Content uploaded by Stephen Zwolinsky
Author content
All content in this area was uploaded by Stephen Zwolinsky on Jan 18, 2016
Content may be subject to copyright.
Chapter 2
How can the health system benefit
from increasing participation in sport,
exercise and physical activity?
Stephen Zwolinsky, Jim McKenna and Andy Pringle
Introduction
Three major interacting factors influence human health and longevity; environment,
behaviour and genetics. In efforts to improve population health, and given our limited
control over genetics, one obvious approach to improving health is to direct
resources to the management of environmental and behavioural factors. However,
while huge leaps have been made reducing environmental factors through hygiene,
safety regulations and vaccinations, relatively little has been done to address
behavioural causes (1). This shortfall has typically been based on a failure to grasp
what the evidence-base is now showing about the responsiveness of participants to
well-developed interventions (2).
Recognising the strong epidemiological links between behaviour and health
outcomes, especially those connected to the rising rates of non-communicable
disease, technologically advanced nations like the USA and many European
countries have revised their approaches to Public Health. More specifically, their
interest has shifted toward promoting low-cost, highly effective healthy lifestyle
behaviours. In this process, critical thinking continues to be revised about how best
to achieve (i) sport engagement (beyond spectatorship), (ii) involvement in exercise
and/or (iii) being more physically active in daily life lifestyles; these issues play out
individually, population-wide and globally. This shift has been so profound that
accumulating these behaviours is now a core priority for every health system with
aspirations of success and sustainability. However, many influential figures within
these systems have yet to recognise the distinctive nature of these behaviours. They
fail to resist the temptation to conflate the behaviours and continue to assume that
interest in one equates to interest in the others. Getting this right offers the best
basis for delivering the considerable potential of each approach; all are underpinned
by a concern to support more people to generate extra energy expenditure.
According to Fineberg (3), and linked to this evolution, a successful and sustainable
health system must be able and willing to adapt to these new demands. For
example, the term ‘health system’ is preferable to ‘health care system’ as the
solutions need to focus on the ultimate outcomes of interest. These outcomes should
address population-wide issues as well as improving individual health, instead of
supporting a formal system of care designed primarily to deal with illness. For
Fineberg, a successful twenty first century health system will have three main
attributes (i) healthy people attaining the highest level of health possible; (ii) superior
care that is effective, timely, patient centred, equitable and efficient and (iii) fairness,
meaning that treatment is applied without discrimination to all individuals and families
regardless of age, gender, ethnicity or identity. For sustainability, contemporary and
future-proof health systems will have to be affordable, adaptable and acceptable to
key constituents. This clearly links to community-based provision of sport-based
behaviours and points to the promotion of sport and its near-neighbours – exercise
and physical activity – as being central to the new approach.
However, the reality is that no single change will make any ailing health system
successful and sustainable. Success will not be achieved by solely aiding
prevention, only championing competition, relying on identifying comparative
effectiveness, establishing commercial influence, only paying family doctors more to
promote this lifestyle or ‘simply’ by reengineering the medical system. It may require
all these changes and more. Central to this understanding is that it will be unwise to
assume that competitive sport can be the mainstay of any Public Health strategy, not
least because so few people can sustain this level of behavioural – or indeed,
exertional - intensity. Furthermore, the negative experiences that it can produce for
participants – perhaps through conflation with school based experiences - can be so
detrimental that it undermines any subsequent interest in living actively, making it
more than counter-productive. The promotion of ‘sport’ will need to be handled with
some delicacy and refinement to deliver on its promise.
To help facilitate the changes that better Public Health will need, it is important to
establish innovative policies and practices. Since a core notion for better Public
Health is that more is done to help the least healthy, it is crucial to move beyond the
assumption that increased activity can only be achieved by promoting sport or by
encouraging activities based on conventional notions about sport. This is important
because sport comes with many subjective understandings, but – and this shocks
many sport advocates – in many of the long-term inactive, previous experiences of
sport are so aversive that they cause outright rejection of even the idea of ever
becoming involved. Central to these aversive experiences are those relating to
competition and to handling high level exertion; when competition entails social
judgements of competence and social standing, for many inactive individuals this is a
powerful reason not to engage.
While policy directed at promoting more active communities is well intentioned, and
based on the latest and strongest research, under recruitment of previously inactive
individuals remains a central problem. This situation continues to point to a
substantial shortfall in how to translate policy into practices that produce the greatest
positive effect (4, 5). Central to this shortcoming, we suggest, is an over-reliance on
identifying sport as the parent discipline of a triumvirate that also features exercise
and physical activity (see Figure 1). Instead, and alongside the good work that
conventional programmes of sport does for those who are attracted to competition
and exertion and so on, we suggest that different programmes are needed that will
attract inactive audiences. These programmes are more likely to feature exercise
and/or physical activity, while sport programmes should be expected to continue
attracting their target audiences and to do better at reaching into those target
audiences.
We further suggest that the easy assumptions which underpin a general promotion
of ‘sport’ also underpin ill-founded notions about how easy it is for inactive people to
change their behaviour. The existing literature is replete with evidence confirming
that behaviour change is demanding and that – in relations to total body movement –
individuals are highly sensitive to differences in mode, frequency and intensity of that
activity. If this literature is correct, these lazy assumptions need to be challenged to
arrest the dramatic increase on health systems that are attributable to inactivity.
The scale of harm that results from not offering accessible and attractive
programmes is due to the negative health effect of inactivity on most bodily systems.
These are equivalent to, and in some instances even outweigh, the effect of other
lifestyle behaviours. The comparative case of anti-smoking is illustrative of key
issues. For example, even though the risk of inactivity is thought to be comparable to
smoking one packet of cigarettes a day (6), only 21% of the population smoke,
whereas it is common in many countries for less than 40% of adults to meet current
physical activity targets (7, 8). For this reason, among others, it is alarming that
sport, exercise and/or physical activity is so underutilized as a prevention strategy
(9), let alone as a treatment.
There is also timeliness about promoting more lifestyle-based interventions. The
prevalence of inactivity-related conditions and their impact on Public Health services
is such that many contemporary health systems are unlikely to survive in their
current forms. As Fineberg (3) has pointed out, many systems now require
wholesale and urgent change to meet the needs imposed upon them. However, to
do this they will have to overcome a range of formidable challenges and these must
not be overlooked, since they are potent individually and worse when combined.
One challenge links to the financial constraints resulting from funding cuts. This
highlights the urgency of supporting prevention efforts, which will reduce the
incidence of disease and improve lifestyles. Health system managers may also face
opposition in their attempts to improve staff productivity while enforcing pay freezes
or worsening working conditions, which, ironically, may make physical inactivity more
likely for staff charged with promoting activity. Further, the staff who service medical
systems are well known for sacrificing their personal needs for those of their
patients, which only undermines the case for active living. Another challenge links to
managerial capacity for enacting these changes, based on current experience and
training. Finally, there is concern that reorganisation will impede attempts to achieve
greater integration of service (10). Ultimately, diminishing resources will necessitate
more so-called ‘joined-up’ thinking from public sector organisations to enact the most
cost-effective solutions.
The health system in the UK has recently undergone a facelift in an attempt to
combat such problems. The recent worldwide economic crisis meant that the
National Health Service (NHS) was required to increase annual productivity by 4%
(11). This convinced the government to introduce two fundamental changes. Firstly,
local commissioning groups became responsible for purchasing hospital and
community services. Secondly, increased competition was introduced with the aim of
increasing productivity among providers of hospital and community services through
the greater use of non-NHS provider (10). This change is likely to allow greater
support for socially-based understandings of ‘health’, which will include prioritising
building friendship networks and improving quality of life as much as altering blood
lipid profiles or reducing levels of body fat. This clearly plays into the hands of
existing sporting provision.
