THE POPULATION OF NHSGGC NEEDS TO GET MORE ACTIVE
Promoting increased levels of physical activity in the population has been described as “a best buy in public health”.(93) Regular physical activity can protect against the risk of high blood pressure, stroke, coronary heart disease, type 2 diabetes, osteoporosis and some cancers.(94) There is evidence to show that those who are physically active have lower rates of smoking and substance misuse.(95) Becoming more physically active can improve mental health and wellbeing, extend our social networks and has a major role to play in weight control.(96) Adults who are regularly physically active have a 20 to 30 percent reduced risk of premature death and up to 50 percent reduced risk of developing major chronic diseases.(97)
The Scottish Physical Activity Strategy states that a one percent reduction each year in the number of inactive Scots for the next five years would have a number of significant impacts including;
The estimated total economic benefit would be £85.2million.(98)
Regular physical activity can help to prevent obesity which was highlighted as a major public health issue in the Director of Public Health’s Report, A Call to Debate: A Call to Action, published in 2007 and continues to be a priority for action.(16)
Concern at a UK government level regarding increasing levels of obesity has led to the establishment of an expert group – Foresight – to consider how best to tackle this important public health issue.(99) The Foresight group estimated that economic costs attributable to obesity at a UK level will rise from £15.8billion in 2007 to £49.9billion by 2050 if no action is taken.(99) If we adjust this to a population of the size of NHSGGC, attributable costs were £316milion in 2007 and will rise to almost £1billion by 2050 (at today’s prices).
An important key to promoting physical activity may lie in changing the environment. The five year review of Let’s Make Scotland More Active concluded that “the creation and provision of environments that encourage and support physical activity offers the greatest potential to get the nation active”.(100)
Therefore, in order to promote successfully physical activity, action on the environment as well as action at an individual, community and organisational level is needed.
In this chapter, we set out trends in national and local physical activity levels; summarise the evolving policy context; outline current action to promote physical activity on the ground; and, finally, present key public health messages and priorities for action that we believe will help to grow a more physically active population. Although this chapter focuses on physical activity it will also discuss some of the issues of diet and nutrition to reverse increasing obesity trends.
TRENDS IN PHYSICAL ACTIVITY
To gain health benefits, adults are currently advised to accumulate at least 30 minutes of moderate intensity activity on most days of the week (five or more) and children should accumulate at least one hour daily. It is recommended that all children and young people aged 5 to 16 participate in physical activity of at least moderate intensity for one hour on most days of the week.(98)
Figure 1 illustrates the sources of physical activity in the population. Importantly, sport only accounts for eight percent of the total physical activity carried out by active adults.
Sources of physical activity in the population
National Data from the Scottish Health Survey and Health Education Population Survey (HEPS) indicate generally low levels of physical activity, with the majority of men and women failing to achieve the recommendations. Most people in Scotland are not active enough; around two thirds of adults living in NHSGGC do not participate in enough physical activity to meet the current recommendations.(101)
HEPS found that between 1996 and 2005 there had been a slight increase in the proportion achieving the recommended levels but no clear trend over time, men achieving higher levels than women.(102) National data presented similar trends to local data but some variance exists between recorded activity levels, with local data showing significantly more respondents meeting the target. This can be seen in Figure 2 which shows trends from the NHSGGC Health and Wellbeing survey. From 1999 to 2002, there was an increase in physical activity involving both males and females, but from 2002 to 2005 this levelled out, followed by a sharp decline,
from 2005 to 2008, from 58% to 45%, in those adults over 16 achieving the recommended levels of physical activity.
Trends in percentage of respondents achieving the recommended levels of physical activity aged 16 plus 1999 to 2008
% of Adults Meeting Physical Activity Recommendations, 1999 to 2008
Source: NHSGGC Health & Wellbeing Surveys
Results from the 2008 NHSGGC Health and Wellbeing Survey show that across NHSGGC less than half the adult population (45%) meet the national recommendations for physical activity.(17,98) These trends will be investigated further when we compare NHSGGC’s Health and Wellbeing Survey data with the 2008 Scottish Health Survey Data.
