Physical Activity Promotion: Prevention of Chronic Disease Morbidity & Mortality Antronette (Toni) Yancey, MD, MPH, FACPM Associate Professor, Dept. of Health Services, Co-Director, Ctr. to Eliminate Health Disparities UCLA School of Public Health www. ph. ucla. edu/cehd www. toniyancey. com
Unhealthy eating and inactivity are leading causes of death in the U. S. Leading Contributors to Premature Death 1 = HHS estimates that unhealthy eating and inactivity contribute to 310, 000 to 580, 000 deaths each year. That’s 5 times more than are killed by guns, HIV, and drug use combined. 1 Diet and Physical Inactivity 310, 000 -580, 000 Tobacco 260, 000 -470, 000 Alcohol 70, 000 -110, 000 Microbial Agents Toxic Agents 90, 000 60, 000 -110, 000 The typical American diet is too high in saturated fat, cholesterol, salt, and refined sugar and too low in fruits, vegetables, whole grains, calcium, and fiber. Such a diet contributes to four of the seven leading causes of death and increases the risk of numerous diseases, including: 35, 000 Sexual Behavior 30, 000 Motor Vehicles 25, 000 Drug Use = Firearms 20, 000 Leading Causes of Death 3 (Diet is a leading risk factor for causes of death shown in bold or green. ) 1. Heart Disease 724, 900 2. Cancer heart disease cancer obesity stroke = 541, 400 diabetes 3. Stroke 158, 400 high 4. Chronic Obstructive Pulmonary Disease 112, 700 blood pressure osteoporosis 60% of Americans are at risk for health problems related to lack of physical activity (ie: get less than 30 minutes of moderate activity 5 or more times per week). 2 5. Accidents 97, 800 6. Pneumonia and Influenza 91, 900 7. Diabetes 64, 900 8. Suicide 30, 500 9. Nephritis 26, 200 10. Chronic Liver Disease/Cirrhosis 25, 100 11. Septicemia 23, 800 12. Alzheimer’s 22, 700 13. Homicide and Capital Punishment 18, 400 14. Atherosclerosis 15, 400 15. High Blood Pressure 14, 300
DIABETES PREVENTION PROGRAM n The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin n All patients had impaired fasting blood sugars, but were not diabetic n Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week n They were followed over 2. 8 years
DIABETES PREVENTION PROGRAM Lifestyle intervention was much more effective than either placebo or metformin DPP Research Group. N Engl J Med. 2002; 346: 393 -403.
Fitness & Mortality • Low fitness is bad for health
Walking & CVD • Walking as little as 5 mins. daily is beneficial for fitness • 30 mins. daily provides best health benefit (heart disease prevention) • 60 mins daily can cause reversal of heart disease
Physical Activity & Risk of Common Cancers Colon: 30 -40% decreased risk among active men & women (Rectal—no association) n Breast: substantial evidence for dec risk; strength of assn--time period may be critical n Prostate: findings inconclusive n Possible mechanisms: 1. decreased GI transit time (dec carc expos) 2. enhanced immune function (moderate PA) 3. lowered levels of reproductive hormones n
Population Attributable Fraction Cancer Mortality – Male Never Smokers Population Exposure* RR† 25. 0 -29. 9 42% 1. 1 4. 0% 30. 0 -34. 9 21% 1. 4 >35. 0 13% 1. 3 6. 8% 3. 4% BMI PAR (%) 14. 2% *NHANES 2000, men age 50 -69
Population Attributable Fraction Cancer Mortality – Women Never Smokers BMI Population Exposure* RR† PAR (%) 25. 0 -29. 9 29% 1. 1 3. 3% 30. 0 -34. 9 23% 1. 3 35. 0 -39. 9 11% 1. 4 6. 1% 3. 5% 8% 1. 9 7. 0% >40. 0 19. 8% *NHANES 2000, women age 50 -69
http: //apps. nccd. cdc. gov/brfss/Trends/trendchart_c. asp? state_c=CA&state=US&qkey=10020&SUBMIT 1=Go YEAR % Obese % No LTPA 1991 10% 23. 3% 1995 14. 4% 22. 7% 1998 16. 8% 25. 5% 1999 19. 6% no data 2000 BRFSS DATA 19. 2% 26. 5% 20 % obese 30 15 25 10 20 5 15 1991 1995 1998 2000 % No LTPA
Lesser Effectiveness of Key Environmental Interventions in Underserved Groups: Example Posting of Signs Promoting Stair Usage n n n (suburban Baltimore mall) Overall, stair use increased from 4. 8% to 6. 9%, 7. 2%, depending upon which of 2 signs used Among whites, increased from 5. 1% to 7. 5%, 7. 8% Among blacks, changed from 4. 1% to 3. 4%, 5. 0% Among n’l wt, inc from 5. 4% to 7. 2%, 6. 9% Among overwt, inc from 3. 8% to 6. 3%, 7. 8% Andersen, Franckowiak, Snyder et al. , Ann Int Med, 1998; 129: 363 -369.