This chapter aims to show that inactive communities which increase participation in
sport, exercise and physical activity will benefit health and fitness. By implication,
these changes in biological status can have far reaching implications for
contemporary health systems. To establish an appropriate representation of the pros
and cons associated with this approach, the discussion also will explore the benefits
and potential risks of increased participation. Finally, we explore examples of good
practice, including the deployment of a particular evaluation framework, as they
apply to using sport, exercise and physical activity to improve Public Health.
1. Defining Physical activity, sport and exercise
Encouraging and enabling participation in sport, exercise and physical activity
requires coherent articulation of the exact nature of each discipline to generate
engagement. Clear delineation between these constructs already exists; therefore
clarity concerning characterization is essential to promote uptake, especially among
inactive individuals.
Physical activity is an umbrella term, of which sport and exercise are two significant
and meaningful forms (figure 1). We propose that physical activity encapsulates the
full range of major movements undertaken by any individual, including those not
subject to structure or form. According to Bouchard and Shephard (12), physical
activity represents any bodily movement produced by skeletal muscle resulting in
energy expenditure above a resting level. Clearly, this definition encompasses a
wide range of ambulation and movement not related to sport or formal exercise. At
the same time, it integrates the pleasure and the health benefits that might accrue
from being active through gardening, walking or doing housework. It also includes
activity which is incidental to pursuing some other purpose, such as walking to and
from work or gardening to grow vegetables for the table. Importantly, the appeal of
incidental physical activity should not be confused with upholding any interest in
either sport or exercise, or indeed, of even being convertible into such an interest.
It is also important to have a clear understanding of what sport is and how it is
defined, so that its overall appeal in a population can be identified. McKenna &
Riddoch (13) suggest that sport (a subset of physical activity) comprises structured
competitive situations governed by rules. However, it is essential to remember that
some activities, considered by their participants and administrators as sports, do not
always sit comfortably within this conceptualisation. One of the most contentious
issues that impedes the promotion of sport as a health-promoting behaviour is the
role that intense competition may play; as compelling as it is for those who enjoy
winning and losing, it is equally repulsive to the many others who have much to gain
from increasing their activity levels.
While exercise can occur as a consequence of participating in sports, it can also be
practised outside a sporting environment for its own sake. This differentiates sport
from exercise. Exercise is usually seen to be volitional, planned, structured, and
repetitive with particular fitness-related objectives in mind. It has been describe as ‘A
form of leisure time physical activity with a specific external objective, such as the
improvement of fitness, physical performance or health (in which the participant is
advised to a recommended mode, intensity, frequency or duration of such activity)’
(12).
When assessing physical activity, sport, and exercise it is useful for practitioners to
be aware of the five basic dimensions – typically drawn from studies centred in the
training paradigm - of all physical activities and how they relate to fitness outcomes
and to health-related benefits:
I. Frequency – How often an individual takes part, usually stated as the
number of sessions per week.
II. Intensity – How hard an individual is working, typically categorised as light,
moderate or vigorous, referring to rates of energy expenditure (kcal/min-1),
metabolic rate (METs), oxygen consumption (ml/kg-1. min-1) or heart rate
(beats/min-1).
III. Time/Duration – Time spent on a single bout of activity.
IV. Type/Mode – A qualitative descriptor such as walking, jogging or running.
V. Volume – Total quantity of physical activity expressed over a specified
period. Usually as kcal/day or week. It can also be expressed as MET
hours/day or week.
2. Defining Health and Fitness
Beyond distinguishing the different modes of achieving additional energy
expenditure, there are two further relevant and important terms. Worldwide,
individuals involved with the task of improving health and fitness will hold distinctive
and diffuse understandings of these terms. This highlights the need for clarity and
transparency among providers. Despite having independent definitions, the terms
‘health’ and ‘fitness’ are often used interchangeably, which can impede the adoption
behaviours of inactive individuals. However, some standard definitions have endured
the test of time, and they highlight what additional energy expenditure might
contribute to the health of many individuals within society.
Conceptually, health ranges from the narrow technical to all-embracing moral or
philosophical standpoint (14). In everyday use, health is seen as having positive and
negative components. From a negative standpoint, health is simply the absence of
disease. Through a positive lens, health represents a state of well-being; complete
and optimal physical, mental, social and spiritual functioning. It has been interpreted
by Bouchard and colleagues (15) as a:
human condition with physical, social and psychological dimensions, each
characterized on a continuum with positive and negative poles; positive health is
associated with a capacity to enjoy life and withstand challenges, it is not merely the
absence of disease; negative health is associated with morbidity and, in the extreme,
with mortality.
Figure 1: Adapted from the Department of Health, 2011.
Physical Activity:
Expenditure of calories,
raised heart rate
Everyday Activity:
Active travel (walking/cycling)
Heavy housework
Gardening
DIY
Occupational activity
(active/manual work)
Exercise:
(Active Recreation)
Recreational hiking
Recreational cycling
Recreational jogging
Active play
Dance
Sport:
Swimming, tennis, football,
running etc.
Exercise and fitness training
Regular cycling (≥30 minutes
per week)
Formal/informal sport
Competitive physical activity
Therefore, health can be considered to be an all-embracing concept; it has objective,
subjective and individualised elements, meaning that it cannot be solely measured
by objective physical criteria.
In contrast, fitness represents the physical expression of an important element of
health. For physiologists – and doubtless many sports coaches – fitness deals
specifically with the capacity to perform certain tasks. Also referred to as ‘exercise
capacity’ (16), fitness is conventionally thought of in terms of an individual’s capacity
to achieve a physical goal. Increased exercise capacity leads to enhanced health
status in men and women including improved lipoprotein profiles, carbohydrate
metabolism, lower blood pressure and weight loss (17). Further, the literature
highlights the positive effects of aerobic activity on cognitive functioning across the
life cycle (18). This offers another, perhaps overlooked, reason for promoting
involvement with physically demanding activities. This may explain why so many lay
definitions integrate the notion of mental fitness into their understanding.
Fitness can be achieved through most forms of sport, exercise and physical activity.
For example, an older person taking up jogging may experience gains in flexibility
and aerobic capacity, e.g. they may be able to stay on a treadmill longer as the
workload (speed or incline) increases. Subsequently, they may be able to undertake
daily tasks with increased ease and vigour, while also avoiding the negative
consequences of sedentary pastimes. Recent research indicates that an increased
aerobic capacity can improve cognitive functioning across the life course, adding
further reason for promoting involvement in moderate intensity physical activity
wherever possible (19). There are also indications that in children, fitness is linearly
associated with academic achievement and performance (20, 21).
‘Fitness’ is clearly a relative term, and can become ambiguous in lay contexts. Use
of the word is shaped by individual needs and desires, and also dependent upon
political, economic, social and cultural contexts. Employees may think of themselves
a ‘fit’ if they are simply able to complete their tasks at work. In contrast, an
international middle distance runner with a slight injury may be considered ‘unfit;’
when they cannot compete at the national championships. To complete our
hypothetical loop, the doctors of a middle-aged obese individual with diagnosed
cardiovascular disease who has recently been discharged from hospital, may be
described as ‘fit’ to return to work. The runner is significantly fitter in general terms,
but, weighed against his individual needs, has been declared unfit. This distinction
sustains two further, though related, concepts; health-related fitness and
performance-related fitness.
In summary, health is an all-embracing indicator or expression of a person’s state of
being, whereas fitness is one aspect of this which deals with capacity to perform
tasks. Neither is solely confined to physical condition, and a crucial contemporary
issue is to understand the relative importance of physical activity behaviour over any
risks that it might produce (22, 23).
3. Exercise is Medicine
From the earliest recordings of human history participation in sport, exercise and
physical activity has been associated with improvements in health and fitness. This
relationship has been further defined by years of scientific research showing a clear
causal connection between activity and health status (1). Equally important, research
continues to show that important indices of Public Health are responsive to
interventions that successful support additional energy expenditure in community
settings (24). This has lead experts to concur that ‘exercise is medicine’.
