Scotland helped invent inactivity

It is believed that Scotland has been inhabited for over 12 000 years. These early settlers were hunter-gatherers, sustaining regular physical activity in their search for food. Scots take pride in their proud history of innovation and invention. To medicine, we have contributed penicillin, insulin and the ECG. Scots also contributed the three best friends of the couch potato; the telephone, the refrigerator and the television, unwittingly sowing the seeds for one of the biggest public health challenges of the 21st century: physical inactivity.

Steven Blair's research has shown that low cardiorespiratory fitness is responsible for the largest attributable fraction of all-cause mortality.1 Karim Khan framed these data to emphasise that deaths attributable to low fitness exceeded those due to obesity, diabetes and smoking (‘smokadiabesity’) combined.2 The WHO looked at global health risks and found that over 3 million people each year die due to physical inactivity making physical inactivity the fourth leading cause of preventable death.3 It is accepted that increasing physical activity levels is beneficial both to preventing and managing cardiovascular conditions, diabetes, cancer and depression as well as promoting a better quality of life.

The current state of play in Scotland

Is this global problem relevant to Scotland, or do we have bigger fish to fry in our infamous deep fat fryers? WHO data from 2008 show that the UK is one of only seven countries worldwide, where fewer than 40% of adults reach minimum recommendations for physical activity.4 The 2010 Scottish Health Survey found that 39% of adults achieved a minimum of 30 min activity five times per week, while 72% of children reached 60 min of activity daily.5 These figures were based on self-reported activity levels. Scottish Executive figures estimate that 2447 lives are lost prematurely each year due to physical inactivity.6 The 2010 Scottish Health survey identified a failure to meet physical activity recommendations as one of five key risk factors affecting the health of individuals.5

Recognition of importance

Scotland's First Minster Alex Salmond declared that ‘the Scottish Government is very conscious of the population being physically active, and our aim is to get everyone more active.’ In the joint 2011 statement with the other home nations Chief Medical Officers (CMO), Sir Harry Burns stated ‘whatever our age, there is good scientific evidence that being physically active can help us lead healthier and happier lives. We also know that inactivity is a silent killer.’7

The Scottish Government talks of a preventative spend, investing resource to increase activity levels and address other modifiable risk factors now to improve health outcomes, and secure savings in the long term. An increased recognition of the importance of physical inactivity as a risk factor has led to a renewed focus in this area.

Scotland is a proud country, with a romantic glint in its eye. Although a legacy of increased levels of physical activity has never been demonstrated for major multisport games previously, the First Minister has made it clear that while winning medals at the Glasgow 2014 Commonwealth Games is attractive, ‘above all we want Scotland to be active.’

Time for action

For large-scale change to occur, there must be a compelling argument, clear aims, targets and methods to implement change. The argument that physical inactivity is a massive public health problem, and that investments that work for physical activity exist is compelling. The Scottish Government has set targets for 2022 of increasing the number of children reaching minimum recommendations to 80%, and the number of adults meeting minimum criteria to 50%.6 Older people and children have been identified as particularly important target groups. The Minster for Commonwealth Games and Sports, Shona Robison, has made increasing physical activity levels her remit, communicating clearly her vision of a sustainably active Scotland.

A renewed emphasis

Recent months have seen a renewed emphasis on increasing physical activity. In December 2011, ‘increasing physical activity’ was for the first time made a ‘national indicator’, ensuring activity levels are closely tracked and performance measured. This is a significant political commitment.

The decision to place the Sport and Physical Activity Policy Team under CMO's directorate permits a cohesive strategy, recognising the need for collaborative action. In January 2012, Chief Executive Letters were sent from CMO's office to health board chief executives which included a clear emphasis on promoting physical activity.

In this same month Andrew Murray, was appointed ‘Scottish Government Physical Activity Champion’. A general practitioner (GP), and Sports and Exercise Medicine registrar, he recently ran from Scotland to the Sahara desert, partly to increase an awareness of the benefits of exercise.

The media are helping the public better understand the guidelines. An example is the ‘Take Life On’ initiative re-launched in February 2012 which outlines and simplifies recommendations and highlights simple steps parents can take to help their kids get active and stay active. ‘Take Life On’ features video sharing, a dedicated website, and TV, radio and online advertising tailored to the target demographic.

The vision

In a country famed for innovation, bold imaginative steps are required to consolidate gains and translate them into improved outcomes. ‘Start Active Stay Active’, ‘Investments that work for Physical Activity’ and ‘Let’s Make Scotland More Active' will provide a framework to ensure a comprehensive strategy will be used.6,–,8 Policy will include credible approaches to infrastructure, transport, education, the media, workplace, recreation and health systems.

Specific examples include working closely with the Royal College of General Practitioners, Scotland, to increase an awareness of current guidelines and the benefits of physical activity, and integrate non-communicable disease prevention into primary healthcare systems. Brief advice and brief interventions have been advocated to offer exceptional value for money and are recommended by the National Institute for Health and Clinical Excellence.9 Education in this area will advance the situation considerably with an unpublished study in 2006 of primary care staff showing that while 93% of GP's agreed that promoting physical activity was important in primary care, only 13% correctly stated the current guidelines. As stated in ‘Start Active Stay Active’ doctors from the specialty of Sports and Exercise Medicine will have a significant part in information provision and the set-up of services.7

A simple, clear message must be communicated effectively, raising an awareness of recommended guidelines, but also of how to achieve them in an accessible, affordable way. The core messages will be consistently conveyed and have been spread across sectors to ensure this. Campaigns such as ‘Take Life On’ have shown promise, with a 20% increase in an awareness of guidelines following a concerted 6-week campaign. Imaginative ways of conveying this message will be used, targeting each demographic appropriately, and making increasing use of social media and other means of communicating the message virally. Mike Evans brilliantly succinct ‘23 and a half hours’ video, an online sensation with over 2 million hits is an excellent example of an informative yet fun message influencing otherwise difficult to reach demographics.10 Best use will be made of positive role models and the mass media and lessons learnt from examples of good practice.11

Opportunities must be grasped, and Scotland can benefit from several important events taking place on these shores. Global conferences taking place in Scotland in 2012 that may contribute to an increased awareness and provide excitement surrounding this topic include the International Convention on Science, Education, Medicine and Sport and the World Congress on Active Ageing. While there is no evidence that physical activity levels have been increased as a legacy of multisport games, communications have been established with the legacy and games team, to ensure accurate information about the benefits of physical activity, and ways to achieve this are dispensed to the public and the media. Events upcoming include the London 2012 Olympics, the Glasgow 2014 Commonwealth Games and the 2014 Ryder Cup.

Perhaps most importantly, the national collaborative approach will be strengthened, seeking to develop partnerships and influence policy across a range of sectors to include education, transport, recreation as well as health. Policies, practices and programmes can be developed to maximise impact and decrease competition and duplication. Evaluation and monitoring will feedback on successes and lessons to be learnt.

Steven Blair described physical inactivity as the greatest public health challenge of the 21st century.1 The argument is compelling, the aims to increase physical activity levels in Scotland are clear. We must implement effective methods, and evaluate our interventions. This is a challenge we need to embrace and tackle directly.