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Protecting and improving the nation’s healthEverybody active, every dayAn evidence-based approachto physical activityOctober 2014

Everybody active, every dayAbout Public Health EnglandPublic Health England exists to protect and improve the nation’shealth and wellbeing, and reduce health inequalities. It does thisthrough advocacy, partnerships, world-class science, knowledge andintelligence, and the delivery of specialist public health services. PHEis an operationally autonomous executive agency of the Department ofHealth.Public Health EnglandWellington House133-155 Waterloo RoadLondon SE1 8UGTel: 020 7654 @PHEukFacebook: by: Dr Justin Varney, Dr Mike Brannan, Gaynor AaltonenSupported by: Dr Nick Cavill, Stuart King, Luis GuerraDeveloped with over 1,000 health professionals, local authorities,research specialists, educationalists, charities and fitness expertsat national and local levels through a process of discussion andengagement. Crown copyright 2014You may re-use this information (excluding logos) free of charge in anyformat or medium, under the terms of the Open Government Licencev2.0. To view this licence, visit OGL or email Where we have identified any third party copyright informationyou will need to obtain permission from the copyright holdersconcerned. Any enquiries regarding this publication should be sent October 2014PHE publications gateway number: 20144322

Everybody active, every dayContentsAbout Public Health England21. Introduction42. Inactivity: the toll it takes on our health63. Inequalities: closing the gap94. Responding to the challenge105. The four domains for action12Active society: creating a social movement13Moving professionals: activating networks of expertise14Active environments: creating the right spaces16Moving at scale: interventions that make us active186. Measuring impact197. Making it happen208. PHE actions to support implementation219. Chief medical officer’s guidelines22References243

Everybody active, every dayIntroductionA problem that demands a long-term solutionAround one in two women and a third of men in England are damagingtheir health through a lack of physical activity.1 This is unsustainable andcosting the UK an estimated 7.4bn a year.2,3 If current trends continue,the increasing costs of health and social care will destabilise publicservices and take a toll on quality of life for individuals and communities. over one in four women and one in five men do less than 30 minutesof physical activity a week, so are classified as ‘inactive’1 physical inactivity is the fourth largest cause of disease and disabilityin the UK4Public Health England (PHE) wants to drive a step change in the public’shealth. We recently identified seven priorities for the next ten years totackle the behaviour that increases the risk of poor mental and physicalhealth.5 Tackling physical inactivity is critical to delivering many of thosepriorities (eg, dementia, obesity and giving every child the best start in life).We know from other high-income countries like Finland,6 theNetherlands and Germany,7 that this situation can be changed. Thesolution is clear: everybody needs to become more active, every day.A wealth of evidence shows that an active life is essential for physicaland mental health and wellbeing. A number of diseases are currently onthe increase and affecting people at an earlier age. They include cancerand diabetes, and conditions like obesity, hypertension and depression.Regular physical activity can guard us against these.We want to enable people to take control of their current and future health,and to boost parents’ understanding of how active play and ‘physicalliteracy’ is essential for children. Being active at every age increases qualityof life and everyone’s chances of remaining healthy and independent.The benefits don’t stop there. There are many other social, individualand emotional reasons to promote more physical activity. Being activeplays a key role in brain development in early childhood8,9 and is alsogood for longer-term educational attainment.10 Increased energy levelsboost workplace productivity and reduce sickness absence. An activepopulation can even reduce levels of crime and antisocial behaviour.11DefinitionsPhysical activity:body movement thatexpends energy andraises the heart rateInactivity:less than 30 minutesphysical activity aweekSedentary:time spent in lowenergy postures, eg,sitting or lyingEveryday activityincludes cycling,walking, heavyhousework, active ormanual workActive recreationincludes dance,yoga, active play,recreational walking orcyclingSport includesswimming, rowing,fitness training,climbing, parkour,tennis, organisedsportsThe experience of other countries tells us that getting the whole nationactive every day will only happen if we involve all sectors. To makereal and lasting change we need to take a long-term, evidence-basedapproach, building upon what we know works. We need to embedphysical activity into the fabric of daily life, making it an easy, costeffective and ‘normal’ choice in every community in England.4

