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HEALTH ENHANCING PHYSICAL ACTIVITY Individual and Organizational Aspects, Facts, Issues and Evidence Brussels, 22 Feb, 2011 Harri 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 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 Year Average Very good Poor adapted Average muscle strength test results in young men starting their military service in Finland (1982-2009) Distribution of muscular index (%) Very good + Good Poor Year adapted 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 Population Endurance Mixed Power 1 0,8 0,6 0,4 0,2 0 Kujala et al. JAMA 2001;285:44-45 Prevalence of diabetes and CHD in former elite athletes 1,4 1,2 ORs compared to controls, and adjusted for age, BMI, smoking, and SES 1 Controls Endurance Mixed Power 0,8 0,6 0,4 0,2 0 Diabetes CHD 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? Physical activity and health (WHO) 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 Stroke, Alzheimer’s disease, Dementia Physical activity is effective! • AHA/ASA Guideline 2001 : Physical inactivity ”less-well documented risk factor” AHA/ASA Guideline 2006 : Physical inactivity ”welldocumented 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 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 6 Kiiskinen et al. The Finnish Health. Duodecim 2005, Prime Minister’s Office 4/2007 Paying for Disease or for Health? Official Finnish Statistics 1972-92 Direct treatment costs Indirect costs / loss of productivity Costs for ”Lifestyle Diseases” • Difficult to estimate • The magnitude for some major risks (FIN) – – – – – Obesity Physical Inactivity Smoking Alcohol Accidents 190 million € 200-250 million € 246 million € 123-226 million € 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) €1780 Savings 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 Exercise on prescription • 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 advice 5) process follow-up, further actions 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 Stages of change in process of stopping smoking. Adapted from Prochaska et al. Clin Chest Med West, R. BMJ 2004;328:338-339 Copyright ©2004 BMJ Publishing Group Ltd. 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: 4556 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 4. Local ideas Fit for Life 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 •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 Fit for Life 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 How to activate Health Enhancing Physical Activity Projects by creating economical resources material education network 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 market 2. Develop segment profiles Physical activity Market Targeting 3. Develop measure of segment attractiveness 4. Select target segments Market Positioning P. Kotler. Marketing management 5. Develop positioning for target segments 6. Develop a marketing mix for each segment Innovation portfolio 1000 100 10 1 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 [email protected]