Excess physical environmental risk in underserved communities: Pervasive targeted commercial marketing n Distance to private fitness facilities n Few worksite fitness opportunities n Few/poor neighborhood recreation facilities n Lesser neighborhood safety n Poorer public/less reliable private transportation n Poorly equipped facilities n Poorly maintained sidewalks, e. g. , cracks, litter, overgr. foliage n Fewer traffic calming devices, e. g. , speed bumps n Ample car “accommodation, ” e. g. , parking, high- speed/multilane roads =“Move insecurity” 1, 2 n 1 Jahns & Jones, AJPM 2004; 26: 186 2 Yancey, AJPM 2003; 25(3 Si) Adapted from Kumanyika S. Obesity in Minority Populations. In Fairburn G & Brownell K, Eating Disorders and Obesity. A Comprehensive Handbook, 2002.
Which billboard(s) is (are) about physical activity?
Media Project: five-city outdoor advertising content analysis Funded by CA DHS, UT, Penn & RWJF Cities: LA, Philadelphia, Austin, Sacramento, Fresno Comparing high & low SES predominantly black, Latino, & white neighborhoods (all 6 categories not available in all cities, e. g. , high SES black in Sacramento and Fresno) Utilizing secondary data from CHIS, LACHS, grocery store scanner (MOU with major supermarket chain) purchase data for correlational analyses
Preliminary findings n n Absence of billboards and near-absence of other outdoor advertising in affluent white neighborhoods—existing ads unrel. to weight Essentially no outdoor advertising of PA-promoting goods & services in any community, but large amount sedentary entertainment & transportation ads in low-inc. communities Pervasiveness of advertising in low-inc. white & Latino communities, but more fast food, sugar-sweetened and alcoholic beverages in latter City of LA has moratorium on new billboards, but in low-inc. Latino comm. , large # of new side of building ads similarly framed Findings must be interpreted in light of historical covenants, fewer ads trad. In unincorp. areas
Excess sociocultural environmental risk in underserved communities: Cultural attitudes about work, activity, rest n Fears about safety n Prevalent obesity/norms n Female roles n Cultural reverence for cars n Hairstyle-related concerns about sweating n Increased screen time, e. g. , TV viewing, movie -going n
LA’s ESPN Radio 710 AM Ad “We’re the prime rib on a dial full of tofu” --March 2006
Cultural reverence for SUVs?
AVERAGE ENERGY EXPENDITURE ESTIMATES Hunter-gatherers 5000 cal 10, 000 yrs ago Agriculture 6000 cal 1915 Laborers 3000 cal NOW Office Workers 1800 cal 1 million yrs ago
Physical Activity Levels, % L. A. County Adults, 1999 District Sedentary (<10 min/wk) County 41 +1 Compton 45 +6 South 50 +9 Inglewood 46 +6 Long Beach 37 +5 West 31 +3
Physical Inactivity Levels: TV viewing/computer use, % L. A. County Adults, 1999 Ethnic Group TV/Computer Use >3 hrs/d (95% CI) County total 21. 7 20. 6 -22. 9 African Americans 36. 5% 32. 4 -40. 5 American Indian 34. 2% 16. 1 -52. 3 Asian/Pacific Isl. 21. 1% 17. 6 -24. 6 Latino 15. 8% 14. 3 -17. 3 White 24. 3% 22. 4 -26. 2
Self-Perceived Overweight by Ethnicity & Gender, % LA County Adults AA Overwt AA Nml wt API Overwt API Nml wt Lat Overwt Lat Nml wt W Overwt W Nml wt Female 67 20 86 28 80 26 84 21 Male 29 -46 10 41 9 46 4
Influence of Self-Perceived Weight Status on PA, n n % LA County Adults Overall, regardless of BMI, those perceiving themselves as overweight more sedentary than those with average wt. self-perception (45% vs. 30%) Influence most pronounced for males and normal weight individuals Overwt. self-perception not assoc. with sedentariness among white women, the only one of the 6 ethnicgender groups included in which BMI<25 normative In multivariate analysis, self-perceived overweight, not BMI, predicts sedentary behavior (OR=1. 40, CI 1. 19, 1. 64) Yancey, Simon et al. , Obes (Res) 2006; 14: 980 -8. Yancey, Wold et al. , Am J Prev Med, 2004; 27: 146 -52.