Older people are less likely to meet the national recommendations, with less than one third (29%) of those aged over 65 meeting the target, while half the 16 to 44-year-olds met the target as Figure 3 illustrates:
% of Adults Meeting Physical Activity Recommendations by Age-group
Source: NHSGGC Health & Wellbeing Survey, 2008
People living in our most deprived communitiesg were less likely to meet the physical activity targets (39%) compared to people who lived elsewhere in NHSGGC, men (47%) were more likely than women (43%) to be physically active enough to meet the target.
Scotland’s routine surveys confirm that compliance with the current recommendations for physical activity is patterned by gender, age and deprivation.
[g Our most deprived communities are defined as those living in the 15% most deprived area using the Scottish Index of Multiple Deprivation]
People living in our most deprived communities were more likely to travel by active means or use public transport, but less likely to use the car, as illustrated in Figure 4.
Percentage of adults that used active, public or car/motorbike as their main modes of transport by deprivation
It is encouraging that many of the children living in the NHSGGC area take either public transport, or walk to school. There is some variation across the area as we would expect due to the variation in dispersion of the catchment areas of schools in the various local authorities.
It is disappointing, however, that the proportion of children journeying to school by car is above the Scottish figure in all but one of our local authority areas, as shown in Table 1. For example, around one third of children travel to school by car in East Renfrewshire and Inverclyde; around a quarter of children travel to school by car in Glasgow City, whereas in Renfrewshire and Scotland as a whole, around a fifth of children travel to school by car. Evidence from NHSGGC Glasgow schools’ survey suggests that although less than 1 in a 100 cycle to school, ten times that number would like to.(85)
Percentage of school children that travelled to school using active means, public transport, or car.
Cycle ownership rates have been identified as being low in Glasgow at just fewer than 20%.(105) To help young people to have access to bicycles, Land & Environmental Services have set up a ‘School Bicycle Loan Scheme’. Schools that are willing to set up a cycling club for their pupils are given 30 mountain bikes, plus supporting equipment. Eleven secondary schools have joined the scheme and 2009 saw the scheme extended to include primary schools.
In 2007 the DPH report highlighted increasing levels of adult obesity, with 60% of NHSGGC’s adult population being either overweight or obese (using statistics from the Scottish Health Survey). Interestingly, those who were underweight/ideal weight were just as likely as those who were overweight/obese to meet the national recommendations for physical activity as Table 2 illustrates.
Percentage of underweight/ideal weight and overweight/obese people who meet the national recommendations for exercise
Adults who were overweight/obese, however, were less likely to participate in any sport in the previous month, with just 31% of overweight/obese people participating and 39% of underweight/ideal weight participating. People who were overweight/obese were also less likely to use an active mode of transport or use public transport, but more likely to use the car than underweight/ideal weight people, as Figure 5 illustrates.
Percentage of underweight/ideal weight and overweight/obese people using active, public or car/motorbike as their main form of transport.
For adults living in the NHSGGC area, relatively few adults had participated in any sport (43%) in the previous month. Further participation in sport is less likely in our most deprived communities where just 27% participate in sport compared to 37% in other areas. Younger people were more likely to report participating in sport with 54% of 16 to 44-year-olds participating compared to just 26% of over 65s, as Figure 6 illustrates.
Percentage of adults who participate in sport by Age-group Source: NHSGGC Health & Wellbeing Survey, 2008
Let’s Make Scotland More Active, the National Physical Activity Strategy, was published in 2003(98) and reviewed in 2008.(100) The review group wanted to look at what has been successful, what the key challenges are and to make recommendations for future priorities.
The recommendations from this review are that by 2022, 50% of adults and 80% of children will be expected to meet the current recommended levels of physical activity.
Healthy Eating Active Living(106) is part of the Scottish Government’s approach to tackle jointly action on physical activity and obesity and has set targets for Health Boards’ to design interventions that will have a positive impact on children’s weight.
The curriculum for excellence aims to achieve a transformation in education in Scotland by providing a coherent, more flexible and enriched curriculum for children and young people aged 3 to18. The curriculum emphasises children’s experience and is outcome-focused on health and well-being, physical education, physical activity and sport.(107) These are the key policy drivers that will support the population to become more active.
SUPPORTING OUR POPULATION TO BECOME MORE ACTIVE
“We should encourage not just the youngsters but also the older generation to do exercise”(20)
Let’s Make Glasgow More Active published in 2007 is the Glasgow City Physical Activity Strategy and “aims to encourage concerted and coordinated action to increase the levels of physical activity for the whole population”.(96) The strategy is underpinned by a partnership model rooted in community planning and has been developed by a multi-agency Physical Activity Forum. Its vision is “More Glaswegians, more active, more often”.