Everybody active, every dayWe want to engage with professionals, providers and commissionersin health, social care, transportation, planning, education, sport andleisure, the voluntary, community and cultural sectors as well as publicand private employers to make the case for more – much more – physicalactivity, every day.The extent of the problem18% of disabledadults regularly takepart in sportcompared to 39%of non-disabledadults33% of men are notactive enough forgood health45% of women arenot active enough forgood health19% of men and26% of women are'physicallyinactive'21% of boys and 16%of girls aged 5-15 achieverecommended levelsof physical activity47% of boys and 49%of girls in the lowesteconomic group are'inactive' compared to26% and 35% in the highest64% of trips are made by car23% of girlsaged 5-7 meet therecommended levelsof daily physicalactivity, by ages13-15 only 8% doWalking tripsdecreased by 30%between 1995and 201322% are made on foot2% are made by bikeData sources: Health Survey for England 2012 (HSE); Active People Survey 8, April 2013-April 2014 (APS); National Travel Survey 2013 (NTS)5

Everybody active, every dayInactivityThe toll it takes on our healthPhysical inactivity directly contributes to one in six deaths in the UK:12 thesame number as smoking.13,14 Around a quarter of us are still classifiedas inactive, failing to achieve a minimum of 30 minutes of activity a week.In some communities only one in ten adults are active enough to stayhealthy. While measurement differences limit direct comparisons, theproblem is worse in the UK than many other countries (see graph below).There are several reasons for this. Social, cultural and economic trendshave removed physical activity from daily life. Fewer of us have manualjobs.16 Technology dominates at home and work, the two places where wespend most of our time. It encourages us to sit for long periods – watchingTV, at the computer, playing games or using mobile phones and tablets.Over-reliance on cars and other motorised transport is also a factor.“Around a quarter ofus are still classifiedas inactive, failing toachieve a minimumof 30 minutes ofactivity a week. Insome communitiesonly one in ten adultsare active enough tostay healthyMany features of cities and towns – and even some parks – work againstphysical activity. The design of schools, public buildings and urbanspaces prioritise convenience and speed ahead of walking or cycling.People sit all day in offices where it is often easier to find the lift thanthe stairs. Concerns about vandalism and maintenance have left publicspaces without the benches and toilets that allow older or disabledpeople to venture out. Cars and other vehicles dominate, not the needs ofpedestrians.The government’s aim, restated in the report ‘Moving more, living more’as a Olympic and Paralympic legacy commitment, is to increase thenumber of adults taking at least 150 minutes of physical activity a weekand to reduce the number taking less than 30 minutes per week, year onyear.17 Although there has been progress, it remains too slow.International comparison of physical inactivity (at ages 15 and over)15Holland 18.2%Germany 28%France 32.5%Finland 37.8%Australia 37.9%USA 40.5%UK 63.3%0%10%20%30%40%50%60%Data source: from 122 World Health Organization member states and a specific criteria for inactivity70%80%6

