supply toward making healthier choices available and affordable.

Similar to dietary choices, physical ac�vity is a complex behavior with mul�ple determinants. Therefore, changes are also needed across the socio-ecologic spectrum to recognize how factors such as organiza�ons, communi�es, and na�onal policies can impede or facilitate choosing a physically ac�ve lifestyle. Such a mul�factor approach is not a novel concept. The last chapter of the 2008 Physical Ac�vity Guidelines for Americans presents a socio-ecologic approach to help make regular physical ac�vity the easy choice for all8. A similar mul�factor approach is also evident in such documents as the US Na�onal Physical Ac�vity Plan14, the Toronto Charter for Physical Ac�vity15, and other na�onal plans (see Na�onal Plan web site for links to plans of other countries h�p://www.physicalac�vityplan.org). These plans provide guidance on how to develop and implement ac�ons to increase the level of physical ac�vity in popula�ons. The plans share several aspects, including a focus on increasing opportuni�es for physical ac�vity; recommended engagement and partnerships of governments, non-government organiza�ons, professional organiza�ons, and other agencies within health, transporta�on, planning and other sectors; recommended broad involvement of affected and targeted cons�tuencies; and relevant to this paper, an evidence-based approach.

38


Role of Physical Ac�vity Guidelines in Systema�c Change to Prevent Inac�vity

We have presented data from the United States that show small improvements, if any, in levels of physical ac�vity over �me and recent levels that indicate that only a minority of the popula�on reports recommended amounts of physical ac�vity. These findings occurred over a period of increasing a�en�on to physical ac�vity and the promo�on of recommenda�ons from several respected professional organiza�ons and government agencies. However, in the case of guidelines for both physical ac�vity and diet, a major assump�on has been that provision of science-based recommenda�ons will lead the popula�on to healthier behavior. The evidence does not support this assump�on, and systema�c changes in policies and environmental factors at mul�ple levels is the recommended alterna�ve. If providing guidance is insufficient, as it appears, what is the role of physical ac�vity guidelines in preven�ng inac�vity?

Guidelines based on an extensive review of the exis�ng science are the founda�on for any effort to make policy and environmental changes to improve the health of the public, including changes in physical ac�vity. First of all, science-based reviews and guidelines are needed for physical ac�vity to jus�fy the expenditure of public funds for promo�on and programming. A scien�fically sound and prac�cal set of guidelines is cri�cal for establishing the legi�macy of physical ac�vity among other public health interven�ons. Second, the guidelines need to define the benefits to be expected by various popula�on groups and the dose of ac�vity considered necessary to achieve these benefits. Third, the guidelines should support a unified message and provide behavior targets that can be used as consistent metrics for short- and long-term evalua�on. Finally, the documented health benefits of physical ac�vity should help support economic arguments in terms of health care cost savings as well as moral jus�fica�on based on equity and human rights. Physical ac�vity guidelines are necessary, but not sufficient, to increase levels of health-enhancing physical ac�vity.


• Provision of informa�on alone, even scien�fically-based physical ac�vity guidelines, is not sufficient to bring about behavior change.

• Science-based physical ac�vity guidelines are an essen�al founda�on for poten�ally beneficial changes in policy and environment that can facilitate the maintenance of a physically ac�ve lifestyle.

• Physical ac�vity guidelines can support a unified message and provide behavior targets for consistent metrics in short- and long-term evalua�on of ac�vity promo�on programs.


39


References

1. Physical Ac�vity Guidelines Advisory Commi�ee (2008). Physical Ac�vity Guidelines Advisory Commi�ee Report, 2008. Washington, DC: US Department of Health and Human Services. Part D: Background.

2. Fletcher GF, Blair SN, Blumenthal J, et al. (1992). Statement on exercise. Benefits and recommenda�ons for physical ac�vity programs for all Americans. A statement for health professionals by the Commi�ee on Exercise and Cardiac Rehabilita�on of the Council on Clinical Cardiology, American Heart Associa�on. Circula�on;86;340-344.

3. Pate RR, Pra� M, Blair SN, et al. (1995). Physical ac�vity and public health: A recommenda�on from the Centers for Disease Control and Preven�on and the American College of Sports Medicine. Journal of the American Medical Associa�on, 273(5), 402-407.

4. NIH Consensus Development Panel on Physical Ac�vity and Cardiovascular Health (1996). Physical Ac�vity and Cardiovascular Health. Journal of the American Medical Associa�on, 276(3)241-246.

5. WHO/FIMS Commi�ee on Physical Ac�vity for Health (1995). Exercise for health. Bulle�n of the World Health Organiza�on, 73(2) 135-136.

6. US Department of Health and Human Services (1996). Physical Ac�vity and Health: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Preven�on.

7. US Department of Health and Human Services (2008). 2008 Physical Ac�vity Guidelines for Americans. Washington, DC: US Department of Health and Human Services.

8. Public Health Agency of Canada (1998). Canada’s Physical Ac�vity Guide to Healthy Ac�ve Living. O�awa, Ontario: Public Health Agency of Canada.

9. Centers for Disease Control and Preven�on (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Preven�on, 1986-2000. h�p://www.cdc.gov/brfss/technical_infodata/surveydata.htm.

10. Na�onal Cancer Ins�tute (2010). Cancer Trends Progress Report – 2009/2010 Update. Na�onal Cancer Ins�tute, Na�onal Ins�tutes of Health, Department of Health and Human Services, Bethesda, MD. h�p://progressreport.cancer.gov

11. Talbot LA, Fleg JL, Me�er EJ (2003). Secular trends in leisure-�me physical ac�vity in men and women across four decades. Preven�ve Medicine, 37:52-60.

12. Steffen LM, Arne� DK, Blackburn H, et al. (2006). Popula�on trends in leisure-�me physical ac�vity: Minnesota Heart Survey, 1980-2000. Medicine and Science in Exercise and Sports, 38(10):1716-1723.

13. Krebs-Smith SM, Reedy J, Bosire C (2010). Healthfulness of the U.S. Food Supply. Li�le improvement despite decades of dietary guidance. American Journal of Preven�ve Medicine, 38(5):472-477.

14. Na�onal Plan for Physical Ac�vity (2010). Na�onal Physical Ac�vity Plan. h�p://www.physicalac�vityplan.org.

15. Toronto Charter for Physical Ac�vity (2010). h�p://www.cflri.ca/icpaph/en/toronto_charter.php.

40



41


III HEALTH AND ECONOMIC JUSTIFICATIONS FOR SPORT FOR ALL

42

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Evert Verhagen and Willem van Mechelen


43

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Evert Verhagen and Willem van Mechelen

Health Issues as Primary Reasons for Choosing Sport for All Programs

Evert Verhagen and Willem van Mechelen

Department of Public and Occupa�onal HealthEMGO Ins�tute for Health and Care ResearchVU University Medical CenterAmsterdam, The Netherlands


Introduc�on

Smoking, excessive alcohol intake and nutri�on (for example, a too high intake of dietary fat or an excessive intake of polyunsaturated fa�y acids, or both) are considered “classic” independent risk factors for mul�-causal chronic disease. The role of physical inac�vity as an independent lifestyle risk factor has long been the subject of debate and controversy. Nowadays it is well-known that physical inac�vity also contributes independently to the burden of disease, death, and disability in developing and developed countries.

Over the years observa�onal studies have accumulated indisputable evidence that a lack of physical ac�vity (PA) increases an individual’s risk for all-cause mortality, and is one of the leading causes of the major chronic diseases, including cardiovascular disease, type 2 diabetes, osteoporosis, and certain types of cancer1,2. Our en�re society is at risk as the nega�ve health consequences of a lack of PA exists throughout all socioeconomic levels, various ethnici�es, and phenotypes3. Observa�onal data can be linked to results from experimental “physiological” studies in which it has been shown that PA improves a number of biological markers that are in the causal pathways for selected chronic diseases. These include, amongst others, posi�ve effects on blood pressure, atherogenic lipoprotein profile, blood clo�ng, insulin-mediated glucose uptake, as well as bone and muscle proper�es2.

Despite this vast, and s�ll growing, body of evidence showing the health benefits of PA, global PA levels have dropped exponen�ally over the past decade1,2,3. Hereby, the promo�on of sufficient physical ac�vity throughout an individual’s lifespan is a vital component of chronic disease preven�on and health promo�on in our contemporary society.

Physical Ac�vity and Public Health

Sufficient PA will not only benefit the individual person’s health through a reduced of risk for contemporary chronic diseases, but the public-health status of a na�on will also benefit from a physically ac�ve lifestyle. The public-health burden of a sedentary lifestyle can be quan�fied by calcula�ng the popula�on a�ributable risk (PAR). PAR is an es�mate of the propor�on of the public-health burden caused by a par�cular risk factor, for example, a sedentary lifestyle. By calcula�ng PAR we may es�mate the propor�on of deaths from chronic diseases (CHD, NIDDM,

44

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Evert Verhagen and Willem van Mechelen 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Evert Verhagen and Willem van Mechelen

cancer, and so on) that would not occur if everyone in a popula�on was sufficiently physically ac�ve3. To calculate PAR, we need to know the rela�ve risk [as a measure of the strength of the rela�on between a risk factor and the (public) health burden] and the prevalence of the risk factor.

Based on available informa�on on both rela�ve mortality risks and prevalence of a sedentary lifestyle, Powell and Blair4 es�mated the PAR of sedentary living for mortality from coronary heart disease (CHD), colon cancer and diabetes mellitus to be 35 per cent, 32 per cent and 35 per cent, respec�vely, meaning that 35 per cent of the CHD deaths, 32 per cent of the colon cancer deaths and 35 per cent of the diabetes mellitus deaths could, theore�cally, be prevented if everyone was more ac�ve.

Herea�er, in the Netherlands similar PAR calcula�ons were made for chronic disease mortality, not only for a sedentary lifestyle, but also for other lifestyle-related risk factors5. For CHD the following PARs were calculated for men and women respec�vely: smoking 42 per cent and 44 per cent, saturated fa�y acid intake (exceeding 10 per cent of total energy intake) 13 per cent and 12 per cent, obesity (body mass index >30 kg/m2) 13 per cent and 15 per cent, and sedentary lifestyle 40 per cent and 40 per cent. Although “old”, from these PARs it seems that for CHD mortality the public-health burden caused by a sedentary life-style is at least of the same magnitude as the public-health burden caused by smoking and about three �mes as great as the burden caused by obesity and the excess intake of saturated fa�y acids.

Unfortunately, more recent PARs are not available in the Netherlands. However, the “true” rela�ve risk is constant, because it is biologically determined and will therefore not change, even though es�mates of rela�ve risk may change because of improvement of scien�fic measurement. Consequently, changes in PAR are highly dependent on changes in prevalence. Meaning that in line with a decrease in overall levels of physical ac�vity, there will be in increase in the associated PARs. Hence, the contemporary PARs associated with a sedentary lifestyle are arguably higher than 10 years ago.

Therefore, from a public-health perspec�ve it may be more appropriate to encourage a physically ac�ve lifestyle, second only to the restric�on of smoking habits, than to emphasize further improvement of the dietary habits or reduc�ons in body weight. S�mula�ng a physically ac�ve lifestyle has other related benefits: a physically ac�ve lifestyle helps to maintain body weight, leads to favorable dietary habits, and leads to a decline in the number of smokers6.

Primary Preven�on

The prolonged nega�ve health consequences of physical inac�vity are of specific concern in children and youth. The level of PA in children and youth has dwindled drama�cally in the past decades. In line with this decline in PA levels there is an exponen�al increase in the prevalence of overweight and obesity within youth worldwide1. Rela�vely recent es�mates of the prevalence of overweight and obesity in school-aged children from 34 countries range from those seen in Malta (25% overweight, 8% obese) and the US (25% overweight, 7% obese) to those seen in Lithuania (5% overweight, 1% obese) and Latvia (6% overweight, 1% obese)7.


45


Overweight and obesity in childhood are known to have significant impact on both physical and psychosocial health. In line with the worldwide rapid “growth” of children and youngsters, there is an increase in reports of hyperlipidaemia, hypertension and abnormal glucose tolerance within this young popula�on. Even so, children are now presen�ng with type 2 diabetes. Such abnormali�es that root in childhood precede many of the cardiovascular consequences that characterize adult-onset obesity. Moreover, childhood obesity is a known independent risk factor for adult obesity and health, making overweight in adolescence a more powerful predictor of future health problems than overweight in adulthood8.

Several systema�c reviews highlight the benefits of PA among healthy children9. Thereby, the promo�on of PA in youth is arguably the most essen�al public health and health promo�on strategy to improve the health of individuals and popula�ons in both the short as well as long term. Nevertheless, it should be said that there is great discrepancy in the literature regarding the actual health effects achieved through PA interven�ons in youth9,10. The major concern here is that although interven�ons targeted at an increase in PA have short term “novelty” effect, the levels of PA diminish again a�er cessa�on of the interven�on. This implies that there is a great need for a more global structural approach that strives to achieve sustaining high PA levels in children. Sport and its associated role models may play a vital role in this effort.

Secondary Preven�on

Type II diabetes mellitus (DM-II) is increasingly becoming a global health concern11. Obesity and physical inac�vity are independent risk factors for type II diabetes mellitus (DM-II). In the Netherlands we have fairly accurate DM-II prevalence data. In 2003, out of a popula�on of about 17 million, 600.000 people were diagnosed with diabetes, of whom 90% had type II diabetes. Furthermore, approximately 900.000 people aged 60+ years suffer from early stage diabetes and 115.000 to 300.000 people are unaware of such status12. The pathogenesis of DM-II is complex; but in most pa�ents the impaired glucose homeostasis is caused by a combina�on of both impaired insulin ac�on, i.e. insulin resistance, and impaired insulin secre�on. Physical inac�vity, diet and obesity, in addi�on to hereditary factors, play a central role in the developing DM-II. The number of Dutch ci�zens with DM-II is expected to double by 202512.

At least 40% of people with DM-II suffer from chronic complica�ons (cardiovascular diseases, neuropathy and re�nopathy). These complica�ons set limits to the mobility of individuals and, therefore, their ability to be physically and socially ac�ve. This results in reduced independence and reduced quality of life. The greatest health benefit can be achieved by ge�ng physically inac�ve DM-II people to become ac�ve. This can delay the development of complica�ons in the long term and support and postpone medicinal treatment. The beneficial effects of PA can be a�ributed, among other things, to changed body composi�on with an improvement of insulin ac�on, resul�ng in be�er glucose control. Other beneficial effects of exercise include lowering of the blood pressure. PA is also responsible for posi�ve effects on the regula�on of the blood glucose level2. PA is not only of importance in the treatment of DM-II, but also halves the risk of developing DM-II. Therefore, PA also has an important role as a primary preven�ve measure.

46

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Evert Verhagen and Willem van Mechelen 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Evert Verhagen and Willem van Mechelen

Ter�ary Preven�on

Advances in the field of medicine have increased life expectancy enormously. Thereby, older adults are a rapidly growing and costly popula�on, which may receive a variety of benefits from being physically ac�ve. Yet the elderly represent one of the least ac�ve segments of our popula�on. Of course, the elderly benefit from PA through a reduced risk of various chronic diseases as cited above. But also, more ac�ve seniors have fewer symptoms of depression, be�er cogni�ve func�on and higher scores on indices of health-related quality of life13. Nevertheless, “elderly” is a broad term consis�ng of different age groups, and specific effects of PA (in for instance frail seniors) need to be established to inform public health officials about how to be�er employ PA to reduce disability and health care costs in this important popula�on group.