One of the earliest studies driving this concept forward involved 31 000 male
employees of the London Transport executive. This study compared the
occupational physical activity of bus drivers and bus conductors (25). The results
identified that the more active bus conductors displayed a reduced relative risk when
compared to their more sedentary, driver, counterparts. A further groundbreaking
study, the Harvard Alumni Study, estimated energy expenditure from self-reported
participation in sport, walking and stair climbing (26). After adjusting the results for
age, smoking and hypertension researchers identified a clear dose-response
relationship between increased physical activity and reductions in death due to
coronary heart disease. These studies, and others like them, gave us the first
empirical insights into the benefits of an active lifestyle, whether based on sports,
leisure time activities or occupational energy expenditure.
Over the past half century data have been accumulating that being unfit or physically
inactive - resulting from a lack of exercise and/or sports participation - has major
negative health consequences throughout the lifespan (27). Being physically active,
however this is achieved, is thought to be the best buy for public health and has
numerous well established benefits (28). These benefits include prevention and
reduction of the risk of all-cause mortality, cardiovascular disease, coronary heart
disease, stroke, type-2 diabetes, obesity, osteoporosis, psychological well-being and
mental health and some cancers (7). While it is not possible to detail all of these
benefits here, we will address the benefits for cardiorespiratory fitness.
We begin by outlining the logic for promoting sports that build cardiorespiratory
fitness. Cardiorespiratory fitness is a key component of many effort-based sports,
including team sports like football, hockey and basketball and of individual activities
like tennis, rowing and cross country running. Therefore, increasing participation
rates in these sports will improve participants’ fitness levels. This, in turn, will
profoundly impact on mortality and morbidity rates for those individuals, communities
and populations who are most at risk. Yet, the evidence is compelling beyond its
face value; it is also vast, robust and consistent (9, 29), as are the relationships
between physical inactivity and various health complications (17).
Putting this into a Public Health context, low cardiorespiratory fitness, as an
attributable fraction (i.e. the proportion of all health problems or deaths that can be
attributed to the risk factor) for all-cause mortality accounts for more deaths in men
and women than smoking, diabetes and obesity combined (27). Notwithstanding that
the death rates associated with physical inactivity are consistent in different
populations (30, 31), the association between cardiorespiratory fitness or physical
activity and disease hold, even after statistical adjustment for blood pressure, weight
loss, lipoprotein profiles, carbohydrate metabolism and other cofounding variables
(17). Given this independent effect, data suggests there is something inherently
beneficial, although unexplained, to the value of exercise for health (9).
The growing arguments around ‘how much for what benefit’ continues to be refined.
This information is probably most relevant for regular, committed exercisers,
especially runners. The old maxim that ‘What doesn't kill you only makes you
stronger’, is often used, whereas the reality is that mortality benefits are best
accumulated by running over shorter distances, specifically <20 miles per week (32).
This research suggests that higher mileage, faster paces, and more frequent running
are not associated with better survival. Data indicates a U-shape relationship
between all-cause mortality and running, with longer weekly distances trending back
toward reduced mortality benefit. These data confirm the value of exercise
prescription based on notions associated with training, while its complexity may
explain why so few health practitioners willingly engage with activity promotion at a
level beyond ‘Do some’. This, along with their access to communities underserved
by conventional activity promoting services, makes them especially well placed to
promoting physical activity, and possibly exercising, leaving the promotion of specific
doses of exercise to specialists.
However, the logic of altering physiological function to improve health can also be
applied to domains beyond sport. Other work has confirmed the cardiovascular
protection afforded by occupational activity (25, 26) and of a ‘lifestyle’ approach to
being active (7). Given the rise of sedentary occupations there is a growing need for
sport, exercise and physical activity that is structured and performed for a specific
reason. While there is evidence that higher intensity exercise will optimise fitness
and health gains (33-35), this intensity is harder to sustain both within an exercise
bout and through longer-term involvement. Thus, it is appealing to fewer people and
possibly, most attractive to those who self-select to this intensity. While these
individuals may enjoy better health than less active individuals, public policy is rarely
based on these groups. Worse, understanding about inactive people suggests that
when expectations exaggerate the exertion required for even a modestly successful
engagement, they can to deter even a try-out let alone sustained engagement.
Instead, in many countries, including the UK and USA, regular moderate intensity
activity is promoted. The thinking is that more people can sustain this level of
involvement, meaning that this will have a stronger Public Health impact. All things
considered, it is important to acknowledge that even though high intensity training
may offer optimal cardio-protection in some instances; this is difficult for most
inactive adults to sustain. Indeed, there is considerable evidence that the biological
markers of high exertion are such that they can be interpreted negatively (32). This
experience can result in increased attrition from sport, exercise or physical activity
interventions, making it almost entirely counterproductive at a population level. The
intensity and prescription has to be matched to the needs and abilities of the
individual.
These issues are important when the idea of becoming more active is discussed.
They are, potentially, even more sensitive when broached in the context of being
unwell or experiencing a disease. In countries like the UK and the USA, General
Practitioners and Physicians are often in the front line of the exercise prescription
process for individuals in this situation. However, recent research from the USA (36)
showed that physicians advised just over one third of patients to begin or continue to
do exercise or become more physically active. Even though these figures represent
a 10% increase since 2000, and notwithstanding that some patients will be
unsuitable for an exercise prescription, most patients who can benefit from increased
physical activity are still not being encouraged to undertake it.
Even though the reasons are unclear – and solutions even less obvious - this
process is also differentiated, with groups being more or less likely to be encouraged
to undertake activity. For example, at every measurement point (36); women were
more likely than men to have been advised to become more active. The percentage
of adults advised to exercise increased with age up to 64 years, and then declined.
Adults aged 18-24 had the smallest increase in rates of being advised to become
more active, and since 2000 remained the age group receiving the least
encouragement. Further, and potentially because of its ubiquity and of the particular
value of physical activity in remediating its effects, adults with diabetes were more
likely than individuals with cardiovascular disease, hypertension and cancer to have
been advised to exercise. Lastly, obese adults were almost twice as likely as
individuals of a healthy weight to have been advised to undertake exercise or
physical activity.
Collectively, this suggests that medical practitioners appreciate that exercise really is
medicine, and while the practice of promoting physical activity is on the increase, it
remains a reactive – and not a universal - approach. It also hints at a lack of
appreciation of the value of preventive intervention based around physical activity,
exercise and/or sport. These figures also confirm that considerable ground has to be
made up to ensure that physical activity is prescribed to all who have the capacity to
engage. Here the challenge is to acknowledge the determinants inherent to the
‘tough sell’ of what advocates clearly see as a ‘best buy’ (37). In the context of most
health systems being able to fund fewer doctors and nurses, the capacity of this
system for achieving widespread adoption of sport, exercise and/or physical activity
must be questioned.
4. Risks of Sport and physical activity
An old epidemiological adage suggests ‘Ain’t no effects without side effects’; this
applies to every Public Health initiative that encourages participation in sport and
moderate intensity exercise and/or physical activity. This is linked to the overall aim
of optimising well-being while managing the risks that emerge while pursuing
progress – typically achieved by manipulating exercise intensity (3). Therefore, it is
important to remember that just as the health benefits accrue from increased
participation, so too do the associated risks.
While the risks of participation in low-to-moderate intensity activities are relatively
small (38), more vigorous past times - including sports participation – bring elevated
risk profiles, regardless of an individual’s athletic ability (9). Sports injuries can be
severe and cause significant discomfort, disability, and reduced short-term
productivity. They can also be responsible for substantial medical expense, whether
or not this is acknowledged by event organisers or by participants. The working rule
seems to be that the more demanding and vigorous the activity, the more demand is
placed on the body, which increases the risk of injury. Unsurprisingly, activities
involving physical contact with others are associated with higher than normal rates of
contact-related injuries, while repetitive activities bring higher rates of injury linked to
repetition.