Current Population Status n n Little change in leisure time physical activity (PA) during past several decades of obesity increases (1 in 5), but marked increases in sedentary entertainment, transportation, and other ADLs (Sturm, 2004) PA levels within increasingly sedentary, deconditioned, overweight population are unlikely to increase primarily through individual motivation and volition—relatively little demand for goods & services or political will to push for aggressive legislative policy change, e. g. , radical alteration in the built environment favoring bicycle, pedestrian, and mass transit over private automobile transportation
Daily “Dose” (Rx) of Physical Activity 30 -60 minutes/day on most (at least 5) days of the week n At least moderate intensity (=walking 1 ½ to 2 miles in 30 minutes) n Can be broken up into 10 -minute stretches throughout the day n Every calorie burned is one that doesn’t end up around your waist! n
AFRICAN AMERICAN WOMEN & HEART DISEASE DIABETES PREVENTION PROGRAM n The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin n All patients had impaired fasting blood sugars, but were not diabetic n Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week n They were followed over 2. 8 years
How much is enough?
Population benefit estimates of risk factor change: PA n n 3 -minute bouts of PA 10 times per day lowers serum triglycerides to same extent as 1 continuous 30 -minute bout of PA (Miyashita et al. , 2006) Maintenance of moderate PA is assoc. with a 1/3 to 2/3 lowering of Type 2 diabetes (DM) incidence over 4 -14 yrs (Clark, 1997) Type 2 DM risk was 50% lower among individuals physically active at any level, and 66% lower among those at least moderately active (James et al. , 1998) Sedentary behaviors (e. g. , TV watching) as well as suboptimal >moderate PA levels contributed to DM & obesity risk over 6 yrs in women (Hu et al. , 2003)
Population Obesity Control: Early stage in development Strategically, why focus on PA promotion first? n Less controversy, conflict, stigma than surrounding diet/nutrition n “Deep pocket” business interests, e. g. , Nike & 24 Hour Fitness, stand to benefit from success of efforts (vs. “Big Food” losing $ because can’t as readily induce over-consumption of H 2 O, whole grains, legumes, F+V) n Cheaper & easier— 10 min. supply 1/3 of PA “RDA” n May positively influence food preferences
Population Obesity Control: Early stage in development To avoid exacerbating health risk/disease burden disparities, push strategies (skipstop/slowed hydraulic elevators, restricted proximal parking, non-discretionary time exercise breaks, walking meetings) should be prioritized over pull strategies (building trails & parks, offering gym membership subsidies/discounts) at this early stage of development of environmental and policy approaches—make it easier to do it than not to do it!