Even so, the ever progressing field of medicine presents us with new specific target groups for PA programs. One of these groups is cancer survivors, as cancer treatment has made substan�al progress in the last decades. Currently the average five-year survival rate is approaching 60% for female and 46% for male pa�ents. Although the survival rates have improved, cancer and its treatment may be associated with psychosocial and physical side effects. Physical side effects include decreased muscle strength, reduc�on of lean body mass, reduced aerobic capacity, bone loss, and fa�gue. Approximately 70% of cancer pa�ents report severe feelings of fa�gue during or immediately a�er chemotherapy and/or radiotherapy. In addi�on, it appears that even years a�er treatment, 30% of the pa�ents s�ll report complaints of fa�gue to such a degree that it results in a substan�ally reduced-health related quality of life (HRQL). Not so long ago, most physicians recommended rest or a reduc�on in the amount of PA as treatment for cancer related fa�gue. This obviously created a physiological paradox, because physical inac�vity induces muscle catabolism causing further de-condi�oning, inci�ng even more fa�gue. Nowadays physical ac�vity is being incorporated more frequently into cancer rehabilita�on programs. However, enthusiasm for prescribing exercise for cancer survivors depends on evidence regarding whether physical exercise during or a�er comple�on of treatment results in improved outcomes. Systema�c reviews of the literature do suggest that, despite methodological limita�ons, cancer pa�ents may benefit from exercise training programs due to improved physical fitness, physical func�oning, fa�gue and HRQL14,15. Nevertheless, this is fairly new area of PA research in which many important ques�ons remain unanswered.

Conclusion

Without hesita�on we dare to state that s�mula�ng a physically ac�ve lifestyle is both an individual’s and the public health’s best buy. The promo�on of PA is an essen�al public health promo�on strategy, and should be advocated to individuals of all ages. Keeping the posi�ve health effects of PA in mind, the applica�ons of PA across the lifespan and across the different modali�es of preven�on are countless. A full overview of possible PA u�liza�ons for public health is beyond the scope of this manuscript. Therefore, we briefly touched upon primary, secondary and ter�ary preven�ve uses of PA, which we believe to have significant contribu�ons to public health.


47



• Public health officials should be made more aware of the universal benefits of physical ac�vity.

• Physical ac�vity should not only serve as a primary preven�ve tool, but can also be used in the secondary and ter�ary preven�on of contemporary health issues.

• No popula�on groups should be neglected when promo�ng physical ac�vity.

• We should remain aware of new specific popula�on subgroups for whom physical ac�vity promo�on may have significant impact.

References

1. World Health Organiza�on. Global strategy on diet, physical ac�vity and health. World Health Organiza�on (WHO) 2004.

2. Physical Ac�vity Guidelines Advisory Commi�ee. Report of the Physical Ac�vity Guidelines Advisory Commi�ee, 2008, DHHS website h�p://health.gov/paguidelines.

3. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. (2007). Physical ac�vity and public health: updated recommenda�on for adults from the American College of Sports Medicine and the American Heart Associa�on. Medicine & Science in Sports & Exercise, 39(8), 1423-34.

4. Powell KE, Blair SN (1994). The public health burden of sedentary living habits: theore�cal but realis�c es�mates. Medicine & Science in Sports & Exercise, 26, 851-6.

5. Ruwaard D, Kramers PGN (1997). Volksgezondheid Toekomst Verkenning 1997: de som der delen. Utrecht: Elsevier/De Tijdstroom.

6. Vuori I, Fentem P (1995). Health, posi�on paper. In; Vuori I, Fentem P, Svoboda B, Patriksson G, Andreff W and Weber W (eds.) The significance of sport for society. Strasburg: Council of Europe Press: 11-90.

7. Janssen I, Katzmarzyk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts C, et al. (2005). Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their rela�onships with physical ac�vity and dietary pa�erns. Obesity reviews, 6, 123–32.

8. Guo SS, Chumlea WC (1999). Tracking of body mass index in children in rela�on to overweight in adulthood. American Journal of Clinical Nutri�on, 70, 145S–8S.

9. Dobbins M, DeCorby K, Robeson P, Husson H, Tirilis D (2009). School-based physical ac�vity programs for promo�ng physical ac�vity and fitness in children and adolescents aged 6- 18. The Cochrane Library, Issue 3.

10. Summerbell CD, Waters E, Edmunds L, Kelly SAM, Brown T, Campbell KJ (2009). Interven�ons for preven�ng obesity in children. The Cochrane Library, Issue 1.

11. Colberg SR, Grieco CR (2009). Exercise in the Treatment and Preven�on of Diabetes. Current Sports Medicine Reports, 8(4), 169-75.

12. Poortvliet MC (2007). Diabetes in Nederland. Omvang, risicofactoren en gevolgen, nu en in de toekomst. Bilthoven: RIVM.

13. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. (2007). Physical ac�vity and public health in older adults: recommenda�ons from the American College of Sports Medicine and the American Heart Associa�on. Medicine & Science in Sports & Exercise, 39, 1435–45.

14. Knols R, Aaronson NK, Ueblehart D, Fransen J, Aufdemkampe G (2005). Physical exercise in cancer pa�ents during and a�er medical treatment: a systema�c review of randomized and controlled clinical trials. Journal of Clinical Oncology, 23(16), 3830-42.

15. Galvão DA, Newton RU (2005). Review of exercise interven�on studies in cancer pa�ents. Journal of Clinical Oncology, 23(4), 899-909.

48

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Pekka Oja


49

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Pekka Oja

Sport for All for Health – Fact Or Fic�on?

Pekka Oja

Tampere, Finland


Introduc�on

Health has been a consistent and central topic in the Sport for All world congresses since the 1990s. The previous congress in Malaysia in 2008 called on governments and public authori�es to focus on the importance of sport and physical ac�vity as a key element of health policies. It recognized that the improved levels of mental and physical health, and reduced health and welfare costs, can be achieved through increasing levels of sport and physical ac�vity. It also affirmed that physical inac�vity is a major risk factor for non-communicable diseases with special emphasis on childhood obesity.

Recent research on physical ac�vity and health provides con�nuing, consistent and increasingly specific evidence for the support of the importance of physical ac�vity for public health. The extensive systema�c review of the scien�fic evidence undertaken by the U.S. 2008 Physical Ac�vity Guidelines Advisory Commi�ee1 presents the most comprehensive summary of the current state of the knowledge. By collec�ng and systema�cally evalua�ng the published literature on the rela�onships between physical ac�vity and health and by assessing the strength of the evidence it concluded the following:

In children and adolescents; there is strong evidence for: improved cardio-respiratory endurance and muscular fitness; favourable body composi�on; improved bone health; improved cardio-vascular and metabolic health biomarkers; and moderate evidence for reduced symptoms of anxiety and depression.

In adults and older adults; there is strong evidence for: lower risk of early death; heart disease, stroke, type 2 diabetes, high blood pressure, adverse blood lipid profiles, metabolic syndrome, colon and breast cancers; preven�on of weight gain; weight loss when combined with diet; improved cardio-respiratory and muscular fitness; preven�on of falls; reduced depression; and be�er cogni�ve func�on (older adults). In addi�on, there is moderate to strong evidence for be�er func�onal health (older adults) and reduced abdominal obesity; and moderate evidence for weight maintenance a�er weight loss; lower risk of hip fracture; increased bone density; improved sleep quality; and lower risk of lung and endometrial cancers.

Based on this evidence and the demonstrated dose-response rela�onships between physical ac�vity and health the U.S. health authori�es issued new physical ac�vity recommenda�ons. These are summarized in Table 1.

50

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Pekka Oja 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Pekka Oja

Table 1. U.S. Department of Health and Human Services physical ac�vity recommenda�ons1.

Target group Recommenda�on

Children and adolescents (aged 6-17)

• Children and adolescents should do 1 hour (60 minutes) or more of physical ac�vity every day.

• Most of the 1 hour or more a day should be either moderate- or vigorous-intensity aerobic physical ac�vity.

• As part of their daily physical ac�vity, children and adolescents should do vigorous-intensity ac�vity on at least 3 days per week. They also should do muscle-strengthening and bone-strengthening ac�vity on at least 3 days per week.

Adults (aged 18-64)

• Adults should do 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes (75 minutes) a week of vigorous-intensity aerobic physical ac�vity, or an equivalent combina�on of moderate- and vigorous-intensity aerobic physical ac�vity. Aerobic ac�vity should be performed in episodes of at least 10 minutes, preferably spread throughout the week.

• Addi�onal health benefits are provided by increasing to 5 hours (300 minutes) a week of moderate-intensity aerobic physical ac�vity, or 2 hours and 30 minutes a week of vigorous-intensity physical ac�vity, or an equivalent combina�on of both. Addi�onal health benefits are gained by engaging in physical ac�vity beyond this amount.

• Adults should also do muscle-strengthening ac�vi�es that involve all major muscle groups performed on 2 or more days per week.

Older adults (aged 65 and older)

• Older adults should follow the adult guidelines. If this is not possible due to limi�ng chronic condi�ons, older adults should be as physically ac�ve as their abili�es allow. They should avoid inac�vity.

• Older adults should do exercises that maintain or improve balance if they are at risk of falling.

From the Sport for All point of view the most important aspect of the new recommenda�ons is the fact that vigorous intensity physical ac�vity is clearly recognized as health-enhancing. While the earlier physical ac�vity recommenda�ons focused on moderate-intensity physical ac�vi�es, e.g. lifestyle ac�vi�es like walking, cycling and gardening, the new recommenda�ons state that both moderate-intensity and vigorous-intensity ac�vi�es, or a mixture of both, benefit health. Furthermore, these recommenda�ons state that higher intensity ac�vi�es are associated with greater improvements for some health outcomes than moderate-intensity ac�vi�es. This new knowledge is of vital importance for the Sport for All community as it invites sports to seriously contribute for public health. We no longer need to feel alien to the rather abstract concept of “physical ac�vity”, but now we can speak about our business – Sport for All for health.

However, we live in the world of evidence-based decision making and the public health field operates on evidence-based informa�on. In order to make ourselves understood and eventually to make a credible case for Sport for All for health, we have to be able to provide evidence that ”sport” benefits health. In this paper I report the evidence I have found to support this case. Is Sport for All for health fact or fic�on?


51


Defini�ons and Methods

The following defini�ons are used:

• Physical ac�vity: any bodily movement produced by skeletal muscles that result in substan�al energy expenditure above the res�ng level.

• Health-enhancing physical ac�vity (HEPA): any form of physical ac�vity that benefits health and func�onal capacity without undue harm or risk: HEPA can take place in the domains of leisure, work, home, and transport.

• Exercise: planned, structured, and repe��ve bodily movements done to improve or maintain one or more components of physical fitness.

• Sport: ac�vi�es prac�ced through exercise and/or compe��ons facilitated primarily by sport organiza�ons.

Electronic data bases of scien�fic publica�ons are important sources of evidence. PubMed, Sport discuss and Physical Educa�on Index were searched using the term “health benefits of sports” and limited to reviews that were published since 2000. A review of the retrieved papers iden�fied 12 relevant reviews for this assessment. The papers fell into two general categories: [1] generic ac�vi�es like resistance training, which is an important element in many sports (4 reviews), and [2] papers repor�ng on specific sport disciplines: mul�ple sports (2), tennis (1), Tai Chi (1), Mar�al arts (1), Kung Fu (1), contemporary dance (1). A similar search was conducted for the “health risks of sports” and 4 reviews were located.

In addi�on, studies on the health of former athletes provide some, although limited, evidence on the health effects of different sports. One review of this type of evidence was also located. Further, one epidemiological study comparing common forms of Sport for All was retrieved. Both are included in this review.

Results and Discussion

Health Benefits of Sports

Four recent reviews focused on the health effects of resistance training (see Table 2). The American Heart Associa�on’s scien�fic statement2 dealt with the overall health effects of resistance exercises. It reported at least moderate posi�ve effects on bone mineral density, lean body mass, muscle strength, insulin response to glucose challenge, insulin sensi�vity, submaximal and maximal endurance �me and submaximal exercise cardiac load. The posi�on paper from the Canadian Society of Exercise Physiology3 stated strongly that despite some doubts about the benefits of resistance training for youth, recent evidence indicates many func�onal and health benefits, provided that the training programs are properly suited for the par�cipants. Benson et al.4 reviewed the literature with par�cular focus on the effects of resistance training on metabolic fitness in children and adolescents. Based on their comprehensive review, they concluded that there is only a small amount of evidence that children and adolescents show metabolic health-related adapta�ons from resistance training. They found several methodological limita�ons in the exis�ng literature and called for more robustly designed randomized controlled trials in order

52


to determine more clearly the health outcomes a�ributable to resistance training. The fourth review on the health effects of resistance training focused on aged persons5. It concluded that, in addi�on to the well documented effects on muscle strength and power, new evidence shows that resistance exercise also promotes metabolic health and thus reduces the risk for diabetes and cardiovascular disease.

Table 2. Selected reviews on the func�onal and health benefits of resistance training.

Author/year Type Target group Conclusions

Williams et al. 2007

Expert panel

Not specified Effects of strength training:

• muscular strength ↑

• muscular endurance ↑

• muscle mass ↑

• bone mineral density ↑

• lean body mass ↑

• insulin response to glucose challenge ↓

• insulin sensi�vity ↑

• submaximal and maximal endurance �me ↑

• submaximal exercise rate-pressure product ↓

Behm et al. 2008

Review Children and adolescents

Resistance training that is within a child’s or adolescent’s capacity and involves gradual progression under qualified instruc�on and supervision with appropriately sized equipment can involve more advanced or intense exercises, which can lead to func�onal (i.e. muscular strength, endurance, power, balance and coordina�on) and heath benefits.

Benson et al. 2007

Systema�c review

Children and adolescents

There is only a small amount of evidence that children and adolescents may derive metabolic heath-related adapta�ons from resistance training.

Philips 2007

Review Aged persons Resistance exercise:

• increases strength

• promotes metabolic health

• reduces risk for diabetes and cardiovascular disease

This knowledge has important relevance to Sport for All, because playing or training for most sports, involves resistance exercises. Adequate muscle strength and power, developed through resistance exercises, is required for successful and enjoyable performance in many sports and it also has many important health benefits. Clearly, there is a scarcity of evidence regarding the func�onal and health benefits of specific sports. Curiously, many rather exo�c sports such as mar�al arts have drawn more scien�fic interest than the mainstream sports.


53


The search revealed two reviews which evaluated the exis�ng evidence concerning the rela�onship between exercise and skeletal health, par�cularly among young people (see Table 3). One of these dealt with bone mineral density, a measure of bone health, in young athle�c women6. The findings showed that athletes have greater bone mineral density than physically ac�ve and non-ac�ve females. Impact loading sports such as gymnas�cs, rugby or volleyball tend to produce a be�er overall osteogenic response (bone strengthening) than sports without impact loading such as cycling, rowing and swimming.

