If there were a pill you could take to reduce your risk of chronic diseases like heart failure, obesity, diabetes, depression, anxiety and more by 20%, chances are you'd be interested in getting your hands on it. Studies continue to extol the virtues of living an active lifestyle, but a growing number of us consistently fail to meet recommended levels of physical exertion. In this episode, we speak with medical experts on why it is so important, whatever your level of fitness, to feel like you can make a positive change to your life through exercise...
In this episode
01:50 - 25% of Brits do fewer than 30 minutes activity a week
25% of Brits do fewer than 30 minutes activity a week
Soren Brage, University of Cambridge
The second pillar of the global obesity pandemic, and a major risk factor for many of the world’s other most deadly diseases, are rising levels of physical inactivity. To illustrate how widespread the problem is, Chris Smith spoke to Cambridge University epidemiologist, Soren Brage…
Soren - If we look at UK surveys, about two thirds of the population are meeting the recommendations of 150 minutes of moderate to vigorous activity a week and a quarter of the population do less than half an hour of activity a week. So that's quite alarming.
Chris - It is alarming, isn't it? What do we mean by activity, though?
Soren - That's a good question. So, obviously our metabolism is mostly made of our resting metabolic rate and activity is the energy expenditure that sits on top of that. And it really is everything we do above that of rest. So even if you move your little finger, technically that is activity, but obviously we'd like people to use their large muscle groups.
Chris - How do we actually get these sorts of numbers, though, to work out that a certain fraction of the population are getting about the right amount of activity and a certain fraction are not? Is that self-reported and is it therefore subject to the same risks of bias where, if you ask people how much they eat, you can get misleading answers?
Soren - It certainly is. So the UK has national surveys where we ask people about their various activities and it's only a fraction of the activities people actually do over the day that you can ask about in a survey like that. Then, we add it all up. If you get to 150 minutes a week, we say you meet the health recommendations. If you get to double that, we say you meet the upper health recommendations for physical activity. But of course that is prone to bias. If we measured things with devices, we would get very different answers, but also very different health associations.
Chris - Is a stroll around the block as good as a jog? Can you actually make that sort of comparison? Or is any activity better than no activity, but the more intense the activity, the better
Soren - Intensity does matter. But really it is important for most people to just think about the totality and worry less about the nuances of intensity. They can do that if they have the luxury of being at a nice high total activity level.
Chris - And if we compare today with, say, 50 years ago, is there a difference?
Soren - So the data is a little bit uncertain on that but if we, for example, look at the makeup of our jobs, we had many more manual jobs in the past. We now have more service oriented types of jobs and desk oriented jobs. So yes, certainly that big proportion of many people's lives would have changed and, accordingly, people's activity levels would also have changed.
Chris - In the nearer term, though, what effect did the pandemic have?
Soren - That data is a little bit more certain because we have standardised surveys that cover this. The Active Life Survey, for example, that Sport England runs, we could see that there was a steady trend and then the pandemic really hit us quite hard because people's opportunities for being active and going to work, either walking or cycling, were taken away from us. So 2020 was not a great year. Levels do seem to have more or less recovered, though, so the latest data do suggest that we're more or less back to where we were except perhaps for one thing: active travel to and from work has not fully recovered yet. That is probably a reflection of our work and whether we work more days from home will obviously mean fewer active journeys for those who would otherwise have walked or cycled to work. So, at a population level, that number has not quite recovered yet.
Chris - In summary, then, you are saying that activity levels now are lower than they have been in the past. Is that just down to doing a job that makes us active or are people just lazier? Why would this have happened otherwise?
Soren - It probably isn't all down to personal level factors. There are many other things in our society. It is perhaps also the way that we have constructed our cities; maybe they're not always so welcoming in terms of being active. If you are afraid you might be run over by a bus or a truck cycling into work, then you are less likely to do that. It is really a 360 sort of approach we need to use when thinking about how we might build a better society and a better infrastructure so that we support people in making the right decisions for their own health.
06:49 - The extensive health benefits of an active lifestyle
The extensive health benefits of an active lifestyle
Scott Lear, Simon Fraser University
So what are the implications of doing fewer than the recommended 150 minutes of moderate to vigorous physical activity a week? And what does exercise actually do for our health? Well, quite a lot as it turns out. Chris also spoke with Scott Lear, Professor in Health Sciences at Simon Fraser University in Vancouver, and author of the ‘Become Your Healthiest You’ blog. He recently conducted a study into the effects of vigorous physical activity on health outcomes…
Scott - Vigorous physical activity is a type of activity where you might find your heart rate going up and your breathing rate going up. If you're able to carry on a conversation while you're walking or going on a jog, that's what we consider moderate, but with vigorous activity you wouldn't be able to carry on a conversation while doing that activity.