From the F.I.T.T. acronym (see section 1) that underpins exercise prescription;
intensity represents the major injury risk factor emerging from involvement in sport
and exercise. While more vigorous forms of exercise and sport are characterised by
increased risk of sudden cardiac arrest, this remains a relatively rare feature (38),
even allowing for the media attention that it can sometimes secure. It is also
especially rare in young athletes, but where it does occur seems to be linked to
previously undiagnosed hereditary congenital cardiovascular disease. While pre-
screening remains contentious, there is some evidence of its capacity to prevent
harm (39, 40). Given these potential complications, gauging the depth of such
problems is a requirement for any individuals promoting sport and physical activity.
With distinctive demands, each activity and sport has its own injuries and injury
mechanisms; therefore, it is beyond our scope to discuss specific sports in full detail.
However we will discuss general issues affecting musculoskeletal injury and sudden
cardiac death.
The risk of musculoskeletal injuries increases with intensity and with the volume of
the activity. It is important that engagement is managed to allow for sufficient
recovery between training sessions. Even starting a walk-jog programme will
requires days of rest between sessions to ensure adequate recovery, especially
among people with long histories of inactivity. For people engaged with competitive
sport, it is also important that practice sessions – which tend to be more directly
linked to competitive elements of performance – are also regulated carefully. At the
start of any new programme it is important to understand the motivational
significance of undertaking a session without having recovered from a previous
session. The well-known phenomena of delayed onset of muscular stiffness
(DOMS), which emerges within 24 hours of exercising and that can last up 5 days
post-exercise, can profoundly affect enjoyment and/or satisfaction (41). This, in turn
will affect the likelihood of subsequent engagement, depending on how each
individual places meaning on these symptoms. Staff who grasp the close
interconnection between bodily symptoms and motivation are differently suited to
promoting physical activity to newcomers compared to those whose only appreciate
the sequence and timing of biological adaptation.
Research suggests that physically active adults tend to experience a higher
incidence of leisure-time and sport-related injuries than their less active counterparts
(42). Jogging is perhaps the most frequently endorsed way of becoming more
engaged with exercise and even this mild form of exercise carries risk. Injury
incidence per exposure (which covers the full range of experience) varies from 7 to
59 per 1000 hours of running (43-45). However, in the only study assessing novices’
preparation to complete a 4-mile (6-7 km) event (46), 21% of the 532 (306 women)
runners had at least one running-related injury. Among these novices the incidence
of running-related injury per 1000 hours of exposure was 33 (95% CI, 27-40), and
the number of injured participants was 20.6 per 100 runners. Given this markedly
high incidence of injury in novice runners, the potential for effective preparation prior
to engagement, including muscle strengthening and preventative interventions, is
high.
Interestingly, adults who meet the current physical activity recommendations by
performing moderate intensity activity have an overall musculoskeletal injury rate
comparable to inactive adults (47). This message is important to underline the
attention paid by Public Health advocates to this message. While the injury rate
reported among active men and women during sport and leisure time physical
activity is higher compared to their rates while not undertaking these activities,
inactive adults report more injuries during the extensive time they spend in non-sport
and non-leisure time activities. For exercisers, this lower injury incidence during non-
leisure time may be attributed to their increased fitness levels – including increased
endurance, strength and balance (48). Given that injury – even just the fear of injury
- is one of the primary reasons for not engaging in activity and sport, this research
suggests that leading a physically active lifestyle is no more likely to result in
musculoskeletal injury than living a sedentary lifestyle. Moreover, if undertaken
appropriately, leading an active lifestyle active can generate a range of physiological,
psychological and psychosocial benefits (7) that will not be attained by sedentary
individuals.
As with musculoskeletal injuries, the risk of sudden cardiac arrest (or myocardial
infarction) is low in asymptomatic – or undiagnosed - adults during moderate-
intensity activities (49). However, and this must be recognised, vigorous exercise
carries a transient increase in sudden cardiac death (50), and the greatest risk is
found in people who do not habitually perform vigorous exercise (46, 51). This risk is
especially elevated when these habitually sedentary individuals also have latent or
documented coronary artery disease (52). For example, a 50 year old man with risk
of sudden cardiac arrest who performs vigorous exercise or sport, will increase his
risk 100 times during the activity, further, this risk remains elevated for an hour post
exercise (6). This contrasts to the situation of the individual who regularly performs
vigorous exercise such as running for one or more hours per week. In this case, the
individual would have a 42% lower baseline risk of having the event, and a lower risk
for exercise associated cardiac arrest. Further the relative risk of myocardial
infarction during vigorous exercise compared with that at all other times of the day,
is 56 times greater among men who exercise infrequently and only 5 times greater
among men who exercise frequently (53).
Although absolute numbers of sudden cardiac deaths during exercise are low,
screening – provided by simple instruments like the Preparation and Readiness for
Exercise Questionnaire (PAR-Q) (54) - will provide important information about the
possible risk. Measures to prevent harm should not stand alone; they are most
effective when integrated into a sequence of prevention. Importantly, and
notwithstanding the value of subjective estimates of risk (e.g., ‘that surface looks a
bit bumpy, so if we run on it, we might risk some ankles being turned’) it is important
that provision and practice is developed and refined using more systematic
approaches. For effective injury prevention, risks must be identified and described –
epidemiologically - in terms of incidence and severity, and the factors and
mechanisms that play a part in the occurrence of injuries have to be identified.
Practitioners should look to introduce measures to that are likely to reduce the risk or
severity of injuries. Finally, the effect of the measures must be evaluated by
repeating the first step which will lead to a time trend analysis of injury patterns.
Ultimately, the evidence that the benefits of participation in sport, exercise and
physical activity outweigh the risks is unequivocal (38). Yet, knowing the risks
associated with them is important to help minimise the risk, in order to maximise the
benefits.
5. How to use sport to get more people active and lower health risk
The London 2012 Olympic and Paralympic games captivated the UK and a global
audience. No doubt it will have inspired some individuals, determined to emulate
their heroes, to get into sport. It is highly likely that this involvement positively
influenced their health. However, whilst global sporting events like this can cause a
significant short-term surge in sports participation levels, maintaining long-term
enthusiasm and engagement is more problematic (55). Fundamentally, without the
necessary infrastructure and encouragement, any claims about ‘legacy’ relating to
the Public Health benefits of such sporting spectaculars have questionable veracity.
To contribute to better Public Health, and to deliver on claims that sport is part of
generating a healthier community, the challenge is to deliver a long-term step
change in the number of people who regularly engage in sport. With the relatively
limited appeal of sport across the community, it makes sense that attention also falls
to the different constituencies who are more attracted to exercise and to physical
activity.
Since 2006, in the UK there has been a 1.4 million increase in people playing sport
at least once a week; the total of people engaged is now 15.3 million. With a
population in excess of 60 million, the relative appeal begins to become clear.
However, this figure looks even less impressive when the number of people engaged
three or more times per week is identified - 7.3 million. This confirms that most
adults, 53.2%, still play no sport at all, while relatively few are firmly committed (56).
Levels of physical activity are equally concerning; only four in 10 men and three in 10
women in the UK meet recommended physical activity guidelines by participating in
150+ minutes of weekly moderate intensity physical activity (5). This figure reduces
further when adults 65+ years are considered (7). With similar profiles reflected
worldwide (57), it is unsurprising that physical inactivity is a major public health
problem of the twenty-first century (58).
One way to improve these figures and use sport to get people more active would be
to target children. Sport England (55) recently outlined how they plan to create a
sporting habit for life through a youth sports strategy. Unhappily, even though this
strategy shows little appreciation of how habits are formed, the approach proposes
to raise the proportion of 14-25 year olds who regularly play sport. Notwithstanding
that this is the age group – who start out as being among the most engaged in sport
- become the group who withdraw from formal sport in greatest numbers, this will be
underpinned by five principles. First is to build a lasting legacy of competitive sports
in schools. Second, links between schools and community sports clubs will be
improved. Third, the governing bodies of sport with focus on youth groups. Fourth,
investment will be made into facilities. Finally, more attention will be paid to utilising
communities and the voluntary sector. Achieving these principles could help increase
participation rates and reduced the burden on global health systems.