Population Obesity Control: Early stage in development (cont. ) n n Synergy will occur when supply (physical environmental access & appeal) meets demand (individual/ sociocultural motivation, prioritization, valuation, skills/interests, political will) Demand must be created—need to structure in “unavoidable” experiences which increase aerobic conditioning, build skills & self-efficacy, foster enjoyment, elevate mood & energy, increase taste for water-bearing foods & less highly-sweetened beverages
Spectrum of Prevention: Health behavior change model n n n Level 1: Strengthening individual knowledge and skills Level 2: Promoting community education Level 3: Educating service providers Level 4: Fostering coalitions and networks Level 5: Changing organizational practice Level 6: Influencing policy and legislation
Spectrum of Prevention: Shift in health promotion field The most effective and sustainable PH intervention approaches of the past two decades are the more “upstream” ones (structural/environmental vs. individuallevel), involving social norm change: n Tobacco control n Alcohol consumption and driving n Breastfeeding n Littering and recycling
Spectrum of Prevention nd level) (2 Level of Prevention Definition of Level Examples of Obesity Prev. Efforts Promoting community education Reaching groups of people with information and resources to promote health Community walkathons / fitness events Media campaigns Neighborhood canvassing for healthy food options Community gardens
ROCK! Richmond n n n Community-level fitness promotion initiative of Richmond City DPH/Medical College of Virginia 3 major components: (1) free fitness instruction in CBOs in underserved areas; (2) environmental changes in conduct of city business (e. g. , low-fat/ high-fiber food choices at city functions); (3) social marketing effort to reinforce norms supporting PA & healthy eating Successful in recruiting disproportionately among population segments at highest risk for chronic disease (older, black, female, family hx of CA, CVD) Yancey, Jordan, Bradford et al. , Health Prom Practice, 2003
Spectrum of Prevention th level) (5 Level of Prevention Definition of Level Examples of Obesity Prev. Efforts Changing organizational practice & policy Adopting regulations and shaping norms to improve health Protocols for MD assessment, sliding fees, counseling & referral Worksite policies (movement breaks, vending, refreshments) School PE content & delivery
Translating Evidence-Based CDC/ACSM Recommendations into Culturally-Targeted Intervention Integrating 10 -’ PA bouts into organizational routine: n Minimal intensity environmental intervention, e. g. , stair prompts n Short bouts accommodate higher proportion sedentary individuals (incremental change) n Variable (max moderate) intensity, low-impact PA accommodates higher proportion overweight/obese and disabled individuals (higher perceived exertion, discomfort, functional limitations) n Passive (“push”) strategy relies less on individual motivation & facility access (early adopters scarce)
Translating Evidence-Based CDC/ACSM Recommendation into Culturally-Targeted Intervention Integrating 10 -’ PA into organizational routine: n Movement to music integral to African-American, Latino culture—dancing normative for adults n Short bouts minimize perspiration, hairstyle disturbance n Social support & conformity desires drive participation (collectivist vs. indiv. orientation) n Addresses less activity conducive outdoor environments (safety, utility, aesthetics) Designed for organizational settings for work, worship, other purposes--less disposable t, $ n
Lift Offs Work!: the Rapidly Growing Evidence Base n n n Documented individual and organizational receptivity to integrating PA on paid work time Contribute meaningfully to daily accumulation of MVPA Motivational “teachable moment” linking sedentariness to health status for inactive folks Improvements in clinical outcomes from as little as one 10 -min. break/day—BP, BMI, waist circ. , mood, attention span, cumulative trauma disorders “Spill-over” or generalization to inc. active leisure Favorable cost-benefit ratio, eg, L. L. Bean mfg plant
LAC Fitness & Wellness Study: design n Randomized, controlled, post-test only, intervention trial testing the effects of incorporation of a 10 -min exercise break into staff meetings & training seminars lasting > 1 hr Outcome measures: (1) participation by sedentary/overweight individuals; (2) mood/affect; (3) satisfaction with health status/fitness level 26 meetings (11 intervention, 15 control) with 449 county employees, mostly women of color
LAC Fitness & Wellness Study: Results (cont. ) More than 90% of meeting attendees participated in the exercises Among relatively sedentary participants: n Intervention participants’ satisfaction with fitness levels more highly correlated with PA stage of change (r=0. 59) than controls (r=0. 38, z=-2. 32, p=0. 02) Among sedentary participants: n Intervention participants’ self-perceived health status ratings were significantly lower than controls (OR=0. 17; 95% CI=0. 05, 0. 60; p=. 0003 n Yancey, Mc. Carthy, Taylor et al. 2004; 38: 848 -856
Fuel Up/Lift Off! LA Video/audio (DVD/CD) excerpt: movement break (Lift Off) demonstration www. ph. ucla. edu/cehd