Khan et al.7 reported that bone mineral density can be most effec�vely increased when the bone is subjected to mechanical loading before the end of puberty and the longitudinal growth of the body (in girls before menarche). They concluded that physical ac�vity during the most ac�ve period of maturity may play a vital role in providing high peak bone mass into adulthood. These observa�ons highlight the importance of bone loading ac�vi�es, especially during childhood and adolescence. These effects have important public health implica�ons especially for women, because high peak bone mass in childhood should reduce the risk of bone fractures in older age. Thus, par�cipa�on in many sports with bone loading and impac�ng features can benefit bone health, which is increasingly threatened by the globally spreading sedentarism.

54


Table 3. Selected reviews on the health benefits of different sport disciplines.

Sport discipline Author/year

Type of review

Target group Conclusions

Mul�ple sports Nichols et al. 2007

Review Young athle�c women

Impact loading sports such as gymnas�cs, rugby or volleyball tend to produce a be�er overall osteogenic response than sport without impact loading such as cycling, rowing and swimming.

Mul�ple sports Khan et al. 2000

Review Children Physical ac�vity during the most ac�ve period of maturity plays a vital role in op�mising peak bone mass and these benefits may extend into adulthood.

Tennis Pluim et al. 2007

Review Not specified People who choose to play tennis appear to have significant health benefits, including improved aerobic fitness, a lower body fat percentage, a more favorable lipid profile, reduced risk for developing cardiovascular disease, and improved bone health.

Tai Chi Hall et al. 2009

Meta-analysis

People with chronic musculoskeletal pain

Tai Chi has a small posi�ve effect on pain and disability in people with arthri�s. The extent to which it benefits other forms of musculoskeletal pain is unclear.

Mar�al arts Woodward 2009

Review Not specified Benefits include be�er overall health and balance, as well as improved sense of psychological well being. They are rela�vely safe compared to many other sports, and most mar�al arts injuries are compara�vely minor.

Kung Fu Tsang et al. 2008

Review Not specified There is no evidence that Kung Fu prac�ce is associated with the preven�on or treatment of any health condi�on.

Dance (contemporary)

Angioi et al. 2009

Review Dance professionals and students

Contemporary dancers at professional and student level have equal or higher aerobic and muscular fitness compared to ballet dancer.

Most of the iden�fied reviews dealt with “physical ac�vity” and “exercise”. While the knowledge derived from these data can also be applicable to many sport disciplines, it does not take into considera�on the many peculiari�es of different sports. The searches revealed two reviews on mul�ple sports and only six reviews on specific sports (see Table 3).


55


The review on health benefits of tennis by Pluim et al.8 concluded that people who choose to play tennis appear to have improved aerobic fitness, reduced body fat, favorable lipid profiles, reduced risk of cardiovascular disease, and improved bone health. Thus, tennis seems to be a suitable form of leisure �me sport from the health promo�on point of view.

Mar�al arts include many types of ancient oriental combat ac�vi�es, some of which have been modified for modern sport and exercise. Woodward9 states that mar�al arts provide be�er overall health and balance, as well as improved sense of psychological well being. As mar�al arts are combat sports they also incur a risk of injuries. This review concluded that mar�al arts are rela�vely safe compared to many other sports, and most mar�al arts injuries are compara�vely minor. The health effects of Kung Fu were reviewed by Tsang et al.10. They concluded that even though Kung Fu may confer fitness benefits, there is no evidence to show that Kung Fu prac�ce is associated with the preven�on or treatment of any health condi�ons. Another oriental exercise, Tai Chi, is not combat sport but rather a musculoskeletal exercise form. The review by Hall et al.11 examined the effec�veness of Tai Chi for musculoskeletal pain condi�ons. While they considered the available data sparse and largely low-quality, they concluded that Tai Chi has a small posi�ve effect on pain and disability in people with arthri�s. The review on contemporary dance12 reported that both professional and student contemporary dancers are fi�er than ballet dancers in terms of aerobic power and muscular endurance.

Studies on former athletes can shed some light on the health impact of different sports. According to Kujala et al.13 former elite athletes from most sports disciplines have lower overall morbidity risk and enjoy be�er self-rated health in later years than the general popula�on and matched controls who were healthy at a young age. This is seen par�cularly among former endurance athletes who have a lower incidence of coronary heart disease and type 2 diabetes mellitus. Most o�en data are available only for men. Par�cipa�on in elite sports cannot be regarded as an overall health hazard. However, aside from a high risk of acute injury in specific sports, possible nega�ve effects of long-standing athle�c ac�vity on the development of osteoarthri�s should not be neglected. It should also be remembered that elite athletes are a biologically and gene�cally select group who are not representa�ve of the popula�on at large.

While many studies on the health benefits of sports are of cross-sec�onal design, and thus the strength of the evidence is rather weak, epidemiological cohort studies provide more convincing evidence. Such a study was conducted by Tanasescu et al.14. More than 40.000 US men were followed for 12 years and the incidence of coronary heart disease in rela�on to sports par�cipa�on was observed. Measured sports included running, jogging, rowing, cycling, swimming and racquet sports. A strong nega�ve associa�on was found for running (40% risk reduc�on) and rowing (20% risk reduc�on), a weaker nega�ve associa�on for racquet sports, and no associa�on for cycling and swimming. It is obvious that more of these kind of studies are needed to provide the kind of evidence necessary to make the case of “Sport for All for health” truly convincing.

Health Risks of Different Sports

Par�cipa�on in sports, par�cularly in combat and high intensity sports, also exposes par�cipants to injury risks. When judging the overall health impact of different sports the balance between the benefits and the risks has to be taken into account.

56


Four recent reviews on sport injuries were iden�fied, two of them repor�ng on mul�ple sports, one on marathon and one on boxing (see Table 4). Collard et al.15 reported published injury rates for different sports among children. The highest injury rates per par�cipa�ng athlete were in cross-country running, soccer, baseball and football among boys, and in cross-country running, so�ball and gymnas�cs among girls. Highest rates per exposure �me were in ice hockey, rugby and soccer among boys, and in soccer, basketball and gymnas�cs among girls. Another review16

reported injury rates in 14 different sports. The highest hourly injury rate was in ice hockey and the lowest in soccer. As men�oned by Collard et al. comparison between different sports is difficult because of the lack of standardized defini�on of sport injury and different measures of injury rate. A further challenge is that sport injuries are geographically and culturally specific and thus broad generaliza�ons are difficult to make.

Table 4. Selected reviews on the injury risks in different sport.

Sport discipline

Author/year

Type of review

Target group

Injury measure Note

Mul�ple Collard et al. 2007

Review Children Injury rate per 1000 athletes:• for boys highest rates in cross-country running, soccer, baseball, football (range 2.0-17.0 per 1000 athletes)• for girls highest rates in cross-country running, so�ball, gymnas�cs (range 3.5-19.6 )

Injury rate per 1000 hours of exposure:• for boys highest rates in ice hockey, rugby, soccer (range 2.3-34.4)• for girls highest rates in soccer, basketball, gymnas�cs (range 0.5-7.9)

There are difficul�es in drawing general conclusions because of different defini�ons of sport injuries and different measures of injury incidence.

Mul�ple Spinks et al. 2007

Review Children under 16 years

14 different sports:• highest hourly injury rate in ice hockey• lowest in soccer

Few studies among children under 8 years.

Few studies in unorganized sports.

Marathon Mailler & Adams 2004

Review Par�cipants in marathon runs

Percent of people affected:• 1-41% for blisters, calluses, cons• 2-16% for joggers’ nipples• 0.4-16% for chafing, abrasions

Only dermatological problems reported.

Boxing Siegel 2009

Review Not specified

Risk in boxing include:• cardiac contusion• commo�o cordis• rupture of the aorta


57


The dermatological problems of marathon running were reviewed by Mailler and Adams17 who found that the most common injuries (up to 40% of par�cipants) were blisters, calluses and corns, followed by “joggers’ nipples” and chafing (up to 16% of par�cipants). Boxing is also an injury prone sport. Serious health risks include cardiac contusion, commo�o cordis (concussion of the heart that is caused by a blow to the chest over the region of the heart by a blunt object) and rupture of the aorta18.

However, many sports injuries can be prevented. A systema�c review was conducted by Aaltonen et al.19 on the effects of randomized controlled interven�ons to prevent sports injuries. Thirty-two trials met the inclusion criteria. Evidence was found of the preven�ve effect of 3 types of injury preven�on interven�ons. In 5 trials, including 6 different comparisons, custom-made or prefabricated insoles reduced lower limb injuries, compared with no insoles in military recruits (risk reduc�on ≥50% in 4 comparisons). All 7 studies inves�ga�ng external joint supports showed a tendency to prevent ankle, wrist, or knee injuries (risk reduc�on ≥50% in 5 studies). All 6 mul�-interven�on training programs were effec�ve in preven�ng sports injuries (risk reduc�on ≥50% in 5 studies). Thus, a decreased risk of sports injuries was associated with the use of insoles, external joint supports, and mul�-interven�on training programs.

What is the balance between the health benefits and the health problems in sports for all? No systema�c assessment of the health balance is known to this author. The U.S. Physical Ac�vity Guidelines Advisory Commi�ee1 concluded that regarding the benefits and risks of “physical ac�vity” the public health benefits far outscore the risks. However, as many sports involve vigorous and usually high levels of effort, the poten�al injury risk, par�cularly among untrained people, can be substan�al. Therefore, the injury issue has to be taken seriously whenever spor�ng ac�vi�es beyond moderate-intensity life-style physical ac�vi�es are promoted for health.

Summary and Conclusions

In light of the exis�ng evidence on the health effects of physical ac�vity, Sport for All ac�vi�es have the poten�al to significantly benefit public health. This review of scien�fic reviews a�empted to find evidence for the case of Sport for All for health.

A search from three electronic data bases resulted in 12 recent reviews, which were considered relevant for Sport for All, on the health benefits, and four reviews on the health risks. In addi�on a single epidemiological study on the health benefits, and one review on the preven�on of sport injuries were included in this assessment.

Overall, in the published literature there is an obvious shortage of sport discipline specific data. Excluding the reviews on resistance training, fewer than 20 specific sports have been considered for benefits and even fewer for health risks. Taking into account the plethora of Sport for All ac�vi�es, exis�ng knowledge covers only a very small frac�on of ac�vi�es.

This review of reviews on the health impacts of Sport for All reveals a scarcity of high quality sport discipline specific evidence. In order to argue seriously for the public health significance of Sport for All, more and be�er evidence is needed. Moreover, in order to establish the public health impact of Sport for All, be�er understanding of the balance between the health benefits and risks of different sports is essen�al.

58


This situa�on presents a call for collabora�on of scien�sts studying the rela�onships between physical ac�vity and health and prac��oners promo�ng Sport for All for health. Accumula�on of good quality research evidence takes �me. In the mean�me, scien�sts and health promoters should join forces to consider the known physiological and biomechanical characteris�cs of different sports, and provide health profiles for different forms of Sport for All. This would be a useful ini�al step in developing a socially credible movement of Sport for All for health. At present many of the claims for health benefits from Sport for All are based on fic�on, rather than on scien�fic fact.


• There are few scien�fic studies of the health benefits of individual sports. Par�cipa�on in running, jogging, rowing, and racquet sports is associated with reduced risk of cardiovascular disease. Tennis appears to have mul�ple benefits (on body composi�on, cardio-vascular disease risk factors, and bone health). Tai Chi has a small effect on the symptoms of arthri�s. Mar�al arts benefit overall health and balance, but they also subject par�cipants to injuries, albeit rela�vely minor ones. There is no evidence to show that prac�ce of Kung Fu is associated with disease preven�on or treatment.

• Sports that include resistance or strength exercises promote metabolic health and reduce the risk of cardiovascular diseases in adults and older people. In adolescents, sports that involve impact loading (e.g. jumping) promote benefits in bone health in later years of life, especially if they are prac�ced during the period of peak growth.

• Injuries are a poten�ally nega�ve health impact of Sport for All. Available evidence indicates that in children the most risky sports rela�ve to exposure �me are ice hockey, rugby and soccer among boys, and soccer, basketball and gymnas�cs among girls. The exis�ng evidence is weakened by the lack of methodological standards and the cultural and geographical specificity of the studies.


59


References

1. www.health.gov/paguidelines

2. Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bi�ner V, Franklin BA, et al. (2007). Resistance exercise in individuals with and without cardiovascular disease: 2007 update. Circula�on, 116, 572-584.

3. Behem DG, Faigenbaum AD, Falk B, Klentrou P (2008). Canadian Society for Exercise Physiology posi�on paper. Applied Physiology, Nutri�on & Metabolism, 33(3), 547.

4. Benson AC, Torode ME, Fiatarone Singh MA (2008). Effects of resistance training on metabolic fitness in children and adolescents: a systema�c review. Obesity Reviews, 9, 43-66.

5. Philips SM (2007). Resistance exercise: good for more than just Grandma and Grandpa’s muscles. Applied Physiology, Nutri�on & Metabolism, 32, 1198-1205.

6. Nichols DL, Sanborn CF, Essery V (2007). Bone density and young athle�c women. Sports Medicine, 37(11), 1001-14.

7. Khan K, McKay HA, Haapasalo H, Bennell KL, Forwood MR, Kannus P, et al. (2000). Does childhood and adolescence provide a unique opportunity for exercise to strengthen the skeleton? Journal of Science and Medicine in Sports, 3(2), 150-64.

8. Pluim BM, Staal JB, Marks BL, Miller S, Miley D (2007). Health benefits of tennis. Bri�sh Journal of Sports Medicine, 41(11), 760-8.

9. Woodward TW (2009). A review of the effects of mar�al arts prac�ce on health. WMJ, 108(1), 40-3.

10. Tsang TW, Kohn M, Chow CM, Singh MF (2008). Health benefits of Kung Fu. a systema�c review. Journal of Sport Science, 26(12), 1249-67.

11. Hall A, Maher C, La�mer J, Ferreira M (2009). The effec�veness of Thai Chi for chronic musculoskeletal pain condi�ons: a systema�c review and meta-analysis. Arthri�s Rheum, 61(6), 717-24.

12. Angioi M, Metsios G, Koutedakis V, Wyon MA (2009). Fitness in contemporary dance: a systema�c review. Interna�onal Journal of Sports Medicine, 30 (7), 475.

13. Kujala UM, Mar� P, Kaprio J, Hernelah� M, Tikkanen H, Sarna S (2003). Occurrence of chronic disease in former top-level athletes. Predominance of benefits, risks or selec�on effects? Sports Medicine, 33:553-61.

14. Tanasescu M, Leitzmann MF, Rimm EB, Willet WC, Stampfer MJ, Hu FB (2002). Exercise type and intensity in rela�on to coronary heart disease in men. JAMA, 288, 1994-2000.

15. Collard DCM, Verhagen EALM, Chin A, Paw MJM, van Mechelen W (2008). Acute physical ac�vity and sports injuries in children. Applied Physiology Nutri�on & Metabolism, 33, 393-401.

16. Spinks AB, McClure RJ (2007). Quan�fying the risk of sport injury: a systema�c review of ac�vity-specific rates for children under 16 years of age. Bri�sh Journal of Sports Medicine, 41, 548-57.