Everybody active, every dayWith time and commitment in short supply, being active every day is – asalways – about weaving incidental activity into our daily lives: taking theopportunity for short trips on foot, by bicycle or on public transport, aswell as doing whatever exercise, dance, leisure or sport we enjoy.A snapshot1. The link between physical inactivity and obesity is well established.With more than half of adults and almost a quarter of childrenoverweight or obese,18,19,20 everyone would benefit from being moreactive every day. It helps to maintain a healthy weight and improveshealth, regardless of weight.2. Only 21% of boys and 16% of girls aged 5-15 in England take theamount of physical activity they need for good development.13. More than 1 in 17 adults in the UK have diabetes;21 90% have type2 diabetes, which is associated with lifestyle. Being active canreduce the risk of developing this condition by 30-40%.22 Peoplewith diabetes can reduce their need for medication and the risk ofcomplications by being more active.234. Persuading inactive people to become more active could prevent onein ten cases of stroke12 and heart disease24 in the UK.5. One in eight women in the UK are at risk of developing breast cancerat some point in their lives.25 Being active every day can reducethat risk by up to 20% and also improve the lives of those living withcancer.22,266. Dementia affects 800,000 people in the UK. Staying active canreduce the risk of vascular dementia and also have a positive impacton non-vascular dementia.277. Depression is increasing in all age groups. People who are inactivehave three times the rate of moderate to severe depression of activepeople.28 Being active is central to our mental health.29Key factOnly 21% of boysand 16% of girlsaged 5-15 in Englandtake the physicalactivity they need forgood developmentKey factPersuading inactivepeople to becomemore active couldprevent one in tencases of stroke andheart disease in theUKDisease and disability create costs, and not just for the NHS. Long termconditions such as diabetes, cardiovascular and respiratory disease leadto greater dependency on home, residential and ultimately nursing care.This drain on resources is avoidable, as is the personal strain it puts onfamilies and individuals.Being inactive is an issue at every age. Generally, the more we do, thegreater the benefit. Moving those who are inactive to a significant levelof activity would have the greatest benefit, but any shift helps. There is athree-year difference in life expectancy between people who are inactiveand people who are minimally active.30 This is an incentive to focus onthe most inactive – we need to identify these individuals and investingresources appropriately.The problem of sedentary behaviourSedentary behaviour is not simply a lack of physical activity. It isspending too much time in positions that do not use energy. Many ofus sit for long periods on the sofa, or at the computer or desk. This7

Everybody active, every daydamages health, because of the way it affects circulation and fails touse muscles and bones. This is a risk even to those who regularly takevigorous regular exercise.31More than 40% of women and 35% of men spend more than six hours aday desk-bound or sitting still. This applies as much to those aged 16-24to those who are 64-75.32 Many of us become more sedentary as we getolder, damaging our bone, brain and muscle health. It does not have tobe that way. Lots of older adults remain active, which helps to keep themhealthy and more engaged, contributing to community and family life, aswell as preventing falls and circulatory problems.While a growing body of evidence points to the risks of sedentarybehaviour, we don’t yet know what exact level harm is incurred.33However, we should try to avoid being sedentary for extended periods.22PaybackIncreasing our physical activity will pay back not just in terms of healthand social care. Although there is still to work to do on the evidence,boosting levels of activity can stimulate economic growth.For instance, sport offers many entry-level jobs and opportunities forvolunteering that can lead to full-time careers. Businesses with activeworkforces are more productive, have lower sickness rates and lowerstaff turnover.34 Pedestrians help keep local high streets alive.In every way, activity gets us out the door and connecting with others,avoiding social isolation, increasing social capital and community spirit.PHE has developed a summary of the tools (including the NICE returnon-investment tool)36 that make the case for investment, and of theguidance on what local authorities and commissioners can do. PHE willalso soon publish a definitive review of the return-on-investment data – incosts to the NHS and wider costs to communities – explaining the origin,components and robustness of figures.Getting the nation moving every day is essential. At a national level it willhelp keep the welfare state economically viable. At a personal level it’sfun and sociable – and helps people stay physically and mentally well.Summary Physical inactivitydirectly contributesto 1 in 6 deaths Around a quarter ofpeople are inactive Physical activitycan prevent or helpmanage over 20common conditions Reducing inactivitycould prevent up to40% of many longterm conditions, eg,diabetes Inactivity createscosts for familiesand services The aim is to havemore adults takingat least 150 minutesactivity a week, andfewer taking lessthan 30 minutes Even small increasesin activity can makea difference Increased activitymeans better healthand has widereconomic benefits8

