World-Wide Physical Inactivity: Scope of the Problem and What

to Do about It

Moscow, RussiaRussia-U.S.A. Scientific Forum

November 17, 2011

Steven N. BlairDepartments of Exercise Science &

Epidemiology/BiostatisticsUniversity of South Carolina

Non-Communicable Diseases (NCDs) Changing patterns in leisure and

work have led to a health crisis NCDs cause 65% of all deaths

worldwide 36.1 million deaths from CVD,

Stroke, Diabetes, Cancer & Respiratory diseases.

Physical inactivity causes 3.2 million deaths/year

WHO. Mortality and burden of disease estimates for WHO Member States in 2008. Geneva: World Health Organization, 2010.

NCDs: Key Risk FactorsBeaglehole et al., Lancet 2011; 377: 1438–47

Direct Causal Factors• Tobacco use• Physical Inactivity• Poor Nutrition

Intermediate Risk Factors• Obesity• Hypertension• Hyperglycemia

• Hypercholesterolemia

High cholesterol

Overweight & obesity

Physical Inactivity

High blood glucose

Tobacco use

High blood pressure

0 1 2 3 4 5 6 7 8

High IncomeMiddle IncomeLow Income

Mortality in millions (total 58.8 million)

Leading risk factors for mortality by income group (estimates from 2004)

© World Health Organization 2009(http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.html)

Self-reported Physical Activity Underestimates the True Effect

Wom

enM

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en0

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LowModerateHigh

• 31,818 men and 10,555 women

• 1492 deaths in men during average follow-up of 14.6 years, and 230 deaths in women during average follow-up of 12.8 years

• PA mortality trends not significant after adj for CRF

• CRF trends significant after adj for PA

Phys Act CRF

Lee DC, et al. BJSM 2011; 45:504-10

Aerobics Center Longitudinal Study

Design of the ACLS

1970 More than 80,000 patients 2005

Mortality surveillance to 2003More than 4000 deaths

Cooper Clinic examinations--includinghistory and physical exam, clinical tests,body composition, EBT, and CRF

1982 ‘86 ‘90 ‘95 ’99 ‘04Mail-back surveys for case finding and monitoring habits and other characteristics

All-Cause Death Rates by CRF Categories—3120 Women and

10 224 Men—ACLS

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Women

Men

Blair SN. JAMA 1989

Does Changing Cardiorespiratory Fitness

Reduce Mortality Risk?

Fitness Change Categories Unfit was defined as the least fit 20% of men

in each age group Men were classified as fit or unfit at both

examinations Change categories

• unfit at both examinations = never fit• unfit at first, fit at second = improvers• fit at both examinations = always fit

Blair SN et al. JAMA 1995; 273:1093-8

Age-Adjusted Death Rates by Fitness Change Groups, Men, ACLS

Age-adjusted Death Rates/10,000 Man-years

Fitness Groups

CVD All-cause

Never fit 65 122

Improvers 31 68

Always fit 14 40

Blair SN et al. JAMA 1995; 273:1093-8

CRF and Other Health Outcomes

CRF and Risk of Incident Hypertension, ACLS Women

4,884 healthy women examined at the Cooper Clinic, 1970-1998

157 women developed hypertension during average follow-up of 5 years

Risk adjusted for age, exam year, alcohol intake, smoking, BP, family history of hypertension, waist girth, glucose, & triglycerides

Series10

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FitnessGroups

Risk of Developing Hypertension

Barlow CE et al. Am J Epidemiol 2006; 163:142-50

P for trend <0.01

CRF and Breast Cancer Mortality

Low Moderate High0

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•14,551 women, ages 20-83 years•Completed exam 1970-2001•Followed for breast cancer mortality to 12/31/2003•68 breast cancer deaths in average follow-up of 16 years•Odds ration adjusted for age, BMI, smoking, alcohol intake, abnormal ECT, health status, family history, & hormone use

Odds Ratio

p for trend=0.04

Sui X et al. MSSE 2009; 41:742

Activity, Fitness, and Mortality in Older Adults

Cardiorespiratory Fitness and All-Cause Mortality, Women and Men ≥60 Years of Age

4060 women and men ≤60 years

989 died during ~14 years of follow-up

~25% were women Death rates adjusted

for age, sex, and exam year

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60-69 70-79 80+

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Moderate

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All-Cause death rates/1,000 PY

Age Groups

Sui M et al. JAGS 2007.