17. Mailler EA, Adams BB (2004). The wear and tear of 26.2: dermatological injuries reported on marathon day. Bri�sh Journal of Sports Medicine, 38, 498-501.

18. Siegel S (2009). Cardiovascular issues in boxing and contact sports. Clinics in Sports Medicine, 28(4), 521.

19. Aaltonen S, Karjalainen H, Heinonen A, Parkkari J, Kujala UM (2007). Preven�on of sports injuries. Systema�c

review of randomised controlled trials. Archives of Internal Medicine,167(15):1585-1592.

60

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Peter T. Katzmarzyk


61

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Peter T. Katzmarzyk

Economic Considera�ons of Sport for All

Peter T. Katzmarzyk

Pennington Biomedical Research CenterLouisiana State University SystemBaton Rouge, LA, USA

Email: [email protected]

Introduc�on

Physical ac�vity is an important component of a healthy lifestyle. The World Health Organiza�on has iden�fied physical inac�vity as the fourth major risk factor for mortality worldwide, accoun�ng for 3.2 million deaths annually, or 5.5% of all deaths1. Thus, the problem of physical inac�vity is now viewed as a global health issue of major importance alongside tradi�onal risk factors such as high blood pressure, tobacco use, high blood glucose, and high cholesterol.

Physical ac�vity occurs in many different domains including work, school, home, transporta�on, and leisure. For many individuals, the domain that offers the greatest amount of personal choice and flexibility with respect to engaging in physical ac�vity is leisure �me. In this context, par�cipa�on in sport represents an important outlet for physical ac�vity and for expending significant amounts of energy. The incorpora�on of sport into the development of healthy ac�vity lifestyles may have significant long-term economic benefits for individuals, communi�es, and en�re socie�es.

The purpose of this paper is to describe the linkages between physical inac�vity and economic costs, in terms of direct health care spending and indirect costs such as lost produc�vity, injury-related work disability and premature mortality. Further, the cost-effec�veness of physical ac�vity interven�ons is explored as a poten�al source of informa�on regarding the prudent distribu�on of public health resources. The basic premise behind this work is that physical inac�vity is a major risk factor for several chronic condi�ons; thus, a por�on of the economic burden ($) associated with these chronic condi�ons is a�ributable to physical inac�vity, and improvements in physical ac�vity should result in decreases in health care spending.

Types of Economic Analyses

Two major types of analy�cal strategies are employed to study the economic aspects of physical ac�vity: [1] economic burden (cost-of-illness) analysis, and [2] cost-benefit or cost-effec�veness analysis. Economic burden studies es�mate the costs associated with physical inac�vity, usually at the level of the popula�on. Popula�on studies o�en use popula�on a�ributable risk (PAR%) methods to es�mate the por�on of disease costs that are a�ributable to physical inac�vity. Using this approach, the PAR% is computed from the popula�on prevalence (P) of physical inac�vity and the rela�ve risk (RR) of a given disease associated with physical inac�vity: PAR% = [P(RR-1)] / [1 + P(RR-1)]. For example, if the rela�ve risk of cerebrovascular disease associated with physical inac�vity is 1.60, and the prevalence of physical inac�vity in Canada is 53.5%, the PAR% would be

62

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Peter T. Katzmarzyk 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Peter T. Katzmarzyk

[0.535(1.60-1)] / [1 + 0.535(1.60-1)] = 24.3%. In other words, 24.3% of cerebrovascular disease cases in Canada would be considered to be directly a�ributable to physical inac�vity 2. With this informa�on, the PAR% can then be applied to the total medical expenditures for cerebrovascular disease to arrive at the physical inac�vity-a�ributable costs. By applying this methodology to all physical inac�vity-related diseases and summing the es�mates, the total health care costs a�ributable to physical inac�vity can be es�mated for a region or a country.

Economic burden analyses can also operate at the level of the individual, by comparing the direct medical costs of physically ac�ve and physically inac�ve people, by linking their data with health insurance or health care u�liza�on databases. This is usually accomplished by using a health insurance number or other iden�fying code. Extrapola�ons from individual-linked health care costs can then be extrapolated to es�mate costs at the popula�on level, based on the number of inac�ve people in the popula�on, and the differen�al health care costs that they incur.

The other major category of economic analysis that is typically conducted for physical ac�vity is cost-benefit or cost-effec�veness analysis. These analyses do not aim to quan�fy the economic burden or the cost of illness associated with physical inac�vity for a given popula�on, rather they es�mate the costs of deploying physical ac�vity interven�ons rela�ve to some marker of their benefit or effec�veness, measured as an outcome of the interven�on. Cost-benefit analyses focus on computa�ons of the ra�o of the cost of the interven�on to the associated cost savings. On the other hand, cost-effec�veness studies compare the monetary cost of an interven�on to the interven�on’s effec�veness at changing a health outcome. For example, an interven�on designed to increase physical ac�vity levels to reduce obesity could compare the costs of conduc�ng the interven�on (hiring and training personnel, ren�ng space, purchasing equipment, developing interven�on materials, etc.) rela�ve to the benefit obtained (actual obtained weight loss, fat reduc�on, etc.). Cost-benefit or cost-effec�veness analyses provide important informa�on with which to iden�fy the best strategies for increasing physical ac�vity levels in the popula�on, especially when fiscal resources are scarce and difficult decisions need to be made.

Overview of the Evidence

Two major categories of economic costs are o�en discussed within the context of physical inac�vity. These are direct costs and indirect costs. Direct costs are those medical costs that are incurred in treatment, care and rehabilita�on of injury or illness. Direct medical costs can include such components as hospital care, physician services, drugs, and care in other ins�tu�ons. Indirect costs are less tangible, and are more difficult to es�mate than direct medical costs. Usually, components of indirect costs include economic output lost due to illness or injury, injury-related work disability, and premature mortality. In order to compute indirect medical costs, a value must be placed on an individual’s life and on their health. In most cases, indirect costs associated with physical inac�vity are far greater than direct medical expenditures.


63


Economic Burden

Several studies have calculated the differen�al medical costs associated with physical inac�vity by comparing medical costs between physically ac�ve and physically inac�ve individuals. By using data from the 1987 Na�onal Medical Expenditures Survey, Pra� and colleagues es�mated a net benefit of $ 330 per person associated with physical ac�vity, which extrapolated to an es�mated $ 77 billion in 2000 for the inac�ve popula�on3. Similarly, Wang and colleagues linked data from the 1996 Medical Expenditure Panel Survey to the 1995 Na�onal Health Interview Survey to es�mate the combined influence of physical inac�vity and cardiovascular disease on medical expenditures4. Their results indicated that, among par�cipants without cardiovascular disease, average medical expenditure of those who were physically inac�ve was $ 114 per year higher; however, among people with cardiovascular disease, annual expenditure among those who were physically inac�ve was $ 2.529 higher than in those who were physically ac�ve4.

Using a similar approach to deriving differen�al health care costs among ac�ve and inac�ve individuals, the annual medical charges were $ 817 lower and $ 1.543 lower in low ac�ve and ac�ve people, respec�vely, compared with inac�ve people among par�cipants in a Minnesota health plan5. In another study among employees in the U.S. auto industry, annual medical costs were $ 260 lower and $ 199 lower in employees who par�cipated in physical ac�vity 1-2 �mes per week and 3 or more �mes per week, respec�vely, compared with people repor�ng no physical ac�vity6. Further, the rela�onship was similar in both normal weight and in obese employees. In Medicare re�rees in the United States, health care costs were progressively lower among those par�cipa�ng in physical ac�vity 1-2 �mes per week and 4 or more �mes per week, compared with those who reported no physical ac�vity7. These results were consistent across normal weight, overweight and obese re�rees (Figure 1). Thus, these studies indicate that annual health care expenses are lower in people who are physically ac�ve than in their physically inac�ve peers.

Figure 1. Annual health care expenditures ($) associated with levels of physical ac�vity among normal weight, overweight and obese Medicare re�rees in the United States. Adapted from Wang et al. (2005)7.

64

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Peter T. Katzmarzyk 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Peter T. Katzmarzyk

In addi�on to the data-linkage studies described above, several studies have a�empted to es�mate the economic burden of physical inac�vity at the popula�on level using the PAR% approach8. In the United States, the economic costs associated with physical inac�vity have been es�mated to be $ 24.3 billion in direct health care costs, or 2.4% of all health care costs in 19959. In Canada, the economic costs associated with physical inac�vity were es�mated to be $ 1.6 billion in direct costs and $ 3.7 billion in indirect costs (2001 dollars)2. Finally, an analysis from the UK has es�mated that physical inac�vity is responsible for £ 1.06 billion per year in direct health care expenditures10. Although it is difficult to compare direct health care expenses between countries due to differing popula�on sizes, economies and health care delivery systems, in general the economic costs associated with physical inac�vity are on the order of 1-3% of total health care expenditures in a given country. These data have been generated mainly from developed countries, and more research is required to understand the economic burden of physical inac�vity in developing countries.

Cost-Effec�veness

Community-based interven�ons may be a preferred avenue to increase physical ac�vity levels of the popula�on as they reach mul�ple demographic groups simultaneously. The U.S. Preven�ve Services Task Force has provided evidence-based recommenda�ons on the effec�veness of different physical ac�vity interven�on strategies11,12. Building on this informa�on, Roux and colleagues modeled the cost-effec�veness of the recommended strategies in order to provide guidance on the prudent alloca�on of resources to increase physical ac�vity levels in the popula�on13. The cost-effec�veness ra�os for seven interven�on strategies, including community-wide campaigns, social support, enhanced access, and individually adapted health behavior programs, ranged from $ 14.000 to $ 69.000 per Quality-Adjusted Life Year (QALY) gained, indica�ng that all of the recommended interven�ons were cost-effec�ve and could be adopted in public health efforts13.

A recent study reviewed published cost-effec�veness analyses of several different published physical ac�vity interven�on strategies14. The results indicated that behavioral interven�ons, environmental interven�ons, and those centered in primary care were effec�ve in increasing physical ac�vity levels, and were cost-effec�ve14. The results from an Australian modeling study also indicated that six physical ac�vity interven�on strategies (out of seven) had a high probability of being cost-effec�ve15. The cost effec�ve interven�ons included a pedometer-based program, a mass media campaign, an internet-based program, GP prescrip�on, and an ac�ve travel program, while GP referrals to an exercise physiologist had a low probability of being cost-effec�ve15.

The weighted evidence indicates that there are many cost-effec�ve approaches to increasing physical ac�vity levels. However, the number of interven�on studies that have provided cost-effec�veness data remains low. At the present �me, there is a lack of data on the cost-effec�veness of sport par�cipa�on per se as a strategy to increase physical ac�vity levels or effect change in health outcomes. Physical ac�vity researchers should be encouraged to partner with experts in health economics in order to provide evidence of the cost-effec�veness of their interven�ons, par�cularly in the sport domain. Knowledge of effec�ve strategies for increasing physical ac�vity, along with the associated costs, will be cri�cal to developing mul�-component interven�ons that will have a high probability of success in crea�ng demonstrable increases in physical ac�vity.


65


Summary and Conclusions

Physical inac�vity is a major risk factor for the development of chronic disease and premature mortality. Informa�on about the economics of physical inac�vity provides useful informa�on on the burden of living a sedentary lifestyle, and on the cost-effec�veness of physical ac�vity interven�ons. Ac�ve individuals incur lower health care expenditures than inac�ve individuals on an annual basis, and the direct and indirect costs of physical inac�vity are substan�al, amoun�ng to 1-3% of total health expenditures in the countries where economic evalua�ons have been undertaken. The results of interven�on studies indicate that many approaches to increasing physical ac�vity, ranging from mass media campaigns and community-based interven�ons to individual behavior change programs, can be cost-effec�ve. There is currently a lack of data on the cost-effec�veness of increasing physical ac�vity through sport par�cipa�on. However, sport represents an excellent opportunity for incorpora�ng physical ac�vity as a regular part of lifestyle, and it is also a major outlet for energy expenditure. More research is required to determine the op�mal mul�-component physical ac�vity interven�on strategy that will bring about large scale popula�on shi�s in physical ac�vity in the most cost-effec�ve manner.


• Public health programs that are designed to improve health should incorporate cost-effec�ve strategies to increase physical ac�vity.

• Achieving demonstrable increases in physical ac�vity in the popula�on should result in measurable decreases in health care spending, and in improvements in chronic disease rates.

• The cost-effec�veness of sport as a means to increasing physical ac�vity and improving health is a fer�le area for further research.

66

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Peter T. Katzmarzyk 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010

References

1. World Health Organiza�on. Global Health Risks: Mortality and Burden of Disease A�ributable to Selected Major Risks. Geneva: World Health Organiza�on; 2009.

2. Katzmarzyk PT, Janssen I. The economic costs associated with physical inac�vity and obesity in Canada: An update. Can J Appl Physiol. 2004; 29: 90-115.

3. Pra� M, Macera CA, Wang G. Higher direct medical costs associated with physical inac�vity. The Physician and Sportsmedicine. 2000; 28(10): 63-70.

4. Wang G, Pra� M, Macera CA, Zheng ZJ, Heath G. Physical ac�vity, cardiovascular disease, and medical expenditures in U.S. adults. Ann Behav Med. 2004; 28(2): 88-94.

5. Anderson LH, Mar�nson BC, Crain AL, et al. Health care charges associated with physical inac�vity, overweight, and obesity. Prev Chronic Dis. 2005; 2(4): A09.

6. Wang F, McDonald T, Champagne LJ, Edington DW. Rela�onship of body mass index and physical ac�vity to health care costs among employees. J Occup Environ Med. 2004; 46(5): 428-436.

7. Wang F, McDonald T, Reffi� B, Edington DW. BMI, physical ac�vity, and health care u�liza�on/costs among Medicare re�rees. Obes Res. 2005; 13(8): 1450-1457.

8. Oldridge NB. Economic burden of physical inac�vity: healthcare costs associated with cardiovascular disease. Eur J Cardiovasc Prev Rehabil. 2008; 15(2): 130-139.

9. Colditz GA. Economic costs of obesity and inac�vity. Med Sci Sports Exerc. 1999;31(11 Suppl):S663-667.

10. Allender S, Foster C, Scarborough P, Rayner M. The burden of physical ac�vity-related ill health in the UK. J Epidemiol Community Health. Apr 2007; 61(4): 344-348.

11. Kahn EB, Ramsey LT, Brownson RC, et al. The effec�veness of interven�ons to increase physical ac�vity. A systema�c review. Am J Prev Med. 2002; 22(4 Suppl): 73-107.

12. Truman BI, Smith-Akin CK, Hinman AR, et al. Developing the Guide to Community Preven�ve Services--overview and ra�onale. The Task Force on Community Preven�ve Services. Am J Prev Med. 2000; 18(1 Suppl):18-26.

13. Roux L, Pra� M, Tengs TO, et al. Cost effec�veness of community-based physical ac�vity interven�ons. Am J Prev Med. 2008; 35(6): 578-588.

14. Muller-Riemenschneider F, Reinhold T, Willich SN. Cost-effec�veness of interven�ons promo�ng physical ac�vity. Br J Sports Med. 2009; 43(1): 70-76.

