HEALTH ENHANCING PHYSICAL ACTIVITY -

Individual and Organizational Aspects,

Facts, Issues and Evidence

Brussels, 22 Feb, 2011Harri Helajärvi, M.D.

Paavo Nurmi Centre, Turku, Finland

Where are we – and why?•

Dec 11th 2003 From The Economist print edition Dec 11th 2003

The Economist

WHO Global Health Report 2010

Actual Causes of Death in the United StatesActual Causes of Death in the United States

Changes in Society

• The average life expectancy for newborns has increased with 15 yrs in two generations (FIN)– General changes in society (2/3)– Improved health care (1/3)

Average Cooper’s Test results in young men starting their military service in Finland (1975-2009)

Distance in 12 mins

Average Very good

Poor

Year

adapted

Average muscle strength test results in young men starting their military service in Finland (1982-2009)

Very good + Good

PoorYear adapted

Distribution of muscular index (%)

Average body weight and height in young men starting their military service in Finland (1993-2009)

Body weight

Height

adapted

Physical Activity and Mortality

Physical Activity and Bone Density

Standardized mortality ratios by Type of Sport

0

0,2

0,4

0,6

0,8

1

Population Endurance Mixed Power

Kujala et al. JAMA 2001;285:44-45

Prevalence of diabetes and CHD in former elite athletes

0

0,2

0,4

0,6

0,8

1

1,2

1,4

Diabetes CHD

ControlsEnduranceMixedPower

ORs compared to controls, and adjusted for age, BMI, smoking, and SES

Kujala et al. Metabolism 1994;10:1255-60

Studies on identical twins 1

Studies on identical twins 2

Ihminen on kokonaisuus

”Lifestyle factor”

• Diet and physical activity are always interrelated

• They cannot be separated

• They form the “lifestyle factor”

• Other factors, e.g. sedentary behaviour, sleep and rest…?

Lifestyle

• Lifestyle factors have become more important reasons for becoming ill and drivers for the costs caused by diseases (e.g. obesity, high blood pressure, type II DM)

• Already about 39% of 45-year-old Finns have diabetes or prediabetes (men > women)

• Own responsibility?

Healthy diets and regular, adequate physical activity are major factors in the promotion and maintenance of good health throughout the entire life course

• Physical inactivity is estimated to cause, globally, about 10-16% of cases each of breast cancer, colon and rectal cancers and diabetes mellitus, and about 22% of ischaemic heart disease

• Overall, 1.9 million deaths are attributable to physical inactivity

Physical activity and health (WHO)

Physical activity is effective!

• AHA/ASA Guideline 2001 : Physical inactivity ”less-well documented risk factor”

• AHA/ASA Guideline 2006 : Physical inactivity ”well-documented risk factor”

– Physical inactivity 30 % • high BP 20 – 40 %• smoking 12 – 18 %• high cholesterol 15 %• obesity 12 – 20%• high alcohol 32 %)

Circulation 2006 Jun 20;113(24):e873-923

Stroke, Alzheimer’s disease, Dementia

A Society Aspect: the Cost of Disease

•Individual•Health care

•Other, e.g. social services•Indirect expenses, so called

productivity costs

Cost of Health Care

• Increases more than the Gross Domestic product (GDP)– Primarily due to the increased costs for

improved and more complex diagnostic methods and treatments

– Secondarily due to aging

The Most Expensive Diseases

Direct costs Million (€)

% Lost work capacity

Million (€)

%

CV diseases 918 17 Mental diseases

2542 26

Mental diseases

692 13 Musculo-skeletal diseases

1971 21

Resp. diseases 589 11 Injuries, poisoning

1495 16

Musculo-skeletal diseases

583 11 CV diseases 1104 12

Nervous system

diseases

446 8 Malignant diseases

608 6Kiiskinen et al. The Finnish Health. Duodecim 2005, Prime Minister’s Office 4/2007

Paying for Disease or for Health?Official Finnish Statistics 1972-92

Indirect costs / loss of productivityDirect treatment costs

Costs for ”Lifestyle Diseases”

• Difficult to estimate• The magnitude for some major risks

(FIN)– Obesity 190 million €– Physical Inactivity 200-250

million €– Smoking 246 million €– Alcohol 123-226 million €– Accidents 207-240 million €

Prevention vs. treatment

• If lifestyle for all would be the same as for the highly educated, incidence of ”lifestyle diseases” would be reduced by 20-40%

• Thought generally to be cost-efficient -> start with activities that result in most significant changes with less effort/cost

• A new way to reduce the increasing costs?

Cumulative Incidence of Diabetes According to Study Group

Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403.

Example Calculation

• NZL Exercise on Prescription programme implementation in FIN– Screening €0,96/pers * 51.000 €49.000 – Intervention €76/pers * 11.780 €895.000– Costs/year in total €944.000– Cost/adequately exercising €800– Cost / Quality adjusted life year(QALY) €1780Savings in health care costs are 4-5x higher than

the investment

Hujanen 2002

Is it worth it?

