Physical Activity: recreational & transportation options Godfrey Xuereb Team Leader, Population-based Prevention Department of Chronic Diseases and Health Promotion World Health Organization

are insufficiently active 1.5 billion adults are insufficiently active Aged 15+; 2008;

Physical inactivity - 4th leading risk factor for global mortality Source: WHO's report on "Global health risks" 60% of global deaths due to NCDs

Percentage of insufficient physical activity comparable country estimates, 2008 Age standardized; by WHO Region and World Bank income group, men and women Source: Global Status Report on NCDs, WHO, 2001

Global response to NCDs 2000 Global Strategy for the Prevention and Control of Non-communicable Diseases 2002 2003 2004 2008 In 2000, Resolution WHA53.17 on Prevention and Control of Noncommunicable Diseases; In 2003, Resolution WHA55.25 on Global Strategy for Infant and Young Child Feeding; In 2004, Resolution WHA57.17 on the Global Strategy on Diet, Physical Activity and Health; (In 2007, Resolution WHA60.23 on Prevention and Control of Noncommunicable Diseases: Implementation of the Global Strategy; and) In 2008, Resolution WHA61.14 on Prevention and Control of Noncommunicable Diseases: Implementation of the Global Strategy, and a six-year Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. In 2008, Resolution WHA61.4, calling for a Draft Strategy to be presented to the Health Assembly in 2010 (through the EB Jan 2010). 2011 High-level Meeting on NCDs (New York, 19-20 September 2011) 5

Recommended actions for Member States "Ensure that physical environments support safe active commuting, and create space for recreational activity"

Recommended actions for Member States Introduce transport policies that promote active and safe methods of travelling to and from schools and workplaces, such as walking or cycling; Ensure that walking, cycling and other forms of physical activity are accessible to and safe for all;

Recommended actions for Member States Improve sports, recreation and leisure facilities Increase the number of safe spaces available for active play Implement school-based programmes Develop and implement national guidelines on PA for health

How much physical activity do we need? New WHO Global Recommendations Main aim: providing guidance on dose response relation between frequency, duration, type and total amount of PA needed for prevention of NCD’s Three age-groups; 5-17 year olds; 18-64; and 65+ Main target audience; national and local policy makers

Children and youth - aged 5-17 at least 60 minutes of moderate to vigorous intensity physical activity daily > 60 minutes provide additional health benefits Should: be mostly aerobic activity include vigorous intensity activities include muscle strengthening and bone health activities at least 3 times per week. In order to improve cardiorespiratory and muscular fitness, bone health, and reduce the risk of NCDs. 10

PA includes play, games, sports, transportation, recreation, physical education, or planned exercise, in the context of family, school, and community activities.

Promoting physical activity: what works?

Policy and environment Interventions targeting the built environment: reducing barriers to physical activity, Supportive transport policies and policies to increase space for recreational activity. Example intervention: In 1987, the Ministry of Health of Mauritius introduced a regulatory policy to change the composition of general cooking oil, limiting the content of palm oil and replacing it with soya bean oil. Five years after the intervention, total cholesterol concentrations had fallen significantly in men and women. Consumption of saturated fatty acids had decreased by an estimated 3.5% of energy intake. This activity was part of the national NCD intervention programme and a demonstration project within WHO's “Interhealth” initiative (10, 28). Ciclovia is an environmental intervention targeting the built environment and a multi-targeted approach to encourage healthier commuting. In 1995, the city of Bogota in Colombia initiated a vast transformation of the physical urban environment, providing accessible pathways for nonmotorized transport and an improved public transport system. A total of 260 km and 16 routes for bicycles have now been constructed. Ciclovia happens every Sunday when 120 km of roadways are closed to motorized vehicles. Results show that woman who usually participate in Ciclovia are seven times more likely to be physically active. Another result of the cycle routes is an improvement in public transport, and the prevalence of persons travelling by car has dropped from 17% to 12% during peak times (15, 29, 30). Summary statement Relatively few policy and environmental interventions have been evaluated in peer-reviewed studies. More research is urgently required. The current review showed that policy and environmental interventions create a healthy environment and support individuals to make healthy choices. These interventions can reach large populations. The evidence showed that regulatory policies to support a healthier composition of foods also work. Policies targeting the built environment or a reduction in barriers to physical activity showed positive results.

Success: Ciclovias, Bogotá, Colombia A cross between a street party and a marathon, Bogota's Ciclovía manages to combine sport, recreation, health, commerce and culture in one package. Improvements in public transport at the city level. % persons travelling by car has dropped from 17% to 12% at peak times. 55% of programmes provide economic opportunities (temporary businesses) 63% of programs reported engaging the community (eg:volunteerism) Ciclovia has now extended to more than 38 cities in at least 11 countries in the Americas. Improvements in public transport at the city level. % persons travelling by car has dropped from 17% to 12% during peak times. 55% of Ciclovias programmes provide economic opportunities through temporary businesses. 63% of programs surveyed reported engaging the community through volunteerism. Ciclovia has now extended to more than 38 cities in at least 11 countries in the Americas.

