Sport and exercise: the public health challenge
John Dryden, in his poem, To my honoured kinsmen, writes: “The wise for a cure on exercise depend”. This is good advice that the NHS is only just beginning to take seriously.
Current policy has rightly focused its attention on improving services to treat the big killers: coronary heart disease, stroke, and cancer. The challenge to reduce premature mortality from these diseases is huge—for example, the National Service Framework on Coronary Heart Disease,1 published earlier this year, has created a blueprint both for improving quality of services (from prevention to palliative care), and for improving access to these services across the country.
In the drive to modernise the NHS more emphasis is being placed on the important role that prevention and early intervention can play. Many are aware of the risk to health from smoking, but far fewer realise that the relative risk from physical inactivity is of a similar order. People who are physically inactive carry twice the risk of coronary heart disease and three times the risk of stroke as their more active counterparts.2
If it is to bring continued health benefits, physical activity needs to be embedded in the daily lives of many more people. Six out of ten men and seven out of ten women in England, between the ages of 16–74, are not physically active enough to benefit their health.3 The recently published National Diet and Nutrition Survey of 4–18 year olds has shown that children are becoming less active.4 About 40% of boys and 60% of girls spent, on average, less than an hour a day in activities of at least moderate intensity and therefore failed to meet our recommendation for young people's participation in physical activity.5
Moreover, participation in physical activity—such as, sports and walking, is strongly related to household income. However, this association between socioeconomic group and physical activity is partly offset by the higher levels of occupational activity in manual social classes. As a result, approximately 50% of men in social classes IV and V do not meet current recommendations in levels of physical activity, compared to two thirds of men in classes I and II.
Overall, the picture for women is worse. In social classes IV and V, nearly 80% of women fail to achieve the recommended level of physical activity. Although activity levels in class I are not significantly different, levels for social classes II and non-manual III are slightly higher.
Physical activity must be one of the most undervalued interventions to improve public health. Its benefits are great. Physical activity is closely associated with better health and reduced all cause mortality, including reduced mortality from coronary heart disease, stroke, colon cancer, and reduced fatality after a heart attack. Exercise helps to reduce blood pressure and hypertension, and can protect against the development of type II diabetes mellitus. It is a vital component of weight control. Weight bearing activity helps to maintain bone mass density and to reduce the risk of osteoporosis; and physical activity generally helps with improved balance, coordination, and endurance in older people. It has an important role in helping people to manage chronic conditions—such as, asthma and arthritis. It also has psychological benefits, including improved self esteem, and lower risk of mild to moderate depression.6 It is not surprising that exercise has been described by Professor Jerry Morris, one of the great figures in public health in the last century (and now in his nineties), as “the best buy in public health for the West”.7
Although the evidence of benefit, which has accumulated steadily over the past 10 years, is now compelling, some health professionals have not kept up with the developments in sport and exercise science. Few undergraduates receive any training in sport and exercise science during their medical training. It is small wonder that they feel ill equipped to give sound advice. Few exercise and sports science graduates are employed in the NHS. This is a challenge for health professionals. We need to be better equipped to meet the challenge of overcoming existing barriers to physical activity, both by simply extolling its virtues—telling people that it is good for them—and by helping with the practical provision of high quality, cost effective, and accessible programmes.
This is particularly important in addressing the socioeconomic gradient. There is evidence to show that the availability of accessible and affordable facilities is a major factor in the levels of physical activity among different groups. This is especially true for older adults.
But there are also wider influences: the fear of crime, which may deter some people from travelling; public transport strategies, which may deter people from walking or cycling; and the location of retail facilities, which may encourage rather than discourage car use. A policy to promote physical activity also needs to address factors such as these.
Primary health care professionals should see the promotion of physical activity as an integral part of their responsibilities. There have been several attempts to build these new responsibilities into a coherent and sustainable plan. Not all have been successful,8 but many are increasingly deserving of support. General practitioner referral schemes offer an opportunity to link public health and exercise, and to bring together the patient, the exercise professionals, and the health professionals in a partnership for better health.
I believe that the opportunities which exist in primary care for exercise promotion are gradually being recognised and exploited by the exercise science community. Some months ago, King called for primary care advice on physical activity to be given in conjunction with referral to appropriate community organisations, in order to facilitate long term increases in exercise participation rates.9 It is a view I share because it recognises the significance of multiagency collaborative working in public health. A good example of such joint working is a project to offer “exercise on prescription” in the Oldham area. This project was established in 1996 between Oldham Education and Leisure Services and West Pennine Health Authority, and Oldham Primary Health Care Teams, and is still in progress today. The scheme provides people with tailored exercise programmes to benefit their own particular health needs.
If we as health professionals must face a challenge, so must those involved in exercise and sports science. As with any health promotion activity, we need more convincing evidence about what interventions work and how to influence behaviour, particularly amongst those who are most at risk from their sedentary lifestyle. Sport and exercise medicine provides opportunities for working with people—to make them stronger, faster, more efficient, better able to deal with stress, and less susceptible to injury. This developing science covers physiological, psychological, biomechanical, and sociological influences on human performance in sport, work, and exercise. The evaluation of data collected from people engaged in sport, at work, or undergoing rehabilitation, supports the research base upon which that promotion is based. Rigorous evaluation of any intervention is vital if it is to be taken up by in modern public health programmes.