The Forum has identified clear outcomes for the strategy which are:
The outcomes will be achieved through the implementation and monitoring of strategic objectives across three strands - city, communities and disadvantaged groups - with the key aim of increasing participation in physical activity with a major focus on those who are least active and most disadvantaged, ensuring widening access and equity of opportunity.
In order to achieve strategic outcomes, approaches need to:
The development of cycling is a theme which runs through all of the above aspirations and Glasgow City Council is drafting a ‘Strategic Plan for Cycling’ which seeks to progress cycle development in a cohesive manner. In doing so, the Council has involved a number of external agencies with an interest in developing cycling within the city.
Glasgow City is one of eight Equally Well test sites in Scotland established to contribute to our learning on how to maximise our impact to reduce health inequalities. The Glasgow City test site focuses on healthy urban policy by developing a healthy sustainable neighbourhood model which can be used by town planners at various stages of the planning process.(108) This initiative recognises that place and space have an impact on human health and well-being. Health considerations are built into the planning processes; with one of the aims being to tackle obesity through environmental action in the City’s more deprived neighbourhoods.
In Dalmarnock, for example, health is being integrated into the master plan in order to deliver a healthy infrastructure to encourage walking and cycling as well as other health benefits of an environment which puts people at its heart. NHSGGC is involved in the development and evaluation of this project, which should lead to changes in planning practice to incorporate health on a more routine basis.
Glasgow City Council is in the process of drawing up a Core Paths Plan, in line with its duties under the Land Reform (Scotland) Act 2003, which records the strategic and important paths and routes around the City.
The Core Paths Plan will connect homes with workplaces, schools, public services, parks, greenspaces, neighbouring communities and the wider countryside and therefore contribute significantly to ensuring that an appropriate level of infrastructure is in place to support informal physical activity, in particular walking, cycling and running.
Encouraging active travel and reducing car use has the potential to integrate more physical activity into the daily routine of many people who are currently not sufficiently active. However, poor transport infrastructure for walking, cycling and public transport can act as a barrier to taking up these more physically active alternatives to the car.(109,110)
Transport infrastructure to support active and sustainable travel should include safe walking and cycle routes with good lighting, CCTV and, where possible, segregation from motorised traffic, dedicated bus lanes and good integration between different modes of transport. Improvements to the transport infrastructure are being progressed through the local authorities’ Local Transport Strategies and the Strathclyde Partnership for Transport (SPT) Regional Transport Strategy.(111)
Another key initiative in this regard is ‘Smarter Choices Smarter Places’, a Scottish Government partnership designed to promote healthy lifestyles, active travel and public transport use and to encourage us out of our cars. NHSGGC community health partnerships, in partnership with three local authorities, have been successful in securing Scottish Government funding to take forward programmes within their local communities.
Work is underway to promote health and well-being in Barrhead through regular walking and cycling.(112) As part of the Glasgow and Clyde Green Network Partnership, East Renfrewshire is also undertaking a consultation process with the local community in Auchenbach to make the best possible use of outdoor spaces. The consultation involved a community photography project and interviews and group discussions to establish attitudes towards physical activity.(113)
East Dunbartonshire CHP is taking forward plans to promote active travel by improving the local infrastructure to promote walking and cycling and develop social marketing techniques to promote behaviour change that will have a positive impact on increasing active travel.
Glasgow – East End
The East End accessibility project aims to encourage residents and visitors in Glasgow’s East End to foster healthier lifestyles by adopting sustainable and active modes of transport. In addition, this project aims to leave a lasting legacy for local residents and future venue users after the 2014 Commonwealth Games.
A key element in transport planning to support active travel is the provision of accessible, up-to-date and reliable information for transport users. This includes maps and route planning advice for walking and cycling, as well as timetables, route maps and interactive journey planning for public transport. One development has been the inclusion of Glasgow in the Walkit.com website which provides a free route planner for walking journeys.(114) In partnership with SPT and Traveline Scotland, NHSGGC has introduced a scheme to provide personalised journey plans with outpatient appointment letters that advise the patient how they can access
their appointments by public transport.(115)
The development of SPT’s Bus Action Plan and the introduction of ‘bus wardens’ to monitor service standards have been significant steps towards better public transport services. Bus passengers have seen many improvements as a result of the enforcement action taken by the bus wardens, which have given bus users more confidence in the services and encouraged greater use of public transport.