Multisectoral approach to implementation

Look for “win-win-win” options, that help each sector achieving its own goals Interest Reduce emissions of: air pollutants; greenhouse gases; noise Environment Health Reduce congestion Transport Reduce road traffic injuries Reduce investments in infrastructure to cater for more cars Improve accessibility and quality of urban life Complement technological improvements to vehicles and fuels Increase physical activity

School-based interventions High-intensity interventions that are comprehensive, multi-component and include: curriculum on physical activity taught by trained teachers; supportive school environment/policies; a physical activity programme; a parental/family component; Example CATCH, a three-year programme from grade 3 through to grade 5 in the United States of America (83, 84, 106, 107, 111, 115, 118, 124- 126, 133, , 138, 166), Pathways, a three-year intervention targeting 8 to 11-year-old indigenous American children (78, 81, 98, 99, 156-158), and Know Your Body, a six-year programme targeting pupils in grades 1 to 6 in Crete (120-123) are all example interventions that are comprehensive, multi-component, school-based, and focus on diet and physical activity. All were grounded on constructs from social learning theory with Pathways placing a strong emphasis on cultural identity. The programmes included curricula offered by trained teachers, a physical activity component and healthier meals offered in the school canteen (CATCH and Pathways). There was also a strong parental focus. The fact that teachers implemented the intervention made it sustainable and cost-effective. Of the family-based components, events at school were the most successful. These programmes demonstrated significant improvements in knowledge and food choices. Children in the Know Your Body programme demonstrated substantive reductions in intake of dietary fat, particularly saturated fat, and four- to five-fold increases in self-reported leisure-time activity. Pathways’ process evaluation found that the intervention was successfully implemented with good reach, and high coverage and intervention fidelity. These programmes demonstrated the importance of community-based participatory research, and that a careful process of formative assessment is key to effectiveness and long-term success. Summary statement School-based interventions show consistent improvements in knowledge and attitudes, behaviour and, when tested, physical and clinical outcomes. Notwithstanding cost-effectiveness research, there is strong evidence to show that schools should include a diet and physical activity component in the curriculum taught by trained teachers; ensure parental involvement; provide a supportive environment; include a food service with healthy choices; and offer a physical activity programme.

School-based interventions High-intensity interventions that are comprehensive, multi-component and include: A focused approach: programmes aimed at reducing sedentary behaviour and increasing participation in physical activity, accompanied by supportive activities within the curriculum. Formative assessments addressing: school needs and cultural contexts Example CATCH, a three-year programme from grade 3 through to grade 5 in the United States of America (83, 84, 106, 107, 111, 115, 118, 124- 126, 133, , 138, 166), Pathways, a three-year intervention targeting 8 to 11-year-old indigenous American children (78, 81, 98, 99, 156-158), and Know Your Body, a six-year programme targeting pupils in grades 1 to 6 in Crete (120-123) are all example interventions that are comprehensive, multi-component, school-based, and focus on diet and physical activity. All were grounded on constructs from social learning theory with Pathways placing a strong emphasis on cultural identity. The programmes included curricula offered by trained teachers, a physical activity component and healthier meals offered in the school canteen (CATCH and Pathways). There was also a strong parental focus. The fact that teachers implemented the intervention made it sustainable and cost-effective. Of the family-based components, events at school were the most successful. These programmes demonstrated significant improvements in knowledge and food choices. Children in the Know Your Body programme demonstrated substantive reductions in intake of dietary fat, particularly saturated fat, and four- to five-fold increases in self-reported leisure-time activity. Pathways’ process evaluation found that the intervention was successfully implemented with good reach, and high coverage and intervention fidelity. These programmes demonstrated the importance of community-based participatory research, and that a careful process of formative assessment is key to effectiveness and long-term success. Summary statement School-based interventions show consistent improvements in knowledge and attitudes, behaviour and, when tested, physical and clinical outcomes. Notwithstanding cost-effectiveness research, there is strong evidence to show that schools should include a diet and physical activity component in the curriculum taught by trained teachers; ensure parental involvement; provide a supportive environment; include a food service with healthy choices; and offer a physical activity programme.

WHO is linking with other sectors 2010 update: Memorandum of Understanding IOC-WHO " …agree to join efforts and to cooperate…to promote healthy lifestyles, physical activity and sport for all among the communities."

Interventions Multi-component interventions Adapted to the local context Culturally and environmentally appropriate interventions Using existing social structures of a community (e.g. schools, weekly meetings of older adults) Multistakeholder involvement throughout the process Listening, learning and targeting populations needs. Interventions targeting the built environment. The evidence reviewed and presented in this report, as well as in the online background Evidence Tables to What Works, shows that many effective interventions exist that policy-makers can implement to improve the dietary habits and physical activity levels of populations. Across categories, interventions that are multi-component and adapted to the local context are the most successful. Those that are culturally and environmentally appropriate are also far more likely to be implemented and sustained. Furthermore, interventions that use the existing social structures of a community, such as schools or the weekly meetings of older adults, reduce barriers to implementation. Implicit in all successful interventions is the participation of the stakeholders throughout the process, e.g. the involvement of workers in the planning and implementation of workplace interventions, and community leaders in the community and religious categories. Listening and learning from these target populations ensures that the interventions address their needs. Interventions in low- and middle-income countries should be sufficiently adapted to the cultural context and involve community members – both in the formative assessment, intervention design and implementation – for the intervention to work. Gaps in knowledge Current data on effective diet and physical activity interventions are generally the result of short-term studies. Psychosocial outcomes may well be perceptible within a short time frame. However, behavioural, physical and clinical outcomes often take much longer to manifest and thus the full impact of the intervention may not be measured within the study follow-up time. Moreover, little is known on the sustainability of interventions over time, nor on the cost-effectiveness of diet and physical activity interventions. Finally, in the literature reviewed, only minimal information was available on the unintended impact of interventions. http://www.who.int/dietphysicalactivity/whatworks/

Thank you http://www.who.int/dietphysicalactivity/pa/en/index.html Summary http://www.who.int/dietphysicalactivity/pa/en/index.html