• Change in prevalence: -1.2%• Cost: approx. 1 million €• Savings: approx. 4-5 million €• Impact on budget?• Included are not

– Indirect productivity benefits– Private costs

Scientific evidence

• Few high-quality randomised clinical trials on effect and cost-efficiency

• A lot of scientific knowledge of effects• We just need to put all that in practice• Maybe also other aspects involved, e.g.

sedentary behaviour (may provide new tools & ways to tackle / promote)

• SO, WHAT DO WE NEED THEN?

Time for New / Combined Approaches?

1. Methodological approach

Example: Exercise on prescription

• ”green prescription”, New Zeeland, UK

• Finnish project • FYSS, Swedish project

• a tool helping doctors to activate people to become physically more active

• information occurs simultaneously when filling up the prescription

• 5 segments:1) exercise habits (enough or not)2) goals for PA 3) new ”dose” for PA (what kind, how many

times, how often, what intensity)4) extra advice5) process follow-up, further actions

Exercise on prescription

Experience…• Hundreds of "exercise on prescription" schemes exist in

general practices in Britain. • In a RCT the most effective intervention for promoting

increased physical activity was intensive motivational interviewing plus a financial incentive.

• A brief intervention was largely ineffective. Short term increases in physical activity were not maintained, regardless of the intensity of intervention. The health benefits of physical activity depend on sustained participation in an active lifestyle.

• These results question the effectiveness of brief interventions to promote physical activity used by many current UK schemes.

Harland, J. et al. BMJ 1999;319:828-832

LATER IN BMJ: "Exercise on prescription is a waste of scarce resources”

On the other hand…

• The Green Prescription program performs well, representing a good buy relative to other published cost effectiveness estimates. Policy makers should consider encouraging general practitioners to prescribe physical activity advice in the primary care setting, in association with support from exercise specialists. Dalziel K, Segal L, Elley CR. Cost utility analysis

of physical activity counselling in general practice Aust N Z J Public Health. 2006; 30:57-

63

2. Psychological approach

The states of change• There is some evidence that the effectiveness of

counseling may be improved by using behavioral theories as a basis for counseling methods. One of the most applied behavioral theories in PA counseling is the transtheoretical model, generally known as “the stages of change” model, which was originally developed by Prochaska and DiClemente

Prochaska JO, DiClemente CC. Stages and processes of self-change in smoking: toward an integrative model of change. J Cons Clin Psych

1983;51:390–5

Copyright ©2004 BMJ Publishing Group Ltd.

West, R. BMJ 2004;328:338-339

Stages of change in process of stopping smoking. Adapted from Prochaska et al. Clin Chest Med

5A’s of Behavior Change

Estabrooks PA, Glasgow RE. Translating Effective Clinic-Based Physical Activity Interventions into Practice American. Journal of

Preventive Medicine 2006; 31: 45-56

3. Equipment approach

• Pedometers, heart-rate monitors, diaries, handhelds, mobiles etc.

• Conclusions The results suggest that the use of a pedometer is associated with significant increases in physical activity and significant decreases in body mass index and blood pressure. Whether these changes are durable over the long term is undetermined.

Bravata et al. JAMA 2007;298: 2296-2304

Ministry of Education

Ministry of Social Affairs and Health

Ministry of Transport and Communications

Ministry of the Environment

Ministry of Agriculture and Forestry

LIKES Research Center

Fit for Life

•Started in 1995•The aim is to encourage the population aged between 40 to 60 to exercise•Support to >600 local projects•2nd 5-year period 2000-2004•The project will extended to include pensioners

4. Local ideas

Aims:• to activate and help

population aged 40-60 to start active way of life

• to create permanent easily accessible exercise services near people

• to give information about positive effects of exercise

Fit for Life

How to activate Health

Enhancing Physical Activity

Projects

by creating

economical resourcesmaterial

educationnetwork support

…and selling

• AIDA-principle

– Attention– Interest– Desire– Action

Strong. The psychology of selling. NY McGraw-Hill, 1925

My choice

• Marketing– for physical activity

• The competitors are: TV, computer, screentime, sofa, car– why don’t we use the same methods

Market Segmentation, Targeting, and Positioning

Market Segmentation

1. Identify bases for segmenting the market2. Develop segment profiles

Market Targeting3. Develop measure of segment attractiveness4. Select target segments

Market Positioning

5. Develop positioning for target segments6. Develop a marketing mix for each segment

P. Kotler. Marketing management

Physical activity

Innovation portfolio

1

10

100

1000

Ideas Experiments Ventures Businesses

G Hamel. Leading the revolution. HBS 2000

How to promote physical activity

• Take home message:– Think globally – Act locally– Have an open mind– Create a full &

devoted team w/ all relevant parties

– JUST DO IT!

Let’s speak with one voice, and without mixed messages

harri.helajarvi@utu.fi