Propuesta de colaboración Implementación de la pausa para la Salud: ü Evaluar los factores de riesgo cardiovascular previo a la intervención de actividad física. ü Promover de 15 a 20 minutos de actividad física dentro de la jornada laboral, iniciando con 10 minutos hasta alcanzar máximo 20 minutos. ü Promover la orientación alimentaria dentro de la jornada laboral. ü Logros alcanzados en un año 0. 4 kg/m 2 menos de BMI (1 kg) y 1. 6 cm menos de cintura promedio en los trabajadores en un año. Lara A, Yancey A, Tapia-Conyer R et al. , in preparation, 2006
Community Health Council’s (CHC’s) REACH 2010 demonstration project--African Americans Building a Legacy of Health Intervention: Multi-component, centered around modeling the behaviors promoted (“walking the talk”)–(1) incorporation of fitness breaks into meetings, events and other gatherings; (2) provision of wellness training focused on changing the norms of organizations to incorporate PA & healthy food choices into their regular conduct of business (organizational wellness); (3) provision of a personal training experience to key organizational leaders; (4) development of a small grants program for ID/creation/promotion of PA opportunities. Sloane, Diamant, Lewis et al. , J Gen Int Med 2003; 18: 1 -8
CHC’s African Americans Building a Legacy of Health: Process evaluation Measures: Primary dependent measure–level of organizational support for physical activity integration, as reflected in intensity of interventions selected for participation; Results: Nearly half (>100) of the 220 participating organizations demonstrated active support for physical activity integration, with >25% committed at the highest level of support. Yancey, Lewis, Sloane et al. , J Pub Health Mgmt Prac, 2004; 10(2): 118 -123
CHC’s African Americans Building a Legacy of Health: Organizational wellness outcome evaluation Participants: 35 organizations, >700 staff/ members/clients, 1 o overwt. /obese black women Measures: Primary dependent—BMI; Secondary— affect, F+V intake, PA level Results (post-intervention f/u): 12 -week intervention—dec. feelings of sadness/depr. (p=0. 00), inc. F+V (+0. 5 svgs, p=0. 00), marginally dec. BMI (-0. 5 kg/m 2 , p=0. 08) 6 -week intervention (re-tooled)—inc. #days in which participated in vigorous PA (+0. 3 days, p=0. 00) Yancey, Lewis, Guinyard et al. , Health Prom Prac, 2006; 7(3): 233 S-246 S
California Fit WIC Staff Wellness Training AIMS: n To provide skills and tools to influence workplace organizational practices and cultural norms to promote physical activity & healthy eating among staff n To provide skills and tools to influence staff to promote physical activity & healthy eating among WIC clients/families
California Fit WIC Staff Wellness Training sessions included: n Engagement around ubiquitous nature of the problem (“toxic” environment surrounding us) n Skills training in workplace practice change (e. g. , movement breaks, walking meetings, leading co-workers to stairs vs. elev. , healthy refreshments & identifying practical strategies to integrate PA (parking farther away, walking around children’s play area, carrying a basket vs. pushing a grocery cart) n Empowerment thru provision of tools, e. g. , videos, audiotapes, bands, pedometers
WIC Staff Wellness Training
California Fit WIC Staff Wellness Training Significant findings: n Increased perceived workplace support for staff PA (96 vs 58%, p=. 002) and healthy food choices (85 vs 28%, p=. 001) n Change in types of foods served during meetings (72 vs 24%, p=. 002) & PA priority in workplace (96 vs 71%, p<. 02) n Increased self-reported counseling behaviors with WIC parents promoting physical activity (64 vs 35%, p<. 05) & sensitivity in handling weight-related issues (92 vs 58%, p<. 01) Crawford, Gosliner, Strode et al. , Am J Public Health, 2004
Community “Cost-Sharing” 1. Leverage funder and/or regulatory roles (foundation, especially government) to mandate healthy/fit workplace practices, with added resource allocation (e. g. , 5%) 2. Change internal organizational culture (social norms) to create healthy/fit health & social services agency workplaces (“Walking the Talk”)
Community “Cost-Sharing” “Healthy/fit” organizational PA promotion practices include core & elective components, e. g. , 10’ movement (or walking) breaks in meetings/ functions & at certain time(s) of day; walking meetings; stair prompts; leading employee groups to stairs in moving between work activities; restricted near parking; incentives for distant parking; model & reward fidgeting and lifestyle PA integration (e. g. , less high heel & tie wearing, more pedometer wearing, formal recognition/kudos to those who jog or swim during lunchtime)
Community “Cost-Sharing” 3. Encourage local school officials to: a. Train teachers of PE in SPARK-type models emphasizing coop. vs. compet. , engaging all kids b. Move student drop-off location as far away from door as possible, e. g. , behind playing field, to maximize distance youth must walk to attend class c. Incorporate Take 10!, Lift Off! or other exercise breaks into academic curriculum 2 x/day, eg, math d. Incorporate structured exercise breaks into PTA meetings, school board meetings, community dialogues, staff meetings & other gatherings to raise visibilty/priority of PA promotion in addressing childhood obesity
Community “Cost-Sharing” “We must become the change we wish to see in the world. ” --Mahatma Gandhi
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