Chris - And does it have to be in those sorts of realms to be beneficial?
Scott - Definitely not. Any activity is better than no activity. We know that the benefits start from the very first step somebody does, whether it's activity or exercise, and the very first minute. The more steps, the more minutes, the more games, the more swimming strokes, the chances for getting diseases like heart disease, cancer, and early death go down the more you are active.
Chris - Do you know by how much? And how are you studying this to try and work out the degree of impact?
Scott - So when we look at these outcomes of disease and early death, we do what we'd call an observational study where we ask people how much they're exercising and then we'll keep studying them for maybe 5, 10, 15 plus years. We look at, is there a difference in who got heart disease based on whether they were active or not, or how much? And we find that people who are more active may have as much as a 20% reduction or protection from early death or getting disease in that 10 year study period compared to those people who are either less active or not active at all.
Chris - How do you control for the fact that people who are more likely to indulge in that sort of activity might be more likely to look after their body, eat a healthy diet, drink less, not smoke? How do we make sure that it's not their lifestyle around the fact, but they're also more motivated to exercise?
Scott - Excellent point. And there's also the consideration that people who might have an illness or a disease but not yet know about it are in the study and that may be why they're not exercising. These are important points. What we would do statistically, basically the analysis would say, well, if everybody was on the same diet, if everybody wasn't smoking, if everybody had the same body weight, this is the effect of exercise. Now, it's not foolproof. So when we do these observational studies where we're just following people and seeing how their exercise relates to their health, we look at multiple studies together and look at a consistency of effect. We also have intervention studies where we take people and exercise them and compare them to a similar group of people and don't exercise them. We see other health parameters improve: reduced body fat, reduced blood pressure, reduced blood glucose, lower chances of getting diabetes.
Chris - So a big reduction, isn't it? If that was a pill, we'd call it a wonder drug. Does the beneficial effect of exercise always apply irrespective of age or are there different forms or formats of exercise that benefit different people at different ages?
Scott - I would say, to the first question, exercise benefits anybody at any age. So if somebody's not exercising, the best time to start doing it is right now, today. It doesn't matter if that person's 70 years old and never exercised for 50 years or even in their life. It's always a good time to start. The benefit somebody gets is relative. If we picture, let's say, that 70-year-old person who's not active and spends a lot of time sitting down, even doing simple things like leg raises or getting up and down out of the chair will improve that person's fitness. Whereas, for somebody who's younger, up and about, that type of exercise isn't going to be a challenge so it's not necessarily going to improve their health. In order to get the benefits from activity and exercise, it needs to challenge the body. That's always relative to what the person is doing, currently. The Olympic athlete has to do a lot more than I need to do in order to improve their fitness.
Chris - The effects aren't just restricted to physical gains, though, are they? Because people who exercise also say they get a big mental boost from this. And indeed, people like Perry Bartlett in Australia showed a number of decades ago that, in fact, it changes the way brain cells, newborn nerve cells in the brain, are born and survive if you exercise more. So it seems to have a very broad range of effects.
Scott - Yes. And I would say that effect that you're touching on right now is why people actually exercise. I can talk about all the long-term health benefits 5, 10, 20 years from now and I know, when I exercise, it's improving my health, but I do it because I enjoy it. I am not thinking, "Oh, this is reducing my risk for cancer by 20%, 10 years from now." I'm thinking, "I feel good doing it, I feel good afterwards." It's that mental benefit that actually is what keeps people exercising.
Chris - Feels awful at the time though, doesn't it? I know only too well.
Scott - Alright. I'm not going to disagree with how you might feel when you're exercising. These are subjective when we ask people, and I can attest to this: if I do moderate versus vigorous activity, I feel better doing the moderate activity at the time than the vigorous activity at the time but, afterwards, it's flipped. This is even when we have people do two different types of exercise, that moderate, lower, less intensity, then the vigorous, higher intensity, they will say, as you point out, the vigorous activity is less comfortable, but they report greater improvements in mood and happiness in the hours following the vigorous activity, more so than those who did the moderate type of activity.
14:40 - Should doctors be prescribing exercise?
Should doctors be prescribing exercise?
Raj Amarnani, Moving Medicine
With the extensive health benefits of exercise as they’ve been outlined, it’s time to drill a bit deeper into the reasons as to why many aren’t enjoying them. To get some answers, and find out what we could do about the problem, I visited Raj Amranani, sports and exercise medicine specialist at University College Hospital in London…
Raj - There are really lots of challenges, both from a personal point of view, but also from an environmental point of view, that people find difficult to overcome in order to engage with physical activity. Across studies, the top three significant barriers have often been time, energy, and motivation. There are lots of other barriers and these include things such as cost of access to exercise resources, a lack of facilities in the local area, concerns around illness and injury, and not having the confidence to take part in physical activity. There's also other areas around family and lifestyle. So, for example, unaffordability of childcare in order to be able to engage with physical activity, but also finding programmes that are near to people so they feel suitable or comfortable engaging with them. So, as we can see, a huge host of barriers towards physical activity.