Walking has been described as the ”nearest activity to perfect exercise”.(93) The five-year review of Let’s Make Scotland More Active concluded that “the creation and provision of environments 91
that encourage and support physical activity offers the greatest potential to get the nation active.”(100)
Walk Glasgow is a partnership project that aims to develop and promote walking opportunities across the city. The initiative focuses on three key areas: communities, workplaces and schools. Training and support is provided to enable volunteers to set up and lead short health walks in their neighbourhood, for colleagues at work or local school children.
Glasgow City Health Commission recommended further support for green travel plans. These plans encourage employers to develop plans with their staff to optimise the use of active and sustainable transport to and from work and during the working day.(116) NHSGGC and most local authorities in the NHSGGC area have green travel plans in place for staff and have been taking forward a range of initiatives to promote staff travel by walking, cycling and public transport.
One programme that encourages our population to become more active is the NHSGGC Live Active Referral Scheme delivered jointly with our local authority partners. The programme involves health professionals referring inactive patients to a supported physical activity programme in local authority sports centres across the area. The first phase of the evaluation will report later this year. Early findings indicate that of the 3,139 patients referred to the scheme, 69% attended following baseline appointment. Participants are encouraged to exercise independently and progress is monitored at six and 12 months. Twenty three percent of
participants attended the six-month consultation and 14% attended the 12-month consultation. While the numbers completing the programme are relatively small, they compare well to other programmes. Significant health benefits are seen in those who complete the programme. For example, weight loss between start and six months, which was sustained at 12 months and reduction in anxiety and depression scores measured by the HADS scale (Hospital and Anxiety Depression Scale). There was an increase in overall physical activity.
Vitality is the NHSGGC’s new referral exercise scheme offering classes suitable for people with different physical abilities and medical conditions, including: older adults, stroke survivors, people with heart conditions, people living with Parkinson’s disease, multiple sclerosis, osteoporosis and breathing difficulties. Led by highly trained and experienced instructors, these classes are suitable for different levels of ability and are open to anyone who feels that they need support to live more actively.
For individuals not participating in any physical activity, the biggest perceived barrier is time.(96) It is important therefore for individuals to see physical activity as part of their daily routine and not in addition to it. For that reason the workplace is an ideal setting to deliver physical activity programmes and to provide working age people with the knowledge, confidence and skills to make healthier lifestyle changes.
Active travel to and from work in particular can be effective at integrating physical activity into one’s daily routine.(117) Organisations and employers can provide facilities such as showers and bicycle racks to promote active travel, incentivise staff through Bike to Work or salary-sacrifice bus ticket schemes and provide public transport information to their staff and customers. They can also establish lunchtime walking and running groups or run on-site fitness classes. They can engage in national campaigns to provide information on the benefits of exercise, promote and support events such as Walk to Work week, provide information on local sporting facilities and also participate in schemes to purchase corporate membership of local authority sporting facilities for their employees. Cycling Scotland offers a ‘Cycle Friendly Employer Scheme’. The
aim of the award is to give employers the incentive to achieve a nationally recognised award for promoting cycling in the workplace which will result in benefits for employers and staff.(118)
A good example of this in practice is Activity Works a Healthy Working Lives and Health at Work initiative piloted with Culture and Sport Glasgow. This initiative delivers structured packages of activity that companies can use to work towards the Healthy Working Lives award scheme.
The NHSGGC Health at Work team have in place a three-year strategy to deliver programmes in the workplace and this incorporates promotion and provision of physical activity initiatives. They have developed resources and training for employers to support these programmes and the majority of this work is delivered under the banner of the Healthy Working Lives award scheme. This national award programme provides a framework to enable workplaces to sustain and improve staff health and well-being.
NHSGGC is participating in Healthy Working Lives and has developed a Staff Health Action Plan in partnership with Glasgow City Council. The aim is to improve the health and well-being of staff by providing access and support to a variety of healthy lifestyle options and by engaging and listening to staff. The action plan sets out a commitment to health and well-being, focusing on alcohol, physical activity and mental health.