15. Cobiac LJ, Vos T, Barendregt JJ. Cost-effec�veness of interven�ons to promote physical ac�vity: a modelling study. PLoS medicine. 2009; 6(7): e1000110.


67


IV STRATEGIES FOR PROMOTING SPORT FOR ALL

68

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Victor K.R. Matsudo


69

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Victor K.R. Matsudo

Transla�ng Evidence into Effec�ve Programs and Prac�ce

Victor K.R. Matsudo

Center of Studies of the Physical Fitness Research Laboratory São Caetano do Sul (CELAFISCS)São Paulo, Brazil


Introduc�on

The World Health Organiza�on (WHO) first considered physical inac�vity as an independent risk factor in 1992. However, since then, WHO has promoted many important events in the area, such as: support for the development of a instrument for measuring physical ac�vity (IPAQ)1, the celebra�on of World Health Day 2002 on behalf of physical ac�vity (Agita Mundo/Move for Health Day), and the approval of the Global Strategy on Diet, Physical Ac�vity and Healthy Behaviors2. Recently, the WHO concluded that physical inac�vity is the fourth cause of premature mortality, among the 20 main causes of 59 million total global deaths in 2004 (Table 1). It corresponds to over 3.5 million deaths per year, and it represents a greater impact than obesity and hypercholesterolemia.

Table 1. Leading causes of a�ributable global mortality and burden of disease, 2004. (Total Global Deaths in 2004: 59 million). Source: WHO 2009.

A�ributable Mortality Percentage

1 - High Blood Pressure 12.8%

2 - Tobacco Use 8.7%

3 - High Blood Glucose 5.8%

4 - Physical Inac�vity 5.5%

5 - Overweight and Obesity 4.8%

6 - High Cholesterol 4.5%

7 - Unsafe Sex 4.0%

8 - Alcohol Use 3.8%

9 - Childhood Underweight 3.8%

10 - Indoor smoke of solid fuels 3.3%

70

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Victor K.R. Matsudo 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Victor K.R. Matsudo

Issues in Promo�ng Physical Ac�vity at Popula�on Level

It is easier to define, to talk about, or to do research on physical ac�vity (PA), than it is to promote it, par�cularly in the general popula�on. Although almost 9.000 papers (8.940) analyzing the rela�onship of PA with cardio-vascular health/disease, have been published (most of these 5.284) in the previous 5 years, and 511 in the last year), there is a paradox. Sedentarism has increased around the world during the last decades. It is clear therefore that it is not a ma�er of lack of evidence; instead it is �me for ac�on. It is clear that knowledge, although essen�al, is not enough to produce changes in behaviour. Knowledge management is crucial if we are to tackle this situa�on.

In these terms, it is important to combine tradi�onal or wri�en knowledge with verbal or un-wri�en knowledge, and context knowledge, as well. One of the main reasons for explaining this is the fact that professionals involved in research in this area in general have limited experience of promo�ng PA. On the other hand, those involved in health promo�on usually do not have the skills for evalua�ng interven�on processes and outcomes. Moreover, there is the financial problem, where tradi�onal restric�ons in public health budgets may restrict the promo�on, the evalua�on, or both components of the program.

Considering the complexity of sedentarism, the promo�on of physical ac�vity requires a more holis�c approach, such as that proposed by the “Mobile management” adapta�on3 of the ecological model that comprises intra-personal, socio, and physical environment factors4. A key point for the success of this model was the use of strategic partnerships, matching the ecological items to the partner ins�tu�ons’ capaci�es5. This approach allows many items to be addressed in a synergis�c way6. More details are available on the website www.agitasp.org.br.

Agita São Paulo: Pu�ng Theory and Prac�ce in the Same Sentence

One of the longest standing examples of a community based interven�on for physical ac�vity is called Agita São Paulo. It is recognized interna�onally as a model for promo�ng physical ac�vity5,7,8. Agita is around 13 years old, and is a comprehensive interven�on reaching schools, worksites, older adults, and hundreds (350) of partner organiza�ons and communi�es across the state of São Paulo. A main goal is to increase physical ac�vity by 30 minutes of moderate ac�vity at least five �mes a week. Physical ac�vity is promoted not just in leisure �me, but also in the home (chores, gardening) and in transport (walking, taking stairs).

A�er thirteen years of experience we are able to summarize the main aspects that have permi�ed to the program to move from scien�fic evidence to effec�ve programs and policies, as follows.

• The Model

It is quite important to develop a wri�en version of the program, and in that sense an interven�on model is central. In the case of Agita São Paulo, we developed a “mobile management” adapta�on of the ecological model, in which a�en�on was given to intrapersonal, social and physical environmental factors, in a dynamic way. The contribu�on of each set of determinants is “weighted” according to perceived importance, so that the relevant resources to address each set can be determined and allocated (see Figure 1).


71


Figure 1. The “Mobile Management” adapta�on of the Ecological Model.

• Strategic Partnerships

All efforts are necessary to face “the monster called sedentariness”, par�cularly considering the high prevalence of this risk factor in the general popula�on. It is clear that no one can overcome this challenge alone. Establishing a careful strategic partnership is therefore of utmost importance. In our case we have developed an Intellectual Partnership, that comprises na�onal and interna�onal scholars, who give the program a sound scien�fic basis; these people comprise the Scien�fic Board. In contrast, the Ins�tu�onal Partnership comprises governmental, non-govermental and private ins�tu�ons, represen�ng the central core of the program. These people comprise the Execu�ve Board, which meets monthly to discuss the latest achievements and the next challenges.

• A Le�er of Agreement

The Le�er of Agreement is a simple but efficient way to establish a more permanent support for the partnership, moving from a personal to an ins�tu�onal rela�onship.

• Inter- and Intra-Sectoral Partners

In building this coali�on, it is interes�ng to note the importance not only of the classical inter-sectoral support, but also the importance of intra-sectoral balance. For example, when one ins�tu�on from a par�cular area, i.e. GM from the car industry, agrees to par�cipate in the partnership, another ins�tu�on from the same area (i.e. Ford) is immediately invited to also take part in the coali�on.

72


• Name, Slogan, Mascot

We have learned from social marke�ng the importance of some factors that may increase the chances of interven�on success. Special a�en�on should be paid to the name, which should express the “spirit, the heart, the soul” of the program. In the case of Agita, it took about two years for the marke�ng group to develop the “brand”. Agita is an idioma�c expression that means much more than shake-up your body; it also means move your mind, your social a�tude, be ready for change.

A slogan may help to quickly spread the program message. In the case of Agita, we took: “30 minutes make the difference”. However, the development of a mascot is crucial, because it allows easy iden�fica�on of the program brand and message. In the case of Agita, the Half-Hour Man is a self-explanatory figure. There is now also a Half-Hour Woman and a whole family of mascots (see Figure 2).

Figure 2. The Half-Hour Man, Mascot of Agita São Paulo.

• Clear Message

Many programs nicely describe purposes and aims, strategies and evalua�on approaches, but do not dedicate enough a�en�on to building a strong message that addresses, in appropriate way, the interven�on objec�ves. In the case of Agita São Paulo, the CDC/ACSM recommenda�on that all subjects should take at least 30 minutes of moderate intensity physical ac�vity per day, on most days of the week, in con�nuous or accumula�on mode, was the main objec�ve.

• Moderate/Accumula�on

The use of the “moderate message” encourages people who dislike intense exercise to get involved. It also diminishes the high chances of drop-out which are o�en seen in vigorous exercise programs. On the other hand, the accumula�on approach counteracts the excuse of lack of �me as a barrier to physical ac�vity.


73


• Inclusion Approach

It is important to do everything possible to encourage inclusion. The use of the moderate and accumula�on message and social marke�ng tools, like a strong name, a mascot, and a slogan, can foster a more inclusive climate.

• The Medical Sector

The difficul�es of working with the medical sector are well-known. However, physicians are considered by many to be the most important health professionals in terms of encouraging behavior change. To build a strong coali�on with the medical sector is therefore crucial. In the Agita program a partnership was established with the São Paulo Medical Associa�on, which comprises about 100.000 medical doctors. A special mascot, the MD half-hour man, was developed and the associa�on magazine dedicated its front page to the celebra�on of the World Day of Physical Ac�vity. Their Scien�fic Journal has also published a series of ten ar�cles about Agita concepts.

• Cultural Links

It is well known that if a behavior becomes part of popula�on culture, it will no longer be necessary to promote the behavior change program. Promo�ng cultural links is therefore of utmost importance for interven�on success. Many ac�ons were made by Agita São Paulo with that purpose. For example, the Mascot Championship, which was developed among students to design the mascot that best represented that group; and the Samba School which took Agita as the central theme for the Carnival Parade.

• Two-Hats Approach

In light of poli�cal instability and the fact that new governments o�en try to forget former programs, it can be useful to use what we have called “a two-hats approach”. In that strategy a balance is reached by working with a government department, as well as with the non-government and private sectors, so that any poli�cal changes can be overcome.

• S�ckers

Among the adver�sing materials, none has worked be�er than the s�ckers. The famous red and white s�ckers from Agita São Paulo have been shown all around the world, in different places, such as on telephones, on drier machines in toilets, and on conference delegates’ coats, dresses and shirts. The s�ckers have helped to develop visual iden�ty in mass demonstra�ons, and represent a most cost-effec�ve dissemina�on instrument.

• Mega-Events (WDPA, Agita Galera)

In order to give the program more visibility, the organiza�on of mega-events is quite instrumental. In the case of Agita São Paulo, two mega-events, one per semester, are strategically organized: [1] the Agita Galera, or the Day of Ac�ve Community, which is addressed to the school sector, and reaches over 6 million students, every last Friday in August; and [2] the Agita Mundo Parade, or the World Day for Physical Ac�vity, that takes place on April 6th, comprising over 2.500 events around the world every year.

74


• Promo�ng Indigna�on

A major reason for a mega-event is to call the a�en�on of authori�es policy-makers and change-agents to a social problem – in this case sedentarism. The “social percep�on” of the risk factor depends on the perceived risk of the problem and the indigna�on it causes in the popula�on. Although the risk of sedentarism is high, the social percep�on of the risk is low, because the popula�on indigna�on is also low.

• Good Prac�ce Forum and Book

The best prac�ces developed by the partners ins�tu�ons are highlighted every year in a Forum, organized during the celebra�ons of the World Day for Physical Ac�vity. Besides the presenta�ons, ins�tu�ons are proud to have their work published in the Good Prac�ce Year Book.

• Bulle�n & Website

A monthly Bulle�n (Agita News) brings scien�fic updates and reports from different partner ins�tu�ons, at local, na�onal and interna�onal level. The most interes�ng news is included on the program website.

• Evalua�on

The use of process, impact (short term) and outcome (long term) evalua�on is most important. In the case of Agita, each component of the model is monitored, providing the opportunity for feedback, which can some�mes serve as a reward for the campaign, and help to maintain the mo�va�on of the group. It is important to assess changes in a�tudes, as well as changes in the physical ac�vity behavior itself.

Several factors have shown the posi�ve impact of the Agita São Paulo program. In terms of intrapersonal factors, the program has had a stronger impact on women’s program recall (67% vs 59% in men), knowledge (32% vs 24%), sedentariness (10% vs 15%), and the prevalence of sufficient ac�vity (66% vs 56%). There has also been an improvement in program recall (reached 63% of the popula�on), and program purpose knowledge (31%), which probably explains part of the decline in sedentarism from 14.9% (1999) to 11.2% (2004). This decline was more marked among those who knew the Agita message (7.1%) than among whose did not know it (13.1%). Conversely there was an increase in sufficiently ac�ve people from 54.8% in 1999 to 61.8% in 20047.

Cross-sec�onal surveys were carried out in 2002, 2003, 2006 and 2008 in the state of São Paulo, Brazil using comparable sampling approaches and similar sample sizes. In all surveys, physical ac�vity was measured using the short version of the Interna�onal Physical Ac�vity Ques�onnaire (IPAQ). Separate weekly scores of walking, moderate- and vigorous-intensity physical ac�vity prac�ce were generated; cut-off points of 0 and 150 min/week were used. Also, we created a total physical ac�vity score, by summing these three types of ac�vity. The prevalence of no physical ac�vity decreased from 9.6% in 2002 to 2.7% in 2008, whereas the propor�on of subjects below the 150-minute threshold decreased from 43.7% in 2002 to 11.6% in 2008 (Figure 3). These trends were mainly explained by increases in walking and moderate-intensity physical ac�vity. Increases in physical ac�vity were slightly greater among women than among men. Logis�c regression models confirmed that these trends are not due to any different composi�on of the samples9.


75


Figure 3. Trends of physical ac� vity categories in the state of São Paulo, Brazil (2002, 2003, 2006 and 2008).

The CDC has reviewed the evidence of eff ec� veness of alterna� ve interven� ons to promote physical ac� vity. The review uses rigorous criteria for eff ec� veness. It is not complete, but Community-wide campaigns such as Agita São Paulo are strongly recommended, along with school-based physical educa� on, among others. The interven� on cost-eff ec� veness analysis found that Agita São Paulo is an excellent investment in public health10. It is cost saving, and es� mated to be an excellent “buy” in terms of cost-eff ec� veness (cost per DALY saved). Ac� vi� es similar to Agita that have begun in other states are also likely to be cost-eff ec� ve. Given these results, states and municipali� es without physical ac� vity interven� ons should consider star� ng similar programs. It will be important to con� nue evalua� ng these programs and gathering evidence about what is eff ec� ve in Brazil and what is not.

Based on these data, the World Bank has evaluated the impact of the Agita São Paulo program and concluded that it means a saving of 310 million US dollars per year in the health costs of São Paulo State. The World Bank has stated that Agita São Paulo was found to be extremely cost-eff ec� ve. Very few public health or clinical interven� ons actually save money. Agita is one of a small number of very eff ec� ve interven� ons that produce benefi ts that outweigh the investment to improve health. The threshold for cost eff ec� veness is o� en set at USD 50.000-100.000/QALY. Thus, a cost saving interven� on is an especially good investment in public health11.

This evalua� on has been inspiring programs at the na� onal and interna� onal level, as well as the strategic role of con� nental (Physical Ac� vity Network of Americas – RAFA/PANA) and world (Agita Mundo) networks. Agita Mundo Networks comprise over 250 ins� tu� ons in 64 countries in the fi ve con� nents, which celebrate the World Day for Physical Ac� vity, around April 6th, involving around 2.500 events every year.

76


Conclusions

Based on these experiences we conclude that we are reaching a promising phase of new design interven�ons; where efficacy is maximized by using the following strategies in a synergis�c way: scien�fic transla�on; knowledge management; a mul�-level approach; clear, inclusive and tailored messages, emphasizing the role of fun, moderate, and accumula�ve PA; target groups; cultural adapta�on; social-marke�ng; a combina�on of mega-events with permanent ac�ons; self-sustainable strategies (“two-hats” approach; un-paid media, strategic partnerships, among others); local, na�onal, and interna�onal networking; and strong advocacy using vast social mobiliza�on, where change in the social percep�on of the risk of sedentarism is central.