James - I know there's been talk of a tool in the arsenal being doctors prescribing people with exercise. Is that something that can work? Is it effective?
Raj - It's a really good question, and I think we know that being very prescriptive and telling patients exactly how to exercise often can be really unsuccessful, actually. It's actually about having what we call active conversations with patients in order to encourage them to take part in physical activity and make it a part of their lifestyle. Despite this, however, we know that there's a huge challenge for healthcare professionals because, from a knowledge point of view, we know that physical activity often isn't taught in medical curriculums, and often we find that healthcare professionals struggle with having those skills in motivational interviewing and behavioural change counselling.
James - Especially with the health benefits as they've been outlined, and the thought that, if exercise were a pill, it'd be a trillion dollar enterprise or more, to hear you say that medical professionals often don't feel confident in having those conversations with patients is quite shocking.
Raj - No, absolutely. Another sad, unfortunate situation is that of course with the NHS and the pressures that it's going through at the moment, often appointments are very streamlined and often doctors find that they don't have the time to have those conversations with patients. And actually there's lots of resources now that are coming out to try and address that. One example is the Moving Medicine initiative that provides free to access resources for healthcare professionals on how to have those active conversations. Even if you have one minute at the end of your consultation, to start that conversation around physical activity, we know that it could be really beneficial and it can help patients start thinking about how they move towards a more physically active lifestyle.
James - And on those conversations, as you were saying, people generally don't really like being told what to do that much and, as much as they might know it could benefit their health, it's that lack of autonomy that stops people engaging with it. So tell me a bit about those strategies to overcome this and make it feel like more of a decision they've come to themselves rather than something they're being instructed on.
Raj - We normally suggest talking to them in such a way where it actually ends up them telling themselves that a more active lifestyle would be better for them is often a lot more successful. So, for example, rather than jumping in with a suggestion on how to become more active, actually spending that time going through things about what's important to them, how they might best get started, or who they might like to do an activity with can be much more likely to actually change their behaviour and incorporate that physical activity into the day-to-day lives.
James - What happens then if that fails, essentially? If, despite the best intentions of the doctor, they've failed to reach that agreement with the patient. For whatever reason, they are still having trouble with hitting those recommended targets.
Raj - We know that actually there are lots of barriers towards physical activity that we've talked about. And one of the main solutions to try and address that is actually a sense of belonging and a sense of community. So there's lots of initiatives such as Parkrun that do encourage people to come out of their bubble and actually meet their friends, meet family, and do something a bit more physically active. That sense of being part of something that's slightly bigger than them can be really helpful. Often we find that encouraging patients to take part in group exercises and group classes is beneficial.
James - And one of the things that's particularly alarming as well is that youth participation levels in sport where physical activity is traditionally higher anyway is starting to fall. Is there a risk of not establishing those habits, not establishing a relationship with exercise?
Raj - Yes, absolutely. That is hugely important. And we know that actually being physically active at a younger age does set those good habits for the future. There have been studies that children as young as 11 years old, the way they conceptualise physical activity and understand the importance of it really has a lasting association and impact as to how they then engage with it going forward as they get older. So we know that setting those examples at a really young age and getting children outside of computer games and off their phones and back into parks and back into playing sport can be a massive benefit for their future.
James - Thank you very much for speaking with me.
Raj - Thank you very much for having me James.
20:16 - Kit concerns causing girls to quit sport
Kit concerns causing girls to quit sport
Tess Howard, Team GB Hockey
Many point to rising levels of screen time and a lack of access to opportunities to play sport as factors for the fall in exercise among children - but inactivity has become particularly pronounced in girls who are 5% less likely to be active than their male peers. Tess Howard plays hockey for Team GB and has been investigating whether the kit girls are told to wear when playing sport at school is one of the least recognised factors playing a part in lower participation rates. She argues that negative associations with gendered items of clothing such as skorts are a significant part of the problem…
James - It's great to catch up with you Tess. Thanks for chatting with me. It's a shame we couldn't do this in person, but you've got a pretty decent excuse as they go. Tell us where you are right now.
Tess - Thanks. I'm in Buenos Aires getting ready to play in the FIH Pro League, which is a hockey tournament of the top eight teams in the world.
James - How's everything shaping up for the big one, the Olympics, next year?
Tess - Things are going well. We have the Olympic qualifiers in January in Valencia. And then Paris obviously is in July/August time. So all guns blazing to get qualified and then we'll go hopefully to Paris and win another medal.