Cardiorespiratory Fitness and Health Outcomes in Various

Population SubgroupsSuch as People Who Are Overweight or Obese or

Those with Chronic Disease

Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men,

ACLS

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# of risk factors

Risk Factorscurrent smokingSBP >140 mmHgChol >240 mg/dl

Cardiorespiratory Fitness Groups*Adjusted for age, exam year, and other risk factors

Blair SN et al. JAMA 1996; 276:205-10

CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men with Diabetes,

179 CVD Deaths

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18.5 < BMI <25.0 25.0 ≤ BMI <30.0 30.0 ≤ BMI < 35.0

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Church TS et al. Arch Int Med 2005; 165:2114*Adj for age and examination year

p for trend <0.0001p for trend <0.0001 p for trend <0.002

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Controlled HTN Stage 1 HTN Stage 2 HTN

Severity of HTN

P <.001 P <.001 P =.048

CRF:

Age and exam year adjusted rates of total CVD events by levels of CRF and severity of HTN in

8147 hypertensive men

Sui X et al. Am J Hyptertension. 2007

CVD incidence/1000 man-years

Summary

Attributable Fractions (%) forAll-Cause Deaths

40,842 Men & 12,943 Women, ACLS

02468

1012141618

MenWomen

Blair SN. Br J Sports Med 2009; 43:1-2.

Getting People to Be Physically Active

Behavioral Approaches to Physical Activity Interventions

Theoretical foundations• Social Learning Theory• Stages of Change Model• Environmental/Ecological Model

Methods• Problem solving• Self-monitoring• Goal setting• Social support• Cognitive restructuring• Incremental changes• Manipulating the environment

Marcus & Forsyth. Motivating People to Be Physically Active, 2nd edition. 2009. Human Kinetics (www.hkusa.com

Track Record of Lifestyle PA Interventions

Successfully implemented in many different populations and settings• Men and women of all ages• African-American men and women,

Hispanic women• Prostate cancer survivors• Worksites, YMCA’s, public heath

departments, recreation facilities, senior centers, churches

We can get a substantial proportion of inactive people to become active

Using Modern Technology to Promote Healthful

Lifestyles

Promoting PA via PDA 37 healthy, inactive adults, ≥50 years of

age 8-week RCT PDA intervention (93% had not used

PDAs)• Questions about amount and type of PA • Alerted at 2 PM and 9 PM to complete PA

assessment• Gave motivational and behavioral tips

Controls—standard written materials

King AC et al. Am J Prev Med 2007; 34:138-42

Promoting PA via PDA Intervention participants completed 68%

of the 112 PDA entries available After adjusting for baseline differences

• PDA group reported 310.6 minutes of moderate to vigorous PA/week

• Control group reported 125.5 minutes/week• p=0.048 for group comparison

78.6% of PDA group reported enjoying using the device

King AC et al. Am J Prev Med 2007; 34:138-42

The SenseWear Armband (SWA)The SenseWearTM Armband

(BodyMedia, Pittsburgh, PA) Lightweight monitor worn on the

upper left arm Four sensors (skin temp,

galvanic skin response, heat flux, tri-axial accelerometer)

Estimates energy expenditure Physical activity – duration &

intensity

Effects across time for weight. Estimates adjust for age, gender, race, education, and wave.

Baseline Month 4 Month 992

94

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104W

eig

ht

(Kg

)

SWA

GWL + SWA

Standard Care

GWL

GWL=Group Weight LossSWA=SenseWear Armband

Shuger S et al. 2011 IJBNPA

Where Do We Go from Here?

All countries should develop a national

physical activity plan

What is a Physical Activity Plan?

A comprehensive set of strategies including policies, practices, and initiatives aimed at increasing physical activity in all segments of the population.

Sectors•Mass Media•Public Health•Education•Healthcare•Volunteer and Non-Profit Organizations•Transportation, Urban Design, Community Planning•Business and Industry•Parks, Recreation, Fitness, and Sports

Prevention of NCDs Prevention is essential to reduce

immediate burden and protect future generations

NCDs threaten health and social systems and hinder economic performance

A 2% reduction in NCD death rates will achieve an increase in economic growth of 1% per year within a decadeCecchini et al. The Lancet 2010; 376:1775-84

Thank youQuestions?