Scottish Health Survey - topic report: physical activity

2. Background

2.1 Benefits of physical activity and the policy context

The health benefits of a physically active lifestyle are well documented. Globally, physical inactivity is one of the leading causes of chronic disease mortality, such as heart disease, stroke, diabetes and certain cancers^[6]. Lee et al. (2012) estimated that inactivity caused more than 5·3 million deaths globally in 2008, approximately 9% of premature deaths for that year. The impact of inactivity was similar to that for smoking or obesity. Declining physical activity is often associated with rising GDP, though the problem of physical inactivity is increasingly being seen in low income countries as well as middle and high income parts of the world.

The Toronto Charter for Physical Activity^[7], the gold standard advocacy tool for physical activity, was published in 2009 following extensive worldwide stakeholder consultation. The Charter includes guiding principles for a population-based approach to physical activity, including building capacity in research, evaluation and surveillance of population physical activity.

In 2004, WHO published the Global Strategy on Diet and Physical Activity and Health^[8] with the overall goal of protecting and promoting health through healthy eating and physical activity. This was followed in 2010 with the WHO Global Recommendations on Physical Activity for Health^[9], which recommended the setting of national guidelines on the frequency, duration, intensity, type and total amount of physical activity required by different age groups and the establishment of national surveillance mechanisms to monitor population levels of physical activity.

In 2013, the World Health Assembly agreed on a set of global voluntary targets which include a 25% reduction of premature mortality from noncommunicable diseases (NCDs) and a 10% decrease in physical inactivity by 2025. This Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020^[10] guides Member States, WHO and other UN Agencies on how to effectively achieve these targets.

At a UK level, inactivity was estimated to have caused 3% of disability-adjusted years of life lost in 2002, representing a direct cost to the NHS of £1.06 billion^[11],[12]. Few studies have estimated the indirect costs of physical inactivity (in contrast to other issues such as alcohol misuse). One exception is a 2002 study commissioned by the UK Department for Culture, Media and Sport which summed direct and indirect costs to the NHS, including loss of earnings due to inability to work and premature death. This produced a total estimated cost of physical inactivity of £8.2 billion^[13].

In Scotland, it is estimated that low activity contributes to around 2,500 deaths per year and costs the NHS £94 million annually^[14]. This is a conservative estimate as the analysis was limited by what data was available and indirect costs have not been estimated for Scotland.

In addition to the impact on chronic physical health conditions, there is also evidence that increased activity can improve mental wellbeing, a key health priority in Scotland. The Royal College of Psychiatrists recommends exercise as a treatment for depression in adults^[15], and the Scottish Intercollegiate Guidelines Network (SIGN) national clinical guideline for non-pharmaceutical management of depression states that structured exercise programmes may be an option for depressed people^[16],[17]. Physical activity is also associated with better health and cognitive function among older people, and can reduce the risk of falls in those with mobility problems^[18].

For children, evidence suggests that high activity levels in childhood confer both immediate and longer-term benefits, for example by promoting cognitive skills and bone strength, reducing the incidence of metabolic risk factors such as obesity and hypertension, and setting in place activity habits that endure into adulthood^[20].

It is estimated that becoming more active could increase life expectancy by more than a year given the average levels of inactivity at the moment in Scotland^[21]. Doing moderate physical activity for at least 150 minutes a week has been shown to be a key determinant of increased energy expenditure and thus fundamental to energy balance and weight control^[22].

A number of wider global trends have impacted on population physical activity levels in Scotland, as in other high and middle income countries, in recent decades. These include an ageing population, technological change, changes to transport (especially the rise of car use), the rise in sedentary leisure options and decline in manual occupational sector^[23].

In acknowledgement of these wider trends, and the evidence on the benefits of active lifestyles, Scotland has been actively developing national level policy on physical activity for over ten years. The original physical activity strategy, Let's Make Scotland More Active^[24], was published in 2003 and reviewed in 2008^[25]. More recently, the national Physical Activity Implementation Plan (PAIP), A More Active Scotland; Building a Legacy from the Commonwealth Games, was published in 2014^[26]. The PAIP is a new 10 year plan which adapts the key elements of the 2010 Toronto Charter for Physical Activity to Scotland and links this directly to the Scottish Government's legacy ambitions for the 2014 Commonwealth Games.

Specific policies on increasing activity in the composite domains of physical activity have also been developed in Scotland. These include, in the sport and active recreation domain, Reaching Higher, the 2007 sports strategy with twin aims of increasing participation in sport and improving Scotland's high performance sporting success^[27]. More recently, the youth sports strategy, Giving Children and Young People a Sporting Chance, included the aim of reaching those currently disengaged in formal or informal sport^[28].

Active travel policy interventions to encourage more people to undertake more active journeys include the Cycling Action Plan for Scotland^[29], and the most recent physical activity policy, the National Walking Strategy^[30].The latter sets out the case for increased participation in walking, both for recreational purposes and for active travel. It demonstrates the contribution such an increase would make to a range of national government objectives. Work is currently underway to develop a delivery plan underpinning the walking strategy.

2.2 Evidence on factors associated with physical activity

An increasing body of evidence is developing around understanding what factors are associated with being physically active in an effort to find solutions to encourage more people to be more active more often, and to aid in targeting interventions. Figure 1 is one illustration of the wide range of factors, including environmental, socioeconomic, psychological and demographic ones that have been shown to have a relationship to physical activity outcomes^[31].

Figure 1: Social Ecological model of the determinants of physical activity

Edwards and Tsouros (2006)

It is important to emphasise at his point that any model of explanation produced from an analysis, such as in this study, will only be partial. The Scottish Health Survey, and many similar surveys do not cover this range of factors. This study focussed on demographic, socioeconomic and health and lifestyle factors available in the Scottish Health Survey and that were supported for inclusion in our analysis by previous evidence, drawing primarily on a recent systematic review of reviews of correlates and determinants of physical activity by Baumann et al. (2012)^[32]. This mapped the range of factors varyingly associated with physical activity in adults, children and adolescents across high, middle and low-income countries. A review of domain related physical activity by Beenackers et al. (2012)^[33] was also useful.

Bauman et al. (2012) concluded that there was clear evidence that health status and self-efficacy are causally related to physical activity. In addition, they considered there was consistent evidence that age, sex, education level, ethnic origin, being overweight or obese, perceived effort and social support were all associated (correlated) with physical activity. The authors noted, however, that much of the research has concentrated on physical activity during leisure time, with little conducted on other domains of physical activity, such as transport, home-based or occupation related. A view echoed by Beenackers et al. (2012).

The association of ethnicity with physical activity is further supported by findings from analysis of the Scottish Health Survey^[34] and the Health Survey for England^[35]. The 2012 Scottish Health Survey Topic Report: Equality Groups found Pakistani respondents to be least likely of all ethnic groups to meet recommended activity guidelines^[36].

According to the Bauman review, income, socioeconomic status and lower occupational status all had some evidence to suggest they are associated with physical activity, however, marital status was not found to be a determinant and the evidence inconclusive for marital status as a correlate. The study also indicated there is evidence to support the association of mental wellbeing.

The Bauman review does not mention religion, however, the Scottish Health Survey Topic Report: Equality Groups (2012) found that adults who said they belonged to no religion were most likely to meet the physical activity recommendations and participate in sports compared to Muslims and members of the Church of Scotland.