• Despite an exponen�al increase in the number of scien�fic publica�ons, the sedentary epidemic is growing. In any event, most of the most of papers published are based on very short interven�ons, yet sustainable change requires long term “real world” programs. Agita São Paulo is an example of such an interven�on.

• Randomized controlled trials with large popula�ons are extremely difficult and expensive in both the developing and the developed world. Even if they could be done, world diversity prevents a direct applica�on of the research findings in other cultures and countries.

• Recent evidence from the World Bank concludes that mul�-level interven�ons based on the Agita São Paulo model are cost-effec�ve and even cost-saving.

Acknowledgements

The author would like to thank the help and inspira�on provided by Sandra Matsudo, Timoteo Araujo, Luis Carlos de Oliveira, José da Silva Guedes, Glaucia Braggion, Rosangela Villamarin, Leonardo da Silva e Mauricio Santos.


77


References

1. Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, Pra� M, Ekelund U, Yngve A, Sallis JF, Oja P (2003). The Interna�onal Physical Ac�vity Ques�onnaire (IPAQ): A comprehensive reliability and validity study in twelve countries. Medicine and Science in Sports and Exercise 35: 1381–95.

2. WHO (2004). World Health Survey results in Brazil.

3. Matsudo V, Guedes J, Matsudo S, Andrade D, Araújo T, Oliveira L, Braggion G, Ribeiro MA (2004). Policy interven�ons: the experience of Agita São Paulo in using “mobile management” of the ecological model to promote physical ac�vity. In: Oja P, Borms J, eds. Health Enhancing Physical Ac�vity. Berlin: Interna�onal Council of Sport Science and Physical Educa�on; 427–440.

4. Sallis J and Owen N. In Glanz K, Lewis FM, Rimer BK (Eds) (1997). Health behavior and health educa�on: Theory, research and prac�ce. 2nd ed, pp:403-424, San Francisco: Jossey-Bass.

5. Guedes JS, Matsudo VKR, Matsudo SMM (2007). Building strategic coali�ons in promo�ng physical ac�vity in an ecological approach. In: Proceedings of the World Congress in Sports for All.

6. Matsudo SMM, Matsudo VKR, Andrade DR, Araujo TL, Pra� M (2006). Evalua�on of physical ac�vity promo�on program: The example of Agita São Paulo. Evalua�on and Program Planning 29: 301-311.

7. Matsudo VKR, Matsudo SMM, Andrade DR, Araujo TL, Andrade EL, Oliveira LC (Suppl 2005) Diffusion and dissemina�on message efficacy of a program to promote physical ac�vity in a mega-popula�on according to gender. Medicine and Science in Sports and Exercise 37(5) pS249.

8. Matsudo V, Matsudo S, Guedes J, Araújo T, Andrade D, Andrade E, Oliveira L (2007). Promo�ng physical ac�vity in a world of diversity: the experience of Agita Mundo. In: Proceedings of the World Congress in Sports for All.

9. Matsudo VKR, Matsudo SMM, Araujo TL, Andrade DD, Oliveira LC, Hallal PC (2010). Time trends in physical ac�vity in the state of São Paulo, Brazil: 2002-2008. Medicine and Science in Sports and Exercise, Dec 2010 (in press).

10. Roux L, Pra� M, Yanagawa T (2005). Quan�fying something good: Agita São Paulo. In: Forum on Urbaniza�on and Globaliza�on and Physical Ac�vity, Bogota.

11. World Bank (2005). Addressing the challenge of non-communicable diseases in Brazil. Report 32576-BR. November 15th 2005.

78

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Thierno Alassane Diack


79

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Thierno Alassane Diack

Olympafrica: A Program of Social Development Through Sport

Thierno Alassane Diack

Olympafrica Interna�onal Founda�onDakar, Senegal


Everyone is aware of the difficul�es facing the con�nent of Africa. And yet these difficul�es, which are now several decades old, have given rise to new non-governmental organisa�ons which are working to improve the living condi�ons among the people of Africa.

In 1988, the then President of the IOC, Juan Antonio Samaranch, put forward the idea of finding a way for his organisa�on to assist developing countries, by crea�ng centres for dissemina�ng the Olympic idea. The first of these centres was constructed at Somone in Senegal, under the direc�on of the architect Ibrahima Mbaye, and the Interna�onal Olympafrica Founda�on was born on 23rd June 1993. Since that date, the Founda�on, whose overarching aim is social development through sport, has spread across the con�nent, and today encompasses 35 countries.

The chief objec�ves of the Founda�on are:

• To promote the establishment in African countries, which are generally under-equipped, of basic, cheap, func�onal and a�rac�ve mini-complexes dedicated to sport and social educa�on;

• To harness the enormous popular impact of sport to inspire young sportspeople and provide them with opportuni�es for long-term development;

• To contribute to restoring hope to young Africans by giving them the opportunity to be involved in non-conven�onal self-managed educa�onal programs;

• To foster the development of talented young sportspeople through ac�vity programs located near their homes.

80

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Thierno Alassane Diack 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Thierno Alassane Diack

Figure 1. Ground plan for an Olympafrica Centre.

An Olympafrica Centre, built at a cost of USD 180.000, consists of a cinder running track; a football field; a mul�-purpose court (handball, basketball, tennis, etc.); a mul�-purpose room (suitable for mee�ngs, indoor sports, concerts and various shows); and an enclosure consis�ng of a wall about 20 m long and a hedge around the circumference of the centre. These structures can be complemented by a room for young people, a library and internet room, a workshop and medical rooms.

Centres are constructed in areas which are rela�vely under-supplied with sports infrastructure, but with a rela�vely high density of young students. The Centres, which are the property of the Na�onal Olympic Commi�ees, are part of the communi�es and are managed by the local people. These individuals form part of a local Olympafrica Associa�on, and are trained and recruited by the Olympafrica Founda�on.

In a con�nent which suffers from a lack of spor�ng infrastructure and of dedicated leisure and spor�ng spaces, it is clear that the presence of Olympafrica Centres represent a substan�al posi�ve, especially for local educa�onal establishments.

The Olympafrica Centres are characterised by their support for the popularisa�on of sports par�cipa�on, but they are also a bridge to progressing cultural, economic, environmental and social ac�vi�es.


81


Popularisa�on of Sports Par�cipa�on

Naturally, sport occupies an important place in the Olympafrica Founda�on programs. In addi�on to the general sports programs organised by the Founda�on, a number of specific programs have been developed locally in collabora�on with the Na�onal Olympic Commi�ees.

The aims of the spor�ng programs are:

• To allow everyone to par�cipate in sport in a safe and suitable environment;

• To expand the par�cipant base and create a reservoir of talent for na�onal spor�ng federa�ons which rarely have the wherewithal to mount talent iden�fica�on programs;

• To afford educa�onal ins�tu�ons an infrastructure which allows them to conduct physical educa�on classes in the best possible condi�ons;

• To permit young people who belong to different communi�es to work side by side and learn to respect one another in a spor�ng environment.

Specific programs include:

• The Daimler Cup. This is a football tournament for young athletes. It spans more than 25 countries, with each local tournament involving about 550 children. Two regional tournaments are organised each year, each involving three to five countries. In 2010, a total of 15.000 children par�cipated in the Daimler Cup.

• The IBA Scholarship is an exchange program among Olympafrica Centres in the same geographic zone. It includes cultural, ar�s�c and spor�ng ac�vi�es, and elementary informa�on technology training. The most promising youngsters from each centre are chosen. This year, this scholarship program encompassed about 20 centres. Taking into account par�cipants in road races, there were over 11.000 par�cipants.

• IAAF Athle�cs for 13-15 year olds. This is a series of team compe��ons bringing together all par�cipa�ng schools from the eight subscribed Olympafrica Centres. This will include over 210.000 children in the period 2009-2012.

Whereas the programs men�oned above are designed only for young people under the age of sixteen, other events are open to the general public. They have resulted in the discovery of many sportspeople who have gone on to success in na�onal and interna�onal compe��ons, especially in football and athle�cs. Some young people have been selected for the Youth Olympics, World Championships and World Cups, but also for na�onal compe��ons in football, athle�cs, mar�al arts and netball.

The Centres operate full �me, and programs are run on a daily basis, managed by instructors and Centre Managers. Centres have from 200 to more than 600 visitors each day, peaking on weekends and during school holidays. The programs offered range from football, volleyball and netball to mar�al arts, boxing, tennis, basketball and handball. There have even been some cycle tours in Uganda, using bikes borrowed from the inhabitants of Busia, the region which hosts an Olympafrica Centre.

82

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Thierno Alassane Diack 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Thierno Alassane Diack

Nevertheless, it is important to note that lack of sufficient suitable equipment is ac�ng as a brake on mass par�cipa�on in sport. To overcome this problem, Centre infrastructure can be used for physical educa�on classes run by partner schools, equipment (eg for track and field events) can be temporarily loaned to schools, and training programs can be organised. Several training courses have already been organised in partnership with na�onal spor�ng federa�ons, which are usually in a state of poverty.

All the other ac�vi�es — social and economic — of the Olympafrica Centres are linked with par�cipa�on in sport. Choices are made by the local people themselves, with the Founda�on providing support in terms of training, logis�cs and funding. To do this, a number of partnership agreements have been signed, allowing us to strengthen the sports program a li�le more each year.

Economic Ac�vi�es and Social Development

As the Centres were established in underprivileged areas, it soon became apparent that sports programs needed to be complemented by cultural, economic and social ini�a�ves. The crea�on of these ini�a�ves also allowed adults to come to the Centres and their par�cipa�on in Centre ac�vi�es has been encouraged. These cultural ac�vi�es increase the social impact of the Centres on the local popula�on, and include among their main objec�ves:

• The educa�on of young people who do not currently a�end school;

• Extra-curricular ac�vi�es for those young people who do a�end school;

• Improving the nutri�on of the popula�on;

• The implementa�on of projects designed to make the Olympafrica Centres self-sustaining;

• The strengthening of peace and social cohesion;

• Financial support for the most talented youngsters through student bursaries and nutri�onal support.

The Centres sponsor several economic ac�vi�es, including development of micro-gardens in agricultural regions; carpentry skills for fishing projects in Burundi; tex�le workshops; and specific projects for making the Centres self-sustaining. Eight projects are funded each year by the Founda�on, based on local demand. They allow the Centres to educate young people who are not in school, to provide them with an appren�ceship, and to generate funds for the Centre. The profits generated by these enterprises are immediately reinvested in further projects, par�cularly spor�ng and cultural events.

In 2009, for example, we funded the following ac�vi�es: a silk-screen workshop, a sheep-breeding farm, a beauty salon, a factory producing chalk for school use, a dye works, and an HIV-AIDS awareness program.

In regard to the social development of communi�es, we have also created internet rooms, opened libraries, organised blood dona�ons, developed specific entrepreneurship classes for unschooled youth, funded programs that target major epidemics such as AIDS, trained managers to foster peace in countries which are home to Olympafrica Centres, and created a Centre for


83


housing refugees from the Burkina Faso floods. We are about to open a specialised internet facility which will make it possible for all young people to find a space for discussion, appren�ceship and educa�on. This important facility is a joint project with the Free University of Catalonia.

In countries where security remains a problem, these diverse ini�a�ves also make it possible for parents to prac�ce a trade in the same environment as their children, thereby greatly facilita�ng sports par�cipa�on.

Sport and Peace

In a con�nent which is very o�en torn by inter-community strife, the Founda�on decided to create a stream called “Encouraging Peace”. For this reason, Centre Managers now receive training around the theme of peace through sport. Agreements have been signed with partners for the produc�on and development of specific programs.

An ini�a�ve is also being worked out with the United Na�ons Integrated Office in Burundi (BINUB) to foster peace for the general elec�ons scheduled for 2010. The project will involve the crea�on of small economic structures to employ young people, and the use spor�ng events as pla�orms to disseminate messages of peace in Burundi. Workshops have already been set up by the Founda�on in the context of this program.

Currently we are organising sessions in Darfur, in Southern Sudan, and we have launched the construc�on of an Olympafrica Centre in Somalia. The Olympafrica Centre in Kemah Town in Liberia, which was opened in 2008, was constructed en�rely by former young rebels, and is managed by a former soldier. It is showing excellent results.

Sport and Environment

The environment is one area where the Founda�on has been working for several years, largely in the margins of spor�ng events. We can point to reforesta�on programs run internally and in associa�on with Olympic athletes, and other programs developed locally by Centre Managers. For a li�le over a year, the Founda�on has been working on a reforesta�on project on a con�nental scale, a project which will be accomplished with the help of partner schools.

Sport and Educa�on

Educa�on is accepted as a major component of the day to day opera�on of the Centres. As part of this component, the Founda�on has signed agreements with:

• The United Na�ons World Tourist Organiza�on (UNWTO) for the development of the UNWTO/Small Libraries program. Under this scheme the Centres in Mali, Senegal, Cameroon, Mozambique and Benin will receive substan�al funding to build children’s libraries;

• The Free University of Catalonia, with which we are currently developing specific programs and an internet site;

84

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Thierno Alassane Diack 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Tatsuo Araki

• The IOC’s Department of Development and Interna�onal Rela�ons, for the popularisa�on of the Olympic Values Educa�on Program (OVEP) in Africa. Several sessions have been rolled out in 2009 in partnership with the educa�on authori�es in involved countries;

• You First Founda�on, for the crea�on of internet rooms especially for young people, and basketball clinics;

• CONFEJES (the Council of Ministers of Youth in Francophone countries), with which significant programs have been developed;

• Agreements are also being finalised with several Na�onal Olympic Commi�ees as part of an interna�onal coopera�on.

Conclusion

In your countries, sport is in compe��on with various leisure op�ons, such as television, internet, videogames and cinema. In Africa, sport faces even more formidable compe�tors. These include wretched living condi�ons (eg. hunger, idleness; the lack of adequate infrastructure, leisure spaces and equipment; and the absence of a na�onal poli�cal understanding of the posi�ve aspects of sports development. In many countries, less than 0.5% of the total budget is allocated to sport. It is clear that if we want to popularise sport in Africa we need to take these aspects of the situa�on into account.

The film which I invite you to watch is a perfect illustra�on of the vision of the Olympafrica Founda�on. It was shot in Burundi, a country torn apart by the bloody events of a few years ago. I ask you not to focus on the fact that these children aren’t wearing shoes, or on their clothes, but rather on the joy which lights up all their faces. Sport, meaning exchange, communion and fraternity, is helping to heal the wounds of the civil war. You’ll see the joy of these children reflected in the eyes of their parents as they work the fields, a symbol of hope for a be�er future.


• Although the Olympafrica Founda�on is already producing posi�ve outcomes, it is clear that we are limited in terms of our target popula�on.

• We need, in collabora�on with local organisa�ons, to put together strategies for infrastructure development without which the popularisa�on of sports par�cipa�on will never be achieved.


85

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Tatsuo Araki

The Importance of Enjoyment: Recommenda�ons from Japan on “Gymnas�cs for All”

Tatsuo Araki

Gymnas�cs for All CommiteeInterna�onal Gymnas�cs Federa�onTokyo, Japan

E-mail: araki@ni�ai.ac.jp

Introduc�on

Many powerful men have pursued the fruits and medicine of perpetual youth and longevity since �mes of great an�quity. This was indeed considered essen�al for achieving, maintaining and improving health. However, most of the general populace worked for a living and ended their lives without having �me to spend on leisure. They probably did not even have �me to think about the perpetual youth and longevity.