Everybody active, every dayInequalitiesHow to close the gapBeing active every day needs to be embedded across every communityin every aspect of life. The association between physical activity andleading a healthy, happy life means that issues of cost, access or culturalbarriers need to be tackled. Under the Equality Act 2010 there is aresponsibility to consider vulnerable groups – for example, by ensuringaccess, monitoring, and staff training.Common inequalitiesEconomic people living in the least prosperous areas are twice as likely to bephysically inactive as those living in more prosperous areas37Geographic south east England has the highest proportion of men and womenmeeting recommended levels of physical activity; north westEngland has the lowest1Age physical activity declines with age to the extent that by the age of 75years only one in ten men and one in 20 women are active enoughfor good health38 between 2008 and 2012, the proportion of children aged two to 15years meeting recommended physical activity levels fell from 28% to21% for boys and 19% to 16% for girls39Disability disabled people are half as likely as non-disabled people to beactive40 only one in four people with learning difficulties take part in physicalactivity each month compared to over half of those without adisability41Race only 11% of Bangladeshi women and 26% of men are sufficientlyactive for good health compared with 25/37% of the generalpopulation42Gender men are more active than women in virtually every age group18 girls are less likely to take part in physical activity than boys, andparticipation begins to drop even more from the age of ten to 1119Sexual orientation and gender identity half of all lesbian, gay, bisexual and transgender people say theywould not join a sports club, twice the number of their heterosexualcounterparts43Key factPeople in the leastprosperous areas aretwice as likely to beinactive than those inthe most prosperousareasKey factDisabled people arehalf as likely to beactive than nondisabled people9

Everybody active, every dayThe challengeHow we need to respondWe are around 20% less active than in 1961. If current trends continue,we will be 35% less active by 2030.44 We have to turn the tide.Physical activity does not need to be strenuous to be effective. Thirtyminutes a day of moderate aerobic activity can be a brisk walk, aswim, or even a spell of gardening. Each ten-minute bout that gets theheart rate up has a health benefit. Although sport can be part of thepicture, activity can also be more informal. Fitness does not have tobe a ‘regime’. Dancing can be as beneficial as going to the gym,45 andeveryday activity such as walking or cycling to the shops or to work canbe a great way to get the heart pumping.Being active is not just about moving more. We also need to build ourmuscle strength and motor skills, and our ‘physical literacy’. Active play isa fundamental part of physical, social and emotional development frominfancy. Good physical development in children is linked to other typesof positive development, such as speech and coordination. Moreover,being active in childhood builds the foundation for an active adult life.46Once learnt, a skill like swimming or riding a bike is there for life.From the age of 30, an adult’s muscle and bone mass peaks and beginsto decline slowly.47 Performing simple resistance-type activity – suchas press-ups or light lifting – twice a week improves muscle strengthand stability. It also helps prevent the development of musculoskeletaldisease. New evidence from neuroscience suggest that being physicallyactive also supports further brain development during adulthood.48We need to revise our physical literacy as we get older, changing ourexpectations of what we can do so that we have the confidence to do it.That will help maintain mental agility, wellbeing and independence.With around a quarter of the nation not managing even 30 minutesof physical activity a week, this may seem like too great a challenge.However, we know that change on a national scale is possible.Key factPeople in the UKtoday are 24% lessactive than in 1961Key factThirty minutes a weekof moderate aerobicactivity can make abig differenceKey factPeople in Finlandare far more activeafter a long term,nationwide, locallybased campaign toencourage physicalactivity across the lifecourseOnce the world record holder for heart disease, Finland started anationwide campaign for change 40 years ago.6 The government shiftedmoney to local authorities, a move similar to the transfer of public healthresponsibilities to a local level in England. Authorities responded bycreating heritage and conservation trails, building active outdoor playand exercise spaces, and encouraging sport at all levels, formal andinformal. They developed innovative approaches for distinct groups,such as the elderly or the persistently hard-to-reach, that directlyaddressed their problems. Change has run across all age groups: youngpeople, working age and older people are all much more active.610

Everybody active, every dayThe experience in Finland and elsewhere shows that effectivelyincreasing population levels of physical activity49 involves two commonfactors: persistence and collaboration. Creating such a major changerequires all of us to take action: no single agency or organisation canrespond to the challenge alone.“We know thatchange on a nationalscale is possible11