Beyond sport, around the world different societies regard physical activity as a key
priority of many health agencies. Emerging evidence has highlighted that initiatives
to promote physical activity are more effective when health agencies form
partnerships and coordinate efforts with other organisations, including schools,
businesses, policy, advocacy, nutrition, recreation, planning, and transport agencies
and health systems (59). Other effective public communication and informational
approaches for promoting physical activity include community-wide campaigns,
mass media campaigns, and decision prompts (24). Initiatives to increase social
support for physical activity within communities, specific neighbourhoods, and
worksites can also effectively promote physical activity (60).
Comprehensive school-based strategies encompassing physical education,
classroom activities, after-school sports, and active transport also have the potential
to increase physical activity in young people (61). Environmental and policy
approaches can create or enhance access to places for physical activity with
outreach activities. Equally, infrastructural initiatives through urban design of land
use and planning at community and street scales and active transport policy and
practices are effective (24). To properly support initiatives for the promotion of
physical activity, workforces need to be trained in physical activity and health, core
public health disciplines and methods of inter-sector collaboration (62). Although
individuals need to be informed and motivated to adopt physical activity, the public
health priority should be to ensure that environments are safe and supportive of
health and wellbeing (59).
In efforts to advance active lifestyles and population physical activity, growing
attention has focused on the value of mass participation events (63). Typically, and
notwithstanding their portrayal as sporting events, these events promote
engagement with exercise. However, for some participants the event can cross into
becoming sport, when they attempt to win and/or to improve their performance.
While this can be powerfully motivating for these individuals, the downside – for
organisers at least - is that less active participants gauge the behaviour of these
individuals to understand what the events are really all about. Once this is
established, the less active participants can see how well they might fit in – or not.
Our experience is that the more competitive the event, the less likely it is for first-
timers and less active participants - who typically have low confidence about their
engagement and with their physical identity - to engage in subsequent events.
Crucially, and notwithstanding the symbolic value of mass events, better Public
Health through physical activity, exercise and/or sport requires sustained
involvement. Event and programme organisers who aspire to making a contribution
to Public Health - and who may claim public funding using this logic – would do well
to keep this uppermost in their planning. One of the most difficult tasks that event
promoters face is to ensure that exercise events are not hijacked by sport zealots to
use the events to demonstrate physical superiority over others, as many inactive
people assume.
On the other hand, when these events are experienced as being inclusive they can
encourage participation of groups left unreached by conventional approaches and
who demonstrate less than optimal levels of physical activity. These groups include
adult women and the elderly (64); we increasingly see that this is also needed for
adult men too. However, for inactive people, even the suggestion that these events
are sporting may undermine engagement precisely because they associate it with
previous experiences of sport. Typically, these can be unpleasant and aversive.
Sports advocates have much to do to appreciate that for many inactive people,
previous experiences of sport were aversive. Among the most aversive of these
effects – as related to adult engagement with physical activity and/or exercise -
includes associations with unfavourable comparisons with others, emphasises
beating others, and high intensity of effort (which is especially problematic for
subsequent engagement in untrained individuals, (37). Unhappily, and pointing to a
direction for further work, negative experiences of school Physical Education - and
its conflation with school sport – often feature strongly in the accounts of people who
remain stubbornly inactive as adults.
‘Parkrun’ offers one such mass participation event with considerable Public Health
potential for those who can engage with the idea of exercising. In this programme,
now being adopted around the world - but originating in the UK - a network of free
weekly, timed, 5k runs are supported and enacted in public parks. Findings suggest
that not only is ‘Parkrun’ attractive to non-runners, with women, older adults and
overweight individuals well represented, but also that it may also increase physical
activity and wellbeing among community members (65). Participants also indicate
that participation – and the exercise that underpins engagement with the Parkrun
programme – brings important psychological and social benefits, especially among
the sizable proportion of non-runners that Parkrun helps to support into regular
moderate-to-vigorous intensity exercise. It is also important to consider the full
panoply of benefits that involvement in such group-based exercise might generate.
At first glance these may seem unconnected to Public Health, yet so often they
influence a trajectory that ends up complementing the Public health agenda. For
example, outcome evidence suggests a graded and progressive Public Health
benefit linked to the regularity of engagement; much of the enhanced social and
mental functioning will be linked to style of Park Run events, while better physical
functioning will link to both the Park Run’s themselves and to the preparation runs
that underpin that involvement.
However, it is important to recognise that mass participation events need to be
packaged in the right way to encourage regular engagement. When these events
become conflated as sport, physical activity and exercise events, this is often
counterproductive and increases attrition across the constituencies. Further, to
enhance Public Health gain, these events must go beyond supplementing the activity
of the already-active (although this is laudable in its own right), or offer a
replacement for another less attractive option. The best return on the Public Health
pound/dollar is to encourage participation with those individuals who need it most,
which is the least active 20% of the adult population (17). Any programme that
achieves optimum provision for sport, exercise and physical activity will be held in
high regard.
6. Using the RE-AIM Framework: Evaluating what works – and doesn’t -
in relation to achieving participation and health benefits
Remembering the fundamental differences between physical activity, exercise and
sport will be crucial to increasing participation levels at individual, population and a
global level. Furthermore, increased intensity or poorly matched interventions often
lead to increased drop out. It is, therefore, important to utilise evaluation frameworks
that allow practitioners to identify the key components to match participants to
programmes, and at the right intensity.
Contemporary guidance recommends that interventions, including those concerning
sport, exercise and physical activity, should be effectively evaluated, and where
possible strategies should include an economic component (66). Understanding that
evaluating interventions can prove challenging (67), a number of helpful frameworks
exist to help shape the design of evaluations. One such example is RE-AIM,
conceived by Glasgow and colleagues to evaluate health promotion activities. RE-
AIM not only provides a comprehensive framework to assess the effects of
interventions at different levels of the behaviour change continuum (Reach, Adoption
& Maintenance) (68), but also the process (Implementation) (69) which influence the
impact (Effectiveness/Efficacy) of the interventions and how this is obtained.
RE-AIM was originally used for reporting the results of research into health
promotion activities (70), and was later used for reviews of the literature on health
promotion and disease management activities in different settings (71). Following
concerns to translate research into practice, RE-AIM has been used to plan,
implement and evaluate interventions in a logical manner (72). With that in mind, RE-
AIM has been used in the evaluation of sport and physical activity interventions with
a range of groups, including children (73, 74). It has also been used with adults (68,
75) and those with chronic health problems (76). With the location for health
improvement in mind, RE-AIM has also been used to evaluate interventions in a
range of settings including, primary-care (77), workplace (78) and the community
(79).
Given the need to assess both impact and process outcomes, RE-AIM has excellent
synergies for evaluating community health interventions. Recently it has been used
to guide assessments on the effectiveness of football-based health improvement
interventions (80). 'Premier League Health' was a £1.63m three year national
program of men's health promotion delivered in and by 16 top flight professional
English Premier League and Championship football clubs (81). Funded through the
Premier League’s Creating Chance programme (82), the complex evaluation
included quantitative outcome measures to ascertain changes in key lifestyle
behaviours and qualitative data (from a range of interviews and card sort
procedures) to consider wider outcomes and learning about effective processes.
‘Premier League Health’ aimed to improve the health of male football supporters
presenting with unhealthy lifestyles and who were not engaging health services (80).
Interventions were delivered through health trainers, allied health professionals
employed by the clubs (83, 84) and were made up of match day activities and
weekly classes and groups (2). PLH represents differentiate array of programmes. It
ranged from offering sport engagement (i.e., football) in one club, to using a sports
club to promote exercise (i.e., circuit training and running), to promoting low level
physical activity in another. As such, PLH shows the considerable ingenuity that can
be achieved by considering the interplay of sport, exercise and physical activity.
Crucially, PLH drew on the latent appeal of professional football – possibly to men
who used to play football - to engage in a programme located in sporting venues but
not necessarily based on sport.