Generally, in present socie�es, there is more equality, especially in developed countries. Most people pay some a�en�on to the subjects of poli�cs, economy, show business and most of all, health. However, in highly-developed countries there is a great deal of psychological stress, which is the cause of many illnesses. Although once considered to be separate, the body and soul are now perceived as shared, and it is speculated that human rela�onships are a cause of many of these psychosocial health problems.

Movement is crucial for counterac�ng these health problems; and all valid acts of living can be considered as exercise or movement. If we take a typical 24 hour period, for a general worker, we find that about one hour is needed for ge�ng up, showering and having breakfast. Another hour is spent commu�ng to work, and then, on average, 8 hours are spent at work (including the lunch break). Another hour is spent commu�ng from work to home. If 8 hours are spent sleeping, this leaves 5 hours for “ac�vi�es of daily living” (for example, shopping, cooking, cleaning, mending, caring) and leisure �me.

Typically, sport would fit into leisure �me, but many people find they just do not have the �me for ac�ve recrea�on. How then can we use the �me we have available to us to execute movements that will benefit health? How can we get Sport for All into our lives? Might it be possible to incorporate exercise into our working day instead?

In terms of making choices about leisure �me, people appear to fit into four groups: There are those who want to “train” by going to the gym and doing muscle strengthening and aerobic exercises, or joining a spor�ng club. There are those who want to “rest their mind” by reading a book, watching television or listening to music. Then there are those who want to release the stress of work – they typically will head for the pub. And finally there are those who choose to do nothing. Other than for the first group, who choose ac�ve sport and recrea�on, how can exercise be incorporated into daily life?

86

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Tatsuo Araki 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Tatsuo Araki

“Zimmer Gymnas�cs”

The idea of “Gymnas�cs in the room” was first published in Germany in 1891.

This regimen recommends light exercises rather than muscular strength or cardiovascular training. As can be seen in the picture, the exercises can be done in everyday clothing. There are three basic movements: bend and stretch (flexion and extension), turn (rota�on), and twist. The authors suggest that by moving the whole body evenly and “relaxing the mind”, the exercises will be enjoyable and, by varying the movements, par�cipants will not become bored. They even suggest using everyday tools to add varia�on to the exercises.

The following pictures show how these exercises can be modified for use at home and at work. For example, farmers can use farm equipment, office workers can use their desks, and factory workers can use their tools. Women who work at home can also adapt their environment for these exercises. By being crea�ve, exercise can be fun, and gymnas�cs for all can contribute to a healthy life.


87



• Many people do not have �me for structured sport or exercise

• The concept of “room gymnas�cs” (developed in 1891) can be adapted for use in many working environments, to add movement to otherwise largely sedentary lives.

Pictures: • movement with shovel; • with tractor; • with cleaner; • in the stairs; • in cowhouse; • in office; • with wine barrel; • Let’s Happy Exercise with Pot!

88

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Paula Risikko


89

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Paula Risikko

Mul�sectoral Approaches to Promo�ng Sport for All at the Governmental Level

Paula Risikko

Ministry of Social Affairs and HealthHelsinki, Finland


Finnish people have tradi�onally been physically ac�ve, and for leisure-�me physical ac�vity this is s�ll true. Indeed, people of working age have increased their physical ac�vity in recent decades; around two thirds of all adults now take sufficient physical ac�vity for health benefit. Small children are also very ac�ve and pensioners, too, are fairly physically ac�ve.

Everyday Physical Ac�vity Has Decreased Among Finns

Recently, however, several alarming trends have been discussed: everyday physical ac�vity and walking or cycling to work have diminished among Finns, and the endurance condi�on of young men has weakened. It is also worrying that physical ac�vity among young people in their teens has diminished and the propor�on of passive young people is high: as many as 25 per cent of them take very li�le physical ac�vity.

Another significant trend is the socioeconomic and regional differences in physical ac�vity: well-educated white-collar employees take most physical ac�vity, whereas self-employed persons and farmers take least physical ac�vity. People living in towns are more ac�ve than people living in the countryside.

The strongest indicators of too li�le physical ac�vity are an increase in overweight and a higher prevalence of type 2 diabetes, which are now considered to be the most important threats, not only to the health of the Finnish people, but also to the availability of health services in our country. As everyday physical ac�vity decreases, the number of overweight people is steadily increasing; 60 per cent of men of working age and 40 per cent of women are overweight. The increase in overweight has been par�cularly strong among young men.

Economic Losses Are Significant

In Finland, insufficient physical ac�vity is es�mated to cost over 400 million euros to the state, municipali�es, insurance ins�tu�ons and employers. Half of the costs are caused by sickness absence and reduced produc�vity of workers. The rest come from direct health and social expenditure. There are also economic losses for individuals themselves. Insufficient physical ac�vity can affect both physical func�onal ability and mental and social health and wellbeing.

90

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Paula Risikko 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Paula Risikko

How to Increase Physical Ac�vity?

Insufficient physical ac�vity in our popula�on is a hot topic at the moment. How can we get people interested in their health and physical condi�on? While there are no simple solu�ons, we can find a number of ways to diminish the problem.

Not everyone enjoys exercise. Many adults have removed physical ac�vity from their everyday lives. We should, therefore, restore the “ac�ve living culture”, in which everyday situa�ons can be more physically ac�ve. Walking or cycling to work and playing with children are simple methods of increasing daily physical ac�vity.

Research indicates that passive people generally have very li�le earlier experience of exercise or they have more nega�ve experiences than ac�ve people. In consequence, passive people are o�en in need of support from health care and sports professionals in order to get started and to stay ac�ve. Individual exercise programmes can help to increase the physical ac�vity of the adult popula�on. The path towards a physically ac�ve life may require several a�empts, and that is why professional or peer support plays such an important role.

Physical Ac�vity Is Integrated into General Health Promo�on

Promo�ng ci�zens’ physical ac�vity has taken an important role in the preven�ve work carried out by the Ministry of Social Affairs and Health. In our public health programme Health 2015, physical ac�vity is one of the key means of securing the health and wellbeing of all age groups. In the early 2000s the Ministry prepared an extensive report on the development of health-enhancing physical ac�vity in Finland. Its most important proposals were included in a Government Resolu�on.

Mul�sectoral coopera�on between the different ministries has been of vital importance in implemen�ng this resolu�on. To enhance coopera�on, an advisory board was established with representa�ves from five ministries, Finland’s Slot Machine Associa�on and the Associa�on of Finnish Local and Regional Authori�es. Non-governmental organisa�ons in the field of sports and public health, as well as agencies with sports exper�se, are represented on the advisory board. The board is to dra� na�onal guidelines and recommenda�ons, coordinate extensive projects on health-enhancing physical ac�vity, and plan the financing of the projects.

The support from the Ministry and the stronger role of the Slot Machine Associa�on has made it possible to more than double the funding for health-enhancing physical ac�vity in the past eight years. Around 8 million euros annually have been targeted at health-enhancing physical ac�vity in recent years. This has enabled widespread implementa�on of the Government resolu�on.

The funding of most of the projects was based on co-financing, demonstra�ng an increase in mul�sectoral coopera�on. In this way we have improved the opportuni�es for physical ac�vity in, for example, child daycare centres, schools, old people’s homes and service housing. Efforts have also been made to improve the opportuni�es for physical ac�vity for special groups and families, as well as to develop community facili�es for sports and physical ac�vity.


91


Stronger Status for Physical Ac�vity in the Central Government

When we were drawing up the Government Programme two years ago, we knew that Finland is ageing in record speed and that many major chronic diseases will mul�ply due to harmful lifestyles. The Government decided, then, to launch a Policy Programme for Health Promo�on and set the key target at preven�ng chronic diseases by lifestyle changes. Our tools include, for example, reducing obesity among children, young people and people of working age and influencing smoking and alcohol consump�on. We also ini�ated a policy programme for the well-being of children, young people and families.

Changes are impera�ve if are to prevent an uncontrollable growth of the need and costs for social and health services. The policy programmes aim at promo�ng healthy lifestyles, increasing the inclusion of young people, and reducing mental health problems and the risk of social exclusion.

The Government Programme in Finland clearly supports the promo�on of physical ac�vity. Accordingly, sport policy promotes the wellbeing, health and func�onal capacity of the popula�on at different stages of life. A specific mul�sectoral policy programme focusing on health promo�on highlights the fact that people place a high value on health.

This health promo�on programme aims to improve the integra�on of health considera�ons into decision-making and the service system. All decision-making takes health into account so that healthy choices are available, easy and a�rac�ve for the ci�zens. One of the key targets of the programme is to influence lifestyles – including physical ac�vity and nutri�on. The main principle and objec�ve of the programme is “Health in All Policies”. Health promo�on should concern all ministries.

The stronger status of health-enhancing physical ac�vity in the central government has tradi�onally been par�cularly visible in the ac�vi�es of the Ministry of Educa�on and Culture, Ministry of Social Affairs and Health, Ministry of Transport and Communica�ons, and Ministry of the Environment. The goal of health promo�on programme is that all the ministries join enhancing the physical ac�vity of the ci�zens.

A good example of efficient mul�sectoral coopera�on is the na�onal Fit for Life Program. This joint project of four ministries is helping over 40 year olds to adopt physically ac�ve lifestyles. Nearly a thousand local projects have been launched within the programme, with the aim of offering adults and ageing people low-threshold opportuni�es for physical ac�vity.

New Guidelines for Promo�ng Physical Ac�vity and Nutri�on

Two years ago the strong increase in overweight spurred us to draw up new guidelines that combine physical ac�vity and nutri�on in a natural way. The Government issued a resolu�on on the ma�er and adopted an ac�on plan for the implementa�on of the resolu�on. The ac�on plan is strongly based on mul�sectoral coopera�on both at central government and local levels.

We want to promote physical ac�vity and healthy nutri�on for people of all ages and in different popula�on groups. In par�cular, we are trying to reach people with health problems related to overweight and inac�vity, as well as disadvantaged groups.

92

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Paula Risikko 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Eddy L. Engelsman

With the ac�on plan we are encouraging Finns to increase their everyday physical ac�vity, and to improve environmental condi�ons for physical ac�vity, such as community facili�es for sports and physical ac�vity, pedestrian and cycling routes, as well as parks and green areas. The courtyards of daycare centres, schools, educa�onal ins�tu�ons, and service housing are also important for everyday physical ac�vity. We are encouraging local governments to create community environments that a�ract people to physical ac�vity, and to be�er integrate sports and physical ac�vity in their zoning and land use planning.

Coopera�on by Different Sectors

The goal of encouraging people who are insufficiently ac�ve for health benefit to become more ac�ve requires very close coopera�on of the health care and sports sectors. People in different age and popula�on groups, and especially disadvantaged people, must have access to be�er support and guidance so that they can find the form of physical ac�vity that suits them best, and so that they can succeed in changing their lifestyles. Ci�zens must have access to expert lifestyle advice in health services and guidance on local physical ac�vity services. The relevant actors include maternity and child health clinics, school and student health services, primary and occupa�onal health services as well as services for the elderly.

Our Ministry considers reducing health inequali�es to be one of the key themes for the future. It is important to u�lise social policy to influence poverty, educa�on, employment and the use of social and health services. Reducing health inequali�es also requires measures targeted at people at risk within the sports sector.

Examples of targeted measures in Finland include the campaign Joe the Finn launched by the Fit for Life Program. It aims to encourage men in poor physical condi�on to take physical ac�vity and adopt other healthy lifestyles. Another Finnish example of targeted projects is the programme Strength for the Old Ages that aims to increase the physical ac�vity and especially muscular strength of elderly persons; the programme has brought about significant improvements in elderly people’s possibili�es to be physical ac�vity across the country.


• Promo�ng the health of the popula�on and increasing physical ac�vity are challenging tasks.

• Single measures may not have any great impact, but a number of measures together can make a difference.

• Coopera�on and working to achieve similar goals are the only way we can respond to the challenge of inac�vity

• Sharing and distribu�ng efficient examples is important both at the na�onal and interna�onal level.


93

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Eddy L. Engelsman

The World Health Organiza�on Global Recommenda�ons on Physical Ac�vity for Health and the Opportuni�es for the Sports World

Eddy L. Engelsman

Department of Chronic Diseases and Health Promo�on (CHP)World Health Organiza�on, HeadquartersGeneva, Switzerland


Once upon a �me there was a country where “health” and “sport” had been in the same ministry for more than 20 years, but sport was not considered an important instrument to enhance health. Neither by the health, nor by the sport sector. They lived in different worlds. Sports and health, unmistakeably an inseparable duo. Unfortunately they are not.

Global Burden of Physical Inac�vity and Its Global Neglect

Physical inac�vity has been iden�fied as the fourth leading risk factor for global mortality. It is an independent risk factor for noncommunicable diseases (NCDs), causing 1.9 million deaths globally each year. Physical inac�vity is es�mated to be the main cause of around 21-25% of the breast and colon cancer burden, 27% of diabetes and about 30% of the ischaemic heart disease burden. Physical inac�vity is also linked to overweight and obesity. Globally, in 2010 the number of overweight children under the age of five is es�mated to be 43 million, of whom nearly 35 million are living in developing countries. Less than half of these children do not meet the recommenda�on of one hour physical ac�vity per day1.

In spite of these alarming facts, and even though physical ac�vity has been iden�fied by many researchers and the World Health Organiza�on as an important public health issue, physical ac�vity is not high on the agenda of many Member States. Many people s�ll think that infec�ous (communicable) diseases, such as TB, malaria and HIV-AIDS form the vast majority of all global disease burden. They do not. Noncommunicable chronic diseases (NCDs), notably heart disease and stroke, cancers, diabetes and chronic lung diseases are now by far the leading cause of death in the world. Currently, out of every 10 deaths, 6 are due to noncommunicable diseases: in total 35 million people. The burden of NCDs now accounts for nearly half of the global burden of disease2.

94

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Eddy L. Engelsman 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Eddy L. Engelsman

The four leading risk factors for NCDs are tobacco use, unhealthy diet, physical inac�vity and harmful use of alcohol. Unless addressed more ac�vely, the mortality and disease burden will con�nue to increase and WHO es�mates that, globally, NCD deaths will increase by 17% over the next ten years.

NCDs are not primarily a problem of high income countries. The reality is that 80% of NCD deaths occur in low and middle income countries. The greatest increase in mortality in the next ten years will also be seen in low and middle income countries. In the African region this increase will be 27% and the Eastern Mediterranean region 25%3. In the least developed countries of the world, poor people are much more likely than the wealthy to develop a NCD, and everywhere they are more likely to die as a result. NCDs do not mainly affect rich people.

NCDs are not only a problem for older people. In fact, people in low and middle income countries tend to develop disease at younger ages, suffer longer – o�en with preventable complica�ons – and die sooner than those in high income countries. Ignoring all these facts has contributed to the global neglect of NCDs. Ac�ons needed to change this situa�on o�en lack sufficient poli�cal a�en�on, policy instruments, staff and budget. These factors may clarify why NCDs are not included in the United Na�ons Millennium Development Goals (deadline 2015), whereas communicable diseases are. NCDs are o�en neglected by many United Na�ons agencies, such as those related to development. The promo�on of physical ac�vity, including sport for health, could flourish be�er if NCDs were on the development agenda of the en�re UN system.