James - Well, we're all rooting for you. I thought you'd be a good person to talk to this week given that we're addressing levels of physical inactivity among the population. It's so important to get young people in particular in good habits, in good relationships with exercise, and we know that the trends in youth participation in sport are not positive ones, are they?
Tess - It's a problem for all, but specifically young girls experience negative experiences of sport. So my question was, okay, let's take something as mundane as uniform. It's gendered from age five. Does that have an impact on girls' participation in sport? I went into my research and found that it had a huge impact that we needed to address. I found that 70% of women had seen girls drop out of sport because of sports kit and body image concerns. That was extremely alarming for me, and I felt like I was sitting on something that people needed to know. So you have the practicality of the kit - the ergonomics of it, the comfort of it - if you don't have a choice to wear what you feel more comfortable in, you are generally going to have a negative experience of sport. The whole point of sport is to feel free to express yourself. If you can't feel yourself wearing a kit, you're going to associate PE or sport with feeling uncomfortable. Then you have the extra layer of the gender coding of it, and the issue that we have when we separate boys and girls from a very young age, especially in a sports context. It comes from this idea that you have to maintain a traditional femininity. It starts in Victorian public schools: you start off with these incredible images of young girls playing sports in corsets and dresses, you see it move to longer skirts without corsets, then you see it move to pinafores, which are little dresses, and then the evolution moves further to the skort. That was so that, if the wind blows up your skort or, heaven forbid, you roll around on the ground playing hockey, you won't be exposed.
James - And you found from personal experience that the skort was inhibiting your performance as an athlete.
Tess - I always thought of the skort as a metaphor for where women were in sports, because the skort is extremely uncomfortable. The question I would ask is, would you wear a skort to run a marathon in? Would anyone? And the answer would always be no. We've never worn skorts to do fitness tests and we've never worn skorts to train as an elite athlete. When we played, though, before we changed the guidelines this summer, it wasn't even questioned. And the only reason why it wasn't questioned is because it was ingrained in tradition and stepping out of that tradition was worse for you than wearing a pair of shorts.
James - And do you feel that girls feel conflicted about playing sport and being feminine at the same time today? There's still a perceived contradiction there.
Tess - If you ask any girl, or probably any person, what the ideal feminine look is, they'll probably be able to recite exactly what it is because it is so ingrained in us. It happens in pretty much all sports. There are specific barriers to women's kit, whether that's in football wearing white shorts because of period concerns (they've changed to blue shorts now, the Lionesse) or whether it's in gymnastics where they have to glue their leotards to their skin so that it doesn't move because you get deducted points if you are seen to be moving your leotard around. In 2021, Sarah Voss, a German gymnast, wore a full length leotard for the first time in the Tokyo Olympics and it was seen as this massive deal and it's actually the most practical thing to wear because you're not worried about what you're looking like. And, if you think about, at a young age, when girls start going through puberty, their body's change, as boys do, but very obviously for girls when they start to develop breasts and they start to menstruate, you have specific concerns. And if you're putting all of that plus, for your uniform, you might be wearing a T-shirt that is so tight or is cut in such a way that you feel that you are not living up to that standard, and because there's no room in women's experience to have different body types, you have to be a certain way, the pressure that gets built up, it's simply easier to drop out. And that's what we've seen. It's just simply easier to drop out. Then you have the worst part of it, which is that your relationship to sport is defined by how you feel and what you're wearing has a massive impact on how you feel, your self-confidence. Then you see the trends in long-term participation really fall.
James - So in order to reverse this, is it just as simple as we give girls the choice of what to wear? Or is this going to take a long time really before these ingrained cultures start to be reversed?
Tess - Well, in hockey we've managed to change the guidelines, to change the rules internationally. First, we did it domestically to offer choice and then internationally we ran out at the Europeans this summer in a combination of half and half of skorts and shorts, which has never been done before in any team sport, let alone hockey. In one swift move with, if you like, eight pairs of shorts, we redefined what hockey could look like. What I've seen over the last six months since that is a gradual culture shift where clubs are starting to provide women's shorts and, because you can wear them in the leagues now, many women are changing to wearing shorts and messaging me saying, 'thank you so much, I never thought there would be a day that I'd be able to wear shorts.' And you think it's bizarre that the rules said that you couldn't wear them. So it starts, whilst we can talk about choice, it starts with the policy change. It's taken six months really for me to see the change but now I look at my teammates, my GB teammates, and think maybe six of us to start with were quite comfortable wearing shorts for the first time in elite international history and now it's spread in the team. My teammates are coming up to me and saying, 'I don't why I ever wore a skort. We train in shorts every day. It just makes sense to play in shorts!'
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