Using the principles of RE-AIM, self-report measures were used to assess the
number, demographic and health profiles of men who were reached, adopted PLH
and maintained changes in behaviour (80). Process investigations, such as semi-
structured interviews with male participants and the health trainers were also
undertaken (85). Collectively these measures aimed to identify the influential
Implementation (RE-AIM) characteristics impacting on men’s behaviours across the
behavioural continuum (2). The impact (Effectiveness) emerging from PLH have
subsequently been reported (80, 83).
7. Using RE-AIM to increase participation with men: Premier League
Health, a case study
PLH represented a unique contribution to understanding both the effects of football-
based interventions and the process by which the active design characteristics for
engaging, and keeping men involved played out. Using RE-AIM, for evaluations such
as PLH, highlights the necessity to sculpt interventions around an intrinsic model of
health that considers ‘what really matters to you’ as opposed to ‘what’s the matter
with you’. Consequently, using intervention mapping principles (86) with a view to
informing practitioners on assessing needs, planning, implementing and evaluating
gender-specific football-based health interventions; key learning from PLH is
displayed in Box 1 below.
Around four thousand men adopted PLH the majority presenting with unhealthy
lifestyles, and demonstrating limited awareness of their problematic health
behaviours. Over a third reported ‘never’ seeing their doctor and more than half
‘never’ used a health advice service, meaning these men were unlikely to be
reached through health improvement activities delivered in these settings. PLH
resulted in statistically significant improvements in a range of health behaviours for
the majority (80). The design of gender-specific health improvement programmes
delivered in football settings raised a number of important considerations. These
included the use of familiar environments and centring interventions on men’s
interests and hobbies, building men’s trust and confidence in the programme,
developing realistic physical activity options and creating a socially inclusive
atmosphere, especially important for men with no or limited social networks. An
example of some of the interventions can be found in figure 2 below. The health
trainers delivering the interventions offered significant expertise when planning and
delivering the PLH programme and were instrumental to its success. Collectively, it
was design factors such as these that impacted on the health of many men.
Figure 2: Examples of Premier League Health Interventions
Box 1: Lessons from Premier League Health:
PLH provided a unique opportunity to explore how the power of elite football clubs can influence the health
of men. We have outlined a selection of ten of the most important lessons learnt from PLH. These should be
seen as key considerations for planning, implementing and evaluating men’s health interventions delivered
in and by professional football clubs.
1. Use all the assets the club has to offer: Utilise the badge, players (where possible) branding,
communication channels, and mascots to get publicity. Further, make use of facilities and fully
engage volunteers and supporters groups.
2. Consult your target audience when designing interventions. Use social marketing to understand
what will motivate - and discourage - potential participants.
3. Build support networks, make it a social event. This is a key aspect of widening men's social capital
and a real help in times of crisis.
4. On-going activities with no pre-defined engagement periods (i.e. 12 weeks) are more participant-
friendly. They are more likely to induce change.
5. Recognise the importance of identifying and working with partners that have access to your target
audience. Businesses and settings with a high proportion of males (construction sites, taxi ranks,
pubs, betting shops, takeaways etc.), and voluntary organisations or charities can reach out to
those who are unemployed, socially excluded and most health-needy.
6. Don't preach health messages. Have open and frank discussions in short bursts (around 10
minutes), and make it relevant to what the men are doing.
7. Don't restrict activities to just football. Provide an array of fun and enjoyable sports and inclusive
activities that may be more suitable for all participants.
8. Don’t put out too much complex information. Simple messages and language work best. You can
refer people to other sources if they want more detail.
9. Don’t expect everything to happen all at once and work first time. It takes time to get established,
and requires momentum for word-of-mouth to work.
10. Evaluate and follow up all projects so you can show impact and lessons learnt. Think about this
from the start, set realistic aims and objectives, and keep on top of data collection and input.
Conclusion
Worldwide, increasing the number of physically active people through sports and/or
exercise participation can generate system-changing benefits for individuals,
communities and health systems. However, uptake evidence suggests that engaging
inactive people – even for one-off events – can be a tough sell, even though there
are many well documented benefits associated with participation in sport, exercise
and physical activity which are valid, robust and consistent (9, 29). To generate
these benefits, physical activity – which can be undertaken universally - needs to be
packaged in a way that individuals can incorporate into their daily lifestyle with
minimal burden. Conflating distinctive behaviours – sport, exercise a, physical
activity – typically creates confusion and that can generate mixed messages which
make it difficult to communicate with reluctant individuals. Further, the experience of
PLH has shown that attention focused on generating precise and enjoyable
experiences will minimise the attrition of people who do become involved. At all
times it is important to be mindful of the risks associated with increased participation
so we can do all that is necessary to minimise the dangers and maximise the
benefits.
Throughout this chapter we have argued that it is important that sports advocates do
all they can to consider how what they want to promote can be delivered to address
the full panoply of interest in exercise and/or physical activity. As tough as this is for
sports advocates to hear, this may even include creating some distance from the
aversive notions that target audiences may hold about ‘sport’ or ‘exercise’. The
evidence confirms that it is unwise to conflate these behaviours or to assume that
what catalyses one interest group will have equivalent effects in others. Yet, PLH
shows how even the most committed sporting groups – like professional soccer
clubs - can grasp the need to offer something other than conventional sport to attract
inactive groups. This evidence also shows that this approach can be successful,
even if only because it attracts participants through their latent interest in sport.
As increased participation rates generate the ‘biggest bang for your buck’ with the
least active 20% within society (17), this places attention on promoting engagement
of the most sedentary and insufficiently active segments of the community.
Importantly, these groups can hold unfavourable assumptions about what ‘sport’
means and about how ‘exercise’ is relevant to their daily lives. For this reason, it is
important to carefully address their needs and to create interventions that fully meet
their needs. In this understanding and we offer this as a stark assertion, offering
more sport to people who do not like sport cannot be the way to better Public Health.
Further, low active groups typically face substantial barriers to participation and, by
dint of their on-going inactivity, have little capacity to tolerate levels of exertion that
many sport and exercise advocates might regard as derisory. This underlines the
need for reconsidering the relevance of physiologically-oriented themes within
exercise prescription; these have more to do with training than with the types of
physical activity that they can undertake. Once inactive individuals undertake even
some physical activity they may aspire to progress into exercise or even sport, but
this must not be at the expense of engaging with activities they can sustain.
However, for all this to occur, resources need to be effectively directed and targeted
towards addressing behavioural factors of change. Consequently, individuals within
health systems – not health systems themselves - must be willing and capable of
adapting to the changing climate to make the necessary alterations successfully and
sustainable. Understandably, this will not be easy, but this can be assisted by
changes to policy and practice regarding the promotion, adoption and maintenance
of physically active lifestyles which requires buy in from the key stakeholders.
Taking a message from contemporary behaviour change theory, it makes sense that
any such changes bring quick rewards and represent the smallest change that can
be enacted within the existing resources. The reality is that low cost, high
performance, cost effective methods and techniques are needed to deliver on the
promise that is represented by exercise as medicine.
References
1. Sallis RE. Exercise is medicine and physicians need to prescribe it! Br J Sports Med. 2009
Jan;43(1):3-4.
2. Pringle A, Zwolinsky S, McKenna J, Daly-Smith A, Robertson S, White A. Delivering men's
health interventions in English Premier League football clubs: key design characteristics. Public
Health. 2013;127(8):716-26.
3. Fineberg HV. Shattuck Lecture. A successful and sustainable health system--how to get there
from here. N Engl J Med. 2012 Mar 15;366(11):1020-7.
4. Pringle A, McKenna J, Zwolinsky S. Health improvement and professional football: Players on
the same side? . Journal of Policy Research in Tourism, Leisure and Events. 2013;5(2):207-12.
5. The Information Centre for Health and Social Care. Statistics on obesity, physical activity and
diet in England 2013. In: The Information Centre for Health and Social Care, editor. London2013.