Sedentary Lifestyles

What kind of physical ac�vity would contribute most to health enhancement? Sport is certainly indispensable and we can make progress here. With a wider scope of physical ac�vity we may however increase the health benefits.

The inac�vity rate is high. Surprisingly this is not because many people do less sport than in the past. A European study of sedentariness concluded that youth par�cipa�on in sport clubs has never been as high as at present. Nevertheless there is a decrease in physical ac�vity with almost about half of young people not ge�ng the recommended amount of physical ac�vity4.

What’s going on here? The reason is that a great deal of energy expenditure has disappeared from everyday life, leading to sedentary lifestyles. People sit and watch television, sit behind computers, go by car to school, work, shops and even to spor�ng facili�es. Inappropriate urbaniza�on has also contributed greatly to this development. According to a study in the Netherlands, where about 68% of adults (≥18 years old) and 47% of children (4-17 years old) meet the PA-requirements (2008), sport contributes 5% to the total quan�ty of physical ac�vity. It is a minor source of physical ac�vity5.

Physical ac�vity is obviously more than sport. The main sources of ac�vity include simple, daily ac�vi�es such as walking and cycling as means of ac�ve transport, playing, manual labour, odd jobs at home, gardening, dancing and others. The lack of physical ac�vity can never be compensated by sport alone. That would not result in substan�al popula�on changes in physical ac�vity up to the level needed to enhance health, and to lower rates of chronic diseases. The scale of the problem is too big. Bearing this in mind, we must ensure that people who do not want


95


to play sport or are not able to do sport, do not think that they cannot do anything else, because they do not take part in spor�ng ac�vi�es. Other forms of physical ac�vity such as everyday walking and cycling, are needed and have to be promoted more (see the picture of a 87 year old woman who cycles one hour daily). If sports organiza�ons and sports policy makers consider this as sport, which they o�en do, and argue that this is important, why do they concentrate so li�le on these kinds of exercise?

WHO Ac�on: Global Strategy on Diet, Physical Ac�vity and Health

In 2004, the World Health Assembly (WHA) endorsed the Global Strategy on Diet, Physical Ac�vity and Health, providing the WHO Secretariat with a clear mandate and responsibili�es for work related to health promo�on and the primary preven�on of NCDs through diet and physical ac�vity (WHA Resolu�on 57.17)6. The Global Strategy is a comprehensive tool to guide Member States, WHO and interna�onal partners, civil society, nongovernmental organiza�ons and the private sector. WHO provides guidance, development of tools and technical support for Member States, notably the “School Policy Framework”, “Interven�ons on Diet and Physical Ac�vity: What works”, “A Framework to monitor implementa�on”, “A Guide for popula�on-based approaches to increasing levels of physical ac�vity” (h�p://www.who.int/dietphysicalac�vity/PA-promo�onguide-2007.pdf) and “Preven�ng Noncommunicable Diseases in the Workplace through Diet and Physical Ac�vity; WHO/World Economic Forum Report of a Joint Event”. The WHO has also organized several na�onal, regional and global capacity building workshops and ac�vi�es and has been facilita�ng mutual consulta�ons and exchange of experiences between Member States. The WHO has also developed the STEPS approach, an instrument to assess NCD risk factor levels including measuring physical ac�vity and other behavioural parameters, and the capacity to develop and implement na�onal policies, especially in low income countries. STEPS has now been applied in about 100 countries globally. Moreover, the WHO has engaged in dialogues with the global private sector and other UN Agencies.

96


Individual Versus Public Responsibility

It is o�en emphasized that if individuals develop NCDs as a result of unhealthy lifestyles, they have no one to blame but themselves. Therefore government ac�on could be limited to informing and educa�ng people on healthy behaviour. The truth is that the physical environment is of decisive importance for enhancing health. Individual responsibility can have its effect only where individuals have access to healthy life, physical educa�on in school, healthy and safe environments that facilitate and s�mulate physically ac�ve living. This is especially true for children who cannot choose the environment in which they live. These factors can only be seriously influenced by public or government ac�on7. This has major implica�ons for sectors such as transporta�on, urban design and planning, and other environmental and social policy measures. Physical ac�vity-friendly environments may facilitate healthy behaviours and healthier choices. There are also proponents of more compelling alterna�ves where there is no choice. For example, authori�es could create physical ac�vity-friendly environments as the only -healthy- op�on: no motorized transporta�on, no elevators, no escalators etc.

Consequently, the endorsement by the World Health Assembly of the Global Strategy on Diet, Physical Ac�vity and Health represented a major step forward in stressing that improving diet and physical ac�vity habits of popula�ons was a societal issue and not just a ma�er of individual behaviour. The strategy therefore required a popula�on-based and mul�sectoral, mul�-disciplinary “all of society” approach, of which “sports for all” is a component.

WHO Ac�on Plan 2008-2013 for the Global strategy for the Preven�on and Control of Noncommunicable Disease3

The objec�ves for the implementa�on of the Global Strategy on Diet, Physical Ac�vity and Health are integrated and reinforced in the WHO Ac�on Plan 2008-2013 for the Global strategy for the Preven�on and Control of Noncommunicable Disease, endorsed by the WHA (WHA61.14) in 2008. This NCD Ac�on Plan proposed ac�ons promo�ng physical ac�vity for Member States which involve:

• Implemen�ng the ac�ons recommended in the Global Strategy;

• Developing and implemen�ng na�onal guidelines on physical ac�vity for health;

• Implemen�ng school-based programmes in line with WHO’s health-promo�ng schools ini�a�ve;

• Ensuring that physical environments support safe ac�ve commu�ng, and create space for recrea�onal ac�vity, by ensuring that walking, cycling and other forms of physical ac�vity are accessible to and safe for all; introducing transport policies that promote ac�ve and safe methods of travelling to and from schools and workplaces, such as walking or cycling; improving sports, recrea�on and leisure facili�es and increasing the number of safe spaces available for ac�ve play.

The introduc�on of a comprehensive approach to physical ac�vity in the NCD Ac�on Plan involves a paradigm shi� in public health policies of many countries. This comprehensive concept of physical ac�vity has now become an evidence based key element in the upcoming WHO Global Recommenda�ons on Physical Ac�vity for Health8. They offer new opportuni�es for both Member States and sports organiza�ons to work together to promote increased physical ac�vity.


97


WHO Global Recommenda�ons on Physical Ac�vity for Health

The abovemen�oned WHA Resolu�ons WHA57.17 and 61.14 urge Member States to develop and implement na�onal guidelines on physical ac�vity for health, and urge the WHO to provide countries with technical support for either implemen�ng or strengthening na�onwide ac�ons. In order to address these and previous mandates, and in addi�on to the several ac�vi�es described before, WHO has undertaken to develop the Global Recommenda�ons on Physical Ac�vity for Health. Many countries have not developed na�onal guidelines for physical ac�vity, and where they have, they differ from one country to the other. In response to the need expressed by Member States, and according to its norma�ve func�on, WHO developed global recommenda�ons using scien�fic research findings from all over the world and applicable in all WHO regions.

The Global Recommenda�ons aim to provide guidance to na�onal policy makers on the dose-response rela�onship between physical ac�vity and health benefits, i.e. the frequency, dura�on, intensity, type and total amount of physical ac�vity needed for health enhancement and preven�on of NCDs. Primary preven�on of NCDs through physical ac�vity, at the popula�on level, is the focus of the Recommenda�ons. These need to be translated and implemented at na�onal level and may need to be adapted to na�onal and sub-na�onal circumstances. The main recommenda�ons are:

Children and Youth (5-17 Years Old)

• Should accumulate at least 60 minutes of moderate to vigorous intensity physical ac�vity daily. This includes play, games, sports, ac�ve transporta�on, chores, recrea�on, physical educa�on, or planned exercise, in the context of family, school and community ac�vi�es. Amounts of physical ac�vity greater than 60 minutes provide addi�onal health benefits. Most of the daily physical ac�vity should be aerobic. However, vigorous intensity ac�vi�es should be incorporated, including those that strengthen muscle and bone, at least 3 �mes per week of each.

• Compared with physically inac�ve children and youth, ac�ve children and youth have higher levels of cardiorespiratory fitness, muscular endurance and muscle strength. Well-documented health benefits also include reduced body fatness, more favourable cardiovascular and metabolic disease risk profiles, enhanced bone health, and reduced symptoms of anxiety and depression.

Adults (18-64 Years Old) and Older Adults (65 Years Old and Older)

• Should do at least 150 minutes of moderate-intensity aerobic physical ac�vity spread throughout the week or at least 75 minutes of vigorous-intensity aerobic physical ac�vity spread throughout the week or an equivalent combina�on of both types.

• Evidence of acute effects on biomedical markers points to benefits of undertaking regular physical ac�vity throughout the week, such as five or more �mes a week. Moreover this has the poten�al to encourage integra�ng physical ac�vity as part of daily lifestyle, such as ac�ve travel through walking and cycling.

98


• The higher the levels of moderate-intensity physical ac�vity, up to 300 minutes, the higher the health benefits. For addi�onal health benefits adults could also engage in 150 minutes vigorous-intensity physical ac�vity per week, or an equivalent combina�on of more moderate-and vigorous-intensity ac�vity.

• Muscle-strengthening ac�vi�es should be done, involving major muscle groups, on 2 or more days a week.

• Older adults, with poor mobility, should perform physical ac�vity on 3 or more days per week, to enhance balance and prevent falls. When older adults cannot do the recommended amounts of physical ac�vity due to health condi�ons, they should be as physically ac�ve as their abili�es and condi�ons allow.

• The recommenda�ons for adults and older adults are applicable to cardiorespiratory health (coronary heart disease, cardiovascular disease, stroke and hypertension), metabolic health (diabetes and obesity), bone health and osteoporosis, breast and colon cancer and depression. In addi�on, for older adults the recommenda�ons are applicable to preven�on of falls and cogni�ve decline.

Requested Commitment from the Sport World: Engage More People - More Ac�ve - More O�en

Sport is primarily fun - and it should be fun. We also recognize that sport is of great importance to public health. The ques�on is whether the sports world shares this opinion. For many years, the “sports world” has been underes�ma�ng the health enhancing benefits of physical ac�vity. It appeared to be reluctant to develop health enhancing ac�vi�es, and sport seemed to almost be a goal in itself. For example: according to a global study there has been a decrease in school Physical Educa�on (PE) lessons, and as school PE reinforces achievement-oriented compe��ve sport, sport compe��on structures, sports talent development and provision of specialist facili�es, this may limit par�cipatory op�ons9. We can achieve more if the sports movement will accept taking health enhancing tasks on board, and if, in par�cular, it would help to implement WHO’s Global Recommenda�ons on Physical Ac�vity for Health.

Na�onal sport federa�ons and organiza�ons are invited to encourage and facilitate local sports clubs to develop ac�vi�es to reach the inac�ve and less ac�ve. These ac�vi�es must be tuned to the needs of all people: client oriented instead of supply driven. The ac�vi�es should par�cularly be targeted to low and middle income countries.

The interest of sports organiza�ons should be in:

1. Crea�ng new clients, by a�rac�ng new members of sport clubs;

2. Retaining spor�ng people, par�cularly when children finish school and when people re�re;

3. Contribu�ng to social/public health goals.


99


Conclusion

In conclusion, interna�onal, regional, na�onal and local sports organiza�ons could undertake the following strategies in order to promote more widespread Sport for All.

[1] Policy: enter into alliances with public health authori�es and be pro-ac�ve towards health authori�es;

[2] People: tailor ac�vi�es to the inac�ve and less ac�ve (e.g. lower income groups/the poor, unemployed, older adults, ethnic minori�es, people with chronic disease or disability, overweight people etc); pay more a�en�on to gender issues (e.g. enable girls, inac�ve due to cultural or religious background, to become ac�ve);

[3] Places: bring ac�vi�es to where the people are (i.e. communi�es, school, workplace, primary health care, and at the �mes they want); sports facili�es at the edges of urban areas are in the wrong place; promote healthy modes of transporta�on to sport premises, by working with local and na�onal authori�es to develop be�er infrastructure for ac�ve transporta�on and ‘healthy’ urban design;

[4] Par�cipa�on: help to strengthen moderate intensive ac�vity such as walking and cycling, by offering organiza�onal capacity, training and support, and by extending ac�vi�es such as Nordic walking, guided nature walks, culture walks etc., and coopera�ng with walking and cycling NGOs; organize the increasing number of unorganized sportspeople in a “light” form (for example, organizing soccer might be more needed than organizing soccer infrastructure), and offer more par�cipa�ve, instead of compe��ve ac�vi�es;

[5] Programs and promo�on: develop and promote health promo�ng sport clubs (by iden�fying and developing health enhancing profiles of and standards for different sports, as some sports do be�er “for health” than the others); develop new, more modern modes of affilia�ons, instead of membership of sport clubs.


Sports organisa�ons should:

• Offer programs for new target groups; for example, people with a disability or illness, girls and women from different cultures, the homeless and the poor;

• Offer new sports ac�vi�es and new varia�ons of exis�ng sports; for example, Nordic walking, leisure biking, dancing;

• Introduce/develop the concept of healthy sport clubs, with a life�me approach to sport, combining sport and other (e.g. cultural) ac�vi�es, and improving access to facili�es (for example by having flexible memberships, free of charge par�cipa�on, more crea�ve �metabling, outreach services, etc);

• Iden�fy partnerships with other organisa�ons [e.g employers, employees/trade unions, public health authori�es, environmental (“green”) organiza�ons];

• Play an advocacy role in crea�ng urban se�ngs for ac�ve transport and ac�ve leisure, such as community gardens.

100

13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010 • Eddy L. Engelsman 13th World Sport for All Congress — Jyväskylä, Finland, 14-17th June 2010

References

1. World Health Organiza�on (WHO) (2008). World Health Report.

2. World Health Organiza�on (WHO) (2005). Preven�ng Chronic Diseases: a Vital Investment.

3 . World Health Organiza�on (WHO) (2008). 2008-2013 Ac�on Plan for the Global Strategy for the Preven�on and Control of Noncommunicable Diseases.

4. Bre�schneider WD, Naul R (2004). Young people’s lifestyles and sedentariness. European Commission DG EAC.

5. TNO Kwaliteit van Leven, Leiden. Factsheet Bewegen in Nederland 2000-2008, Resultaten Monitor Bewegen en Gezondheid. (2009).

6. World Health Organiza�on (WHO) (2004). Global strategy on Diet, Physical Ac�vity and Health.

7. World Health Organiza�on (WHO) (2007). WHO chronic disease handbook.

8 . World Health Organiza�on (WHO) (2010). Global Recommenda�ons on Physical Ac�vity for Health.

9. Hardman K, Marshall J (2009). Second World-wide Survey of School Physical Educa�on Final report. Interna�onal

Council of Sport Science and Physical Educa�on (ICSSPE).


101


102



103


104


13th world sport for all congress — jyväskylä, …...13th world sport for all congress —...

Documents