Everybody active, every dayActionFour areas where we need to take measuresWhat we need to do is simple: be more active. Now we need it to happen.This is a question of creating cultural change. Many studies have alreadymade the urgent case for a more active nation. There have been reportsfrom national government,17 across political parties,50 the private sector51and from the voluntary sector.52,53“Physical activityneeds to be madeeasy, fun andaffordableIf we want everyone to be active every day, physical activity needs to bemade easy, fun and affordable. Exercise and active recreation must beavailable to all, in every community across England.To deliver this vision requires action across four areas (below), at nationaland local level:1. Active society: creating a social movement2. Moving professionals: activating networks of expertise3. Active environments: creating the right spaces4. Moving at scale: scaling up interventions that make us activeA pro-activity movement needs to cascade right through society. To getthe country back on its feet, we need to think smarter, making better useof existing resources.1. Activesociety4. Activeenvironments2. Movingprofessionals3. Moving atscale12

Everybody active, every day1. Active society: creating a social movementSocial norms can only shift if we can change attitudes radically. Themessage is that being active is not just fulfilling and fun but can also be aneasy choice, and this needs to be a linking thread that unites the publicsector with the voice of charities, local residents and community leaders.It’s a message that can be woven into the policies, commissioning andplanning decisions made every day across the country.This is especially true in communities where there are significantinequalities in health, often within ethnic groups. The communities withthe lowest levels of physical activity often have the highest burden ofdisability and poor health. The most successful agents of change will bepeople from the communities themselves.Good marketing and communications strategies can strike deep into thenational psyche. PHE’s Change4Life ‘10 Minute Shake Up’ campaign withDisney and supported by local partners saw a quarter of a million familiessign up in the first month. PHE plans to expand on this initiative. Othersuccesses include NHS Choices’ ‘Couch to 5K’ an app and podcastdownloaded 209,000 times in its first month, and the range of voluntarysector mass participation challenges such as Race for Life. There is adefinite appetite for more activity. Yet if this is to address the alarmingepidemic of inactivity we need to do much more.PHE can help lead the movement for change, but there is no quick fix. Itwill take long-term promotion of physical activity over months, years anddecades.This can only come about if all sectors in the places we live and work acttogether: national and local government schools, youth clubs, community and voluntary organisations transport, planning, leisure and sports providers employers and business health and social care professionalsSummary Attitudes need tochange Key message:activity is fun,fulfilling and can bean easy choice Physical activityneeds to be a maincomponent ofpolicies and planning People incommunities will beagents of change Good marketing canhelp, but more isneeded PHE can help leadchange, but allsectors need tocommit over the longtermThe common vision is to get everybody active every day, driving a radicalshift in the take-up of physical activity on a national scale – and making ita routine part of daily life in England.13

Everybody active, every day2. Moving professionals: activating networks of expertiseWe already have the ideal information network: the hundreds ofthousands of professionals and volunteers who work directly with thepublic every day. Every one of us – from researchers, receptionists,designers and marketers to park rangers – can help spread the word.Together we can make physical activity the social norm.The existing push for ‘making every contact count’54 needs to comefrom all sectors and disciplines, not just from health specialists. Weneed to activate professionals in spatial planning, design, development,landscaping, sport and leisure, social care, psychology, the media, tradeunions, transport, education and business to bring about radical change.Areas with particular ability to provide leadership include:EducationSchools are a key influence on children’s attitudes to activity. Teachersat every level of education, from early years and primary school to highereducation, have a huge impact on young people’s emotional, physicaland social development and wellbeing. This includes discussing children’slevels of activity and involving them in choosing from available activities:whether it’s sport or other activities like dance, variety is important.Inspiring the next generation can also cross the curriculum: discussingforces and energy transfer in physics, designing active cities with urbanplanning students, or understanding team dynamics within psychologyor business studies. Some children and young people may need moresupport, including those with disabilities or health issues, or in transitionstages (for example, teenage years, leaving school).Summary The thousandsof public-facingprofessionals andvolunteers are aready-made network The push needs toinvolve all sectors,not just health Those sectors ina good position tolead and influenceinclude education,sport and leisure,health and socialcare, and planning,design, developmentand transportSport and leisureIt is easy to assume that sport and leisure professionals do not needsupport, but many would welcome the opportunity to develop theirknowledge about physical activity, as would the many volunteers who runlocal clubs and activities. Enthusiasts find new ways to use knowledgeto motivate and inspire people. We also need to do more to developand engage those professionals working on targeted programmeswith individuals who need extra support to be more active – those withcomplex health needs or impairments.Health and social careFor health professionals in primary, secondary or community care, theevidence is clear: not enough action is taken to integrate and recommendphysical activity as a part of treatment. Physical activity is essential formaximising physical and mental health irrespective of body weight orhealth status. It is particularly beneficial for those with health issues.The NHS and patients will lose out if the message isn’t broadened toaddress the additional barriers some groups face (for example, thedisabled). Social care professionals and volunteers also need much moreinformation about helping others to increase their independence andautonomy.14