6. Kavanagh T. Exercise in the primary prevention of coronary artery disease. Can J Cardiol.
2001 Feb;17(2):155-61.
7. Department of Health. Start Active, Stay Active: A report on physical activity for health from
the four home countries‟ Chief Medical Officers. London: Department of Health; 2011.
8. World Health Organization. Scaling up action against non-communicable diseases: How
much will it cost? . Geneva, Switzerland: World Health Organization2011.
9. Rankin AJ, Rankin AC, MacIntyre P, Hillis WS. Walk or run? Is high-intensity exercise more
effective than moderate-intensity exercise at reducing cardiovascular risk? Scott Med J. 2012
May;57(2):99-102.
10. Black N. Can England's NHS survive? N Engl J Med. 2013 Jul 4;369(1):1-3.
11. Roberts A, Marshall L, Charlesworth A. A decade of austerity? The funding pressures facing
the NHS from 2010/11 to 2021/22. In: Nuffield Trust, editor. London2012.
12. Bouchard C, Shepard R. Physical activity, exercise and health: the model and key concepts.
Champaign, IL: Human Kinetics; 1994.
13. McKenna J, Riddoch C. Perspectives on Exercise and Health. London: Palgrave; 2003.
14. Naidoo J, Wills J. Health Promotion – Foundations for Practice. Second Edition ed. London:
Bailliere Tindall; 2005.
15. Bouchard C, Shepard R, Stephens T, Sutton J, McPherson B. Exercise, Fitness and Health: A
Consensus of Current Knowledge. Champaign, IL: Human Kinetics; 1990.
16. Mark DB, Lauer MS. Exercise capacity: the prognostic variable that doesn't get enough
respect. Circulation. 2003 Sep 30;108(13):1534-6.
17. Blair SN, Kampert JB, Kohl HW, 3rd, Barlow CE, Macera CA, Paffenbarger RS, Jr., et al.
Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause
mortality in men and women. JAMA. 1996 Jul 17;276(3):205-10.
18. Vercambre MN, Grodstein F, Manson JE, Stampfer MJ, Kang JH. Physical activity and
cognition in women with vascular conditions. Arch Intern Med. 2011 Jul 25;171(14):1244-50.
19. Medina J. Brain Rules. Seattle: Pear Press; 2008.
20. Tomporowski PD, Davis CL, Miller PH, Naglieri JA. Exercise and Children's Intelligence,
Cognition, and Academic Achievement. Educ Psychol Rev. 2008 Jun 1;20(2):111-31.
21. Trudeau F, Shephard RJ. Physical education, school physical activity, school sports and
academic performance. Int J Behav Nutr Phys Act. 2008;5:10.
22. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical activity and
public health in older adults: recommendation from the American College of Sports Medicine and
the American Heart Association. Circulation. 2007 Aug 28;116(9):1094-105.
23. O'Donovan G, Blazevich AJ, Boreham C, Cooper AR, Crank H, Ekelund U, et al. The ABC of
Physical Activity for Health: a consensus statement from the British Association of Sport and Exercise
Sciences. J Sports Sci. 2010 Apr;28(6):573-91.
24. Kahn EB, Ramsey LT, Brownson RC, Heath GW, Howze EH, Powell KE, et al. The effectiveness
of interventions to increase physical activity. A systematic review. Am J Prev Med. 2002 May;22(4
Suppl):73-107.
25. Morris JN, Heady JA, Raffle PA, Roberts CG, Parks JW. Coronary heart-disease and physical
activity of work. Lancet. 1953 Nov 28;265(6796):1111-20; concl.
26. Paffenbarger RS, Jr., Hyde RT, Wing AL, Steinmetz CH. A natural history of athleticism and
cardiovascular health. JAMA. 1984 Jul 27;252(4):491-5.
27. Haskell WL, Blair SN, Hill JO. Physical activity: health outcomes and importance for public
health policy. Prev Med. 2009 Oct;49(4):280-2.
28. Van Mechelen W. A physically active lifestyle--public health's best buy? Br J Sports Med.
1997 Dec;31(4):264-5.
29. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially
modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study):
case-control study. Lancet. 2004 Sep 11-17;364(9438):937-52.
30. Paffenbarger RS, Jr., Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and
longevity of college alumni. N Engl J Med. 1986 Mar 6;314(10):605-13.
31. Morris JN, Clayton DG, Everitt MG, Semmence AM, Burgess EH. Exercise in leisure time:
coronary attack and death rates. Br Heart J. 1990 Jun;63(6):325-34.
32. Lee D, Pate R, Lavie C, Blair S. Running and All-cause Mortality Risk - Is More Better Medicine
and Science in Sports and Exercise. 2012;44(5s):3471.
33. Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking
compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J
Med. 2002 Sep 5;347(10):716-25.
34. Sesso HD, Paffenbarger RS, Jr., Lee IM. Physical activity and coronary heart disease in men:
The Harvard Alumni Health Study. Circulation. 2000 Aug 29;102(9):975-80.
35. Tanasescu M, Leitzmann MF, Rimm EB, Willett WC, Stampfer MJ, Hu FB. Exercise type and
intensity in relation to coronary heart disease in men. JAMA. 2002 Oct 23-30;288(16):1994-2000.
36. Barnes P, Schoenborn C. Trends in adults receiving a recommendation for exercise or other
physical activity from a physician or other health professional. NCHS data brief, no 86. Hattsville,
MD: National Centre for Health Statistics; 2012.
37. Ekkekakis P, Parfitt G, Petruzzello SJ. The pleasure and displeasure people feel when they
exercise at different intensities: decennial update and progress towards a tripartite rationale for
exercise intensity prescription. Sports Med. 2011 Aug 1;41(8):641-71.
38. Department of Health. At least 5 a week: Evidence on the impact of physical activity and its
relationship to health. London: Department of Health; 2004.
39. Sheikh N, Sharma S. Overview of sudden cardiac death in young athletes. Phys Sportsmed.
2011 Nov;39(4):22-36.
40. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al.
Recommendations and considerations related to preparticipation screening for cardiovascular
abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart
Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American
College of Cardiology Foundation. Circulation. 2007 Mar 27;115(12):1643-455.
41. Udani JK, Singh BB, Singh VJ, Sandoval E. BounceBack capsules for reduction of DOMS after
eccentric exercise: a randomized, double-blind, placebo-controlled, crossover pilot study. J Int Soc
Sports Nutr. 2009;6:14.
42. Conn V, Hafdahl A, Mehr D. Interventions to increase physical activity among healthy adults:
Meta-analysis of outcomes. Am J Public Health. 2011;101(4):751-8.
43. Bovens AM, Janssen GM, Vermeer HG, Hoeberigs JH, Janssen MP, Verstappen FT.
Occurrence of running injuries in adults following a supervised training program. Int J Sports Med.
1989 Oct;10 Suppl 3:S186-90.
44. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987 Mar-Apr;15(2):168-71.
45. Rauh MJ, Koepsell TD, Rivara FP, Rice SG, Margherita AJ. Quadriceps angle and risk of injury
among high school cross-country runners. J Orthop Sports Phys Ther. 2007 Dec;37(12):725-33.
46. Buist I, Bredeweg SW, Bessem B, van Mechelen W, Lemmink KA, Diercks RL. Incidence and
risk factors of running-related injuries during preparation for a 4-mile recreational running event. Br
J Sports Med. 2010 Jun;44(8):598-604.
47. Carlson SA, Hootman JM, Powell KE, Macera CA, Heath GW, Gilchrist J, et al. Self-reported
injury and physical activity levels: United States 2000 to 2002. Ann Epidemiol. 2006 Sep;16(9):712-9.
48. Hootman JM, Macera CA, Ainsworth BE, Martin M, Addy CL, Blair SN. Association among
physical activity level, cardiorespiratory fitness, and risk of musculoskeletal injury. Am J Epidemiol.