The Commonwealth Games in Glasgow in 2014 offers unprecedented opportunities to focus on physical activity before, during and after the Games. We need to work together with our partner local authorities to ensure that the Games are relevant and encourage participation in sport in all sectors of the community, including older people and those living in our most deprived areas. For example the International Mountain Bicycling Association cited Scotland as a ‘global superstar’. The provision of a mountain bike course within Cathkin Braes Country Park presents the city and particularly the adjacent area of Castlemilk with an opportunity to see a legacy developed in this rapidly growing sport.(119)
During 2008-2009 NHSGGC has been heavily involved in undertaking a Health Impact Assessment (HIA) of the Games. This is an exercise designed to maximise the health potential of the Games and their legacy. The HIA feeds into the development of plans at all stages by providing evidence for decision makers about the effect their decisions are likely to have on the health of the population. These decisions range from transport infrastructure, development of facilities and opportunities for participation to pricing policy and access. The priority of the Commonwealth Games Legacy plan is to get Scotland physically active, with people living long,
healthy lives. This includes the creation of a popular and high profile movement to get people active by encouraging all ages and abilities to get ready for the Games by setting a personal goal to improve their health and fitness. This Active Nation programme could help to motivate the people of NHSGGC to achieve long-term behaviour change and we will work with our local authority partners and sports organisations to help make this a reality.
Physical activity and obesity
“Rather than go outside to play with friends they sit in the house in front of the TV.”(20)
The recommendations state that to prevent adults becoming overweight or obese requires 45-60 minutes of moderate intensity activity per day, particularly if energy intake is not reduced. In addition, people who have lost weight should be advised that they may need to do 60-90 minutes of moderate intensity activity a day to sustain weight loss.(97)
In children, the recommendations for weight loss can be achieved only by sustained lifestyle changes such as a minimum of 60 minutes of moderate/vigorous physical activity per day and by reducing physical inactivity, e.g. watching TV, to less than two hours per day on average.(120)
Physical activity and healthy eating are identified as public health priorities because of their inter-relationship and the recognition that it is the only viable way to reduce the epidemic of obesity. NHSGGC, working with NHS Health Scotland, is in the process of developing an obesity strategy which will be finalised in 2010. A comprehensive programme of work tackling obesity issues is underway in partnership with local authorities. Glasgow City Council Healthy Weight Strategy is an excellent example of a local authority recognising its role in combating obesity.
Shape Up is a weight management programme aimed at those with a BMI of 25-35. This lifestyle programme is delivered by trained coaches through local authorities. In addition, NHSGGC offers a specialist service to people with a BMI over 35. This is by GP referral only and is an area-wide service.
Healthy Weight Communities
Healthy Weight Communities is a Scottish Government initiative that takes an outcome-focused approach to tackling unhealthy weight with a particular focus on children and young people. NHSGGC has two pilot programmes running in East Renfrewshire CH(C)P and South West Glasgow CH(C)P.
Active Children Eating Smart
Active Children Eating Smart is a new childhood obesity intervention developed by NHSGGC in partnership with Culture and Sport Glasgow and other local authority leisure services. The aim of the initiative is to assist children and young people, in cooperation with their families, to either lose or stabilise weight.
The Big Eat In
All first year pupils in eight secondary schools across Glasgow city are being encouraged to stay on the school premises at lunchtime during 2009-2010 academic year.
Education and catering staff have adopted a holistic approach to create an enjoyable, healthy active lunchtime where a healthy lunch will feature but not dominate. A package of initiatives has been established in each school to provide a positive incentive for pupils to remain on the school premises. Initiatives vary from school to school but include recreational activity, sport and lunchtime clubs.
Partnership working, communication and pupil/parent involvement are prominent features of each school’s individual implementation plan.
NHSGGC has developed a number of resources to support physical activity.
PUBLIC HEALTH MESSAGES
Despite the National Physical Activity Strategy, trends in NHSGGC suggest that multi-agency leadership and drive is required if we are to meet the national targets for physical activity.
Physical inactivity remains the most common risk factor for coronary heart disease in NHSGGC today and is a core concern.
Key challenges include:
It’s never too late to start being active to confer health benefits across all ages.
Walking can be described as the nearest activity to perfect exercise and should be a priority activity.
PRIORITIES FOR ACTION