Everybody active, every dayPlanning, design, development and transportThoughtful urban design, understanding land use patterns, and creatingtransportation systems that promote walking and cycling will help tocreate active, healthier, and more liveable communities.55,56 Asset auditshelp to identify innovative uses of existing community resources. A goodexample of using existing infrastructure in new ways is the SustransConnect 2 cycling networks, building new bridges and crossings toovercome busy roads, rivers and railways, and linking them to popularwalking and cycle routes.57Local economic partnerships currently have a similar opportunity tochange public space for the better in more imaginative, sustainable andexciting ways.5815

Everybody active, every day3. Active environments: creating the right spacesThe World Health Organisation defines a healthy city as one that“supports health, recreation and wellbeing, safety, social interaction, easymobility, a sense of pride and cultural identity and is accessible to theneeds of all its citizens”.59 The same principles apply to villages, towns andcommunities of all shapes and sizes, rural and urban.The way land is used in communities has an immense impact on thepublic’s health.60,61 Although it is the quality and not just the quantity ofpublic parks and spaces that encourages people to be active, evidenceshows just having ease of access to open space makes a crucialdifference. One study showed that respondents living closest to parkswere more likely to achieve recommended physical activity levels and lesslikely to be overweight or obese.62Those with close access to green space live longer than those withoutit,63 even adjusting for factors such as social class, employment andsmoking. The health of older people increases where there is more spacefor walking near home, with parks and tree-lined streets nearby.64 Childrenbecome more active when they live closer to parks, playgrounds andrecreation areas.65 The impact is most significant among the least well off.Building more physical activity into daily routines – the commute, walkingthe dog, the journey to the shops, school or workplace – involves creatingthe kinds of environments that support active living.Re-shaping the world we live in can be done with sensitivity, tappinginto and improving existing resources such as canal footpaths, disusedrailways and river paths. We can help older people and those withimpairments to be more active with simple measures, such as benchesand toilets. Providing cycle parking and showers in workplaces, improvingstairwells so they are as attractive a choice as the lifts, and creatingpleasant walkways between buildings and in neglected spaces are just afew effective ways we can make it is easier for people to be routinely moreactive by fitting it in to their schedule. Mixed-use development, streetconnectivity, and good design make walking and cycling more attractiveby reducing psychological and physical barriers.55Summary Healthyenvironmentssupport healthrecreation andwellbeing Land use has a bigimpact on health– green spaces,playgrounds, cyclelanes, age-friendlyhigh streets allencourage people tobe active every day Physical activityneeds to be built intodaily routines Re-shaping existingplaces can make thedifference Local authorities canwork across policyareas and bringtogether experts todeliver real changethat has an impactfor generationsIssues in rural communities, where distances and resource distributioncan be significant challenges, are

A problem that demands a long-term solution Around one in two women and a third of men in England are damaging their health through a lack of physical activity. 1 This is unsustainable and costing the UK an estimated 7.4bn a year. 2,3 If current trends continue, the increasing costs of health and social care will destabilise public

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