2001 Aug 1;154(3):251-8.
49. Whang W, Manson JE, Hu FB, Chae CU, Rexrode KM, Willett WC, et al. Physical exertion,
exercise, and sudden cardiac death in women. JAMA. 2006 Mar 22;295(12):1399-403.
50. Kohl HW, 3rd, Powell KE, Gordon NF, Blair SN, Paffenbarger RS, Jr. Physical activity, physical
fitness, and sudden cardiac death. Epidemiol Rev. 1992;14:37-58.
51. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden
death from cardiac causes by vigorous exertion. N Engl J Med. 2000 Nov 9;343(19):1355-61.
52. American Heart Association & American College of Sports Medicine. Exercise and acute
cardiovascular events: placing the risks into perspective. Med Sci Sports Exerc. 2007 May;39(5):886-
97.
53. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during
vigorous exercise. N Engl J Med. 1984 Oct 4;311(14):874-7.
54. Bredin SS, Gledhill N, Jamnik VK, Warburton DE. PAR-Q+ and ePARmed-X+: new risk
stratification and physical activity clearance strategy for physicians and patients alike. Can Fam
Physician. 2013 Mar;59(3):273-7.
55. Sport England. Creating a sporting habit for life: a new youth sport strategy. London: Sport
England; 2012.
56. Sport England. Active People Survey 7-12 months rolling results: April 2012-April 2013.
London: Sport Endlang; 2013 [cited 2013 3/8/2013]; Available from:
http://www.sportengland.org/research/who-plays-sport/national-picture/.
57. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on
major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.
Lancet. 2012 Jul 21;380(9838):219-29.
58. Weiler R, Stamatakis E. Physical activity in the UK: a unique crossroad? British Journal of
Sports Medicine. 2010 Oct;44(13):912-4.
59. Heath GW, Parra DC, Sarmiento OL, Andersen LB, Owen N, Goenka S, et al. Evidence-based
intervention in physical activity: lessons from around the world. Lancet. 2012 Jul 21;380(9838):272-
81.
60. Lin JS, O'Connor E, Whitlock EP, Beil TL. Behavioral counseling to promote physical activity
and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S.
Preventive Services Task Force. Ann Intern Med. 2010 Dec 7;153(11):736-50.
61. Resaland GK, Anderssen SA, Holme IM, Mamen A, Andersen LB. Effects of a 2-year school-
based daily physical activity intervention on cardiovascular disease risk factors: the Sogndal school-
intervention study. Scand J Med Sci Sports. 2011 Dec;21(6):e122-31.
62. National Institute for Health and Clinical Excellence. Promoting and creating built or natural
environments that encourage and support physical activity. London: National Institute for Health
and Clinical Excellence; 2008.
63. Bauman A, Murphy N, Lane A. The role of community programmes and mass events in
promoting physical activity to patients. Br J Sports Med. 2009 Jan;43(1):44-6.
64. Bauman AE, Reis RS, Sallis JF, Wells JC, Loos RJ, Martin BW. Correlates of physical activity:
why are some people physically active and others not? Lancet. 2012 Jul 21;380(9838):258-71.
65. Stevinson C, Hickson M. Exploring the public health potential of a mass community
participation event. J Public Health (Oxf). 2013 Aug 15.
66. National Institute of Health and Clinical Excellence. Behaviour Change at Population,
Community and Individual Levels. London: National Institute of Health and Clinical Excellence; 2007.
67. Dugdill L, Stratton G. Evaluating Sport and Physical Activity Interventions: A Guide for
Practitioners. London: Department of Health; 2008.
68. Finch CF, Donaldson A. A sports setting matrix for understanding the implementation
context for community sport. Br J Sports Med. 2010 Oct;44(13):973-8.
69. Glasgow RE, Lichtenstein E, Marcus AC. Why don't we see more translation of health
promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public
Health. 2003 Aug;93(8):1261-7.
70. Glasgow RE, Whitlock EP, Eakin EG, Lichtenstein E. A brief smoking cessation intervention for
women in low-income planned parenthood clinics. Am J Public Health. 2000 May;90(5):786-9.
71. Glasgow RE, Klesges LM, Dzewaltowski DA, Bull SS, Estabrooks P. The future of health
behavior change research: what is needed to improve translation of research into health promotion
practice? Ann Behav Med. 2004 Feb;27(1):3-12.
72. Klesges LM, Estabrooks PA, Dzewaltowski DA, Bull SS, Glasgow RE. Beginning with the
application in mind: designing and planning health behavior change interventions to enhance
dissemination. Ann Behav Med. 2005 Apr;29 Suppl:66-75.
73. Dunton GF, Liao Y, Grana R, Lagloire R, Riggs N, Chou CP, et al. State-wide dissemination of a
school-based nutrition education programme: a RE-AIM (Reach, Efficacy, Adoption, Implementation,
Maintenance) analysis. Public Health Nutr. 2012 Dec 6:1-9.
74. De Meij JS, Chinapaw MJ, Kremers SP, Van der Wal MF, Jurg ME, Van Mechelen W.
Promoting physical activity in children: The stepwise development of the primary school-based
JUMP-in intervention applying the RE-AIM evaluation framework. Br J Sports Med. 2010
Sep;44(12):879-87.
75. Estabrooks PA, Bradshaw M, Dzewaltowski DA, Smith-Ray RL. Determining the impact of
Walk Kansas: applying a team-building approach to community physical activity promotion. Ann
Behav Med. 2008 Aug;36(1):1-12.
76. Glasgow RE, Nelson CC, Kearney KA, Reid R, Ritzwoller DP, Strecher VJ, et al. Reach,
engagement, and retention in an Internet-based weight loss program in a multi-site randomized
controlled trial. J Med Internet Res. 2007;9(2):e11.
77. Eakin E, Reeves M, Lawler S, Graves N, Oldenburg B, Del Mar C, et al. Telephone counseling
for physical activity and diet in primary care patients. Am J Prev Med. 2009 Feb;36(2):142-9.
78. Bull SS, Gillette C, Glasgow RE, Estabrooks P. Work site health promotion research: to what
extent can we generalize the results and what is needed to translate research to practice? Health
Educ Behav. 2003 Oct;30(5):537-49.
79. Toobert DJ, Strycker LA, Glasgow RE, Barrera Jr M, Angell K. Effects of the mediterranean
lifestyle program on multiple risk behaviors and psychosocial outcomes among women at risk for
heart disease. Ann Behav Med. 2005 Apr;29(2):128-37.
80. Pringle A, Zwolinsky S, McKenna J, Daly-Smith A, Robertson S, White A. Effect of a national
programme of men's health delivered in English Premier League football clubs. Public Health. 2013
Jan;127(1):18-26.
81. Zwolinsky S, Pringle A, Daly-Smith A, McKenna J, Robertson S, White A. Associations
between daily sitting time and the combinations of lifestyle risk factors in men. Journal of Men's
Health. 2012;9(4):261-7.
82. Premier League. Creating Chances, 2011. London: Premier League; 2012.
83. Zwolinsky S, McKenna J, Pringle A, Daly-Smith A, Robertson S, White A. Optimizing lifestyles
for men regarded as 'hard-to-reach' through top-flight football/soccer clubs. Health Education
Reseasch. 2013 Jun;28(3):405-13.
84. Pringle A, Zwolinsky S, Smith A, Robertson S, McKenna J, A. W. The pre-adoption
demographic and health profiles of men participating in a programme of men’s health delivered in
English Premier League football clubs. Public Health. 2011;125(7):411-6.
85. Robertson S, Zwolinsky S, Pringle A, McKenna J, Daly-Smith A, White A. “It’s fun, fitness and
football really”: a process evaluation of a football based health intervention for men. Qualitative
Research in Sport, Exercise and Health. 2013;In Press.
86. Ransdell B, Dinger K, Huberty J, Miller K. Planning and evaluating physical activity
programmes in Developing Effective Physical Activity Programmes. Champaign, Illinois: Human
Kinetics; 2009.
