Football as Medicine against cardiovascular disease

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Introduction
Football as Medicine
Peter Krustrup and Daniel Parnell
Football has long been a subject of philosophical analysis and has been featured
in various historical and cultural narratives, which should come as no surprise
given its status as the world’s favourite game. In an editorial to the recent Football
is Medicine special issue of the Scandinavian Journal of Medicine & Science in Sports ,
the concept of football as therapy is illustrated through the French philosopher
Voltaire, who describes the potential of football in The Book of Fate ( 1747 ):
full-blown and carefully cover’d with the softest Leather. You must kick this
Bladder, Sir, once a Day about your Hall for a whole Hour together, with all
the Vigour and Activity you possibly can. . . . Ogul, upon making the first
Experiment, was ready to expire for want of Breath. ... In short, our Doctor
in about eight Days Time, perform’d an absolute Cure. His Patient was as
brisk, active and gay, as One in the Bloom of his Youth.
(De Voltaire, 1747/2008; Krustrup et al., 2018 )
From Shakespeare to Shankly, football has been a focus of debate, and it will no
doubt continue to be so. Leeds United manager Marcelo Bielsa stated, as shared
by our colleague Jon Mackenzie:
What happens to their team has a great impact on the life of fans. If the game
is won, you feel better and it affects your personal life. If the team loses, you
become proportionally depressed, it affects everything you do.
Pioneering Professor of the Sociology of Sport John Sugden stated, ‘sport is
intrinsically value neutral and under carefully managed circumstances it can make
a positive if modest contribution to peace building’ ( Sugden, 2010 ) and that ‘sport
alone will not change the world . . . but doing nothing may no longer be an option’
( Sugden, 2005 ).
Indeed, in certain sections of society football has a kind of capital – not too dis-
similar to political and social capital – in that it has power to change, constitutes a
resource for hope and can offer many health benefits to those who have access to
it. Furthermore, it is arguable that when football capital is combined with social

2 Peter Krustrup and Daniel Parnell
capital, its social benefits can diffuse through the network and act as a social learn-
ing tool and genuine positive social activity. If, therefore, we draw on Voltaire
and extend the quote of Albert Camus, who outlined something slightly different
during his interview in the 1950s – ‘What little I know on morality, I learned it on
football pitches and theater stages. Those were my true universities’. – we propose
that this book brings together evidence on what we have learnt from the football
pitches, our universities, on whether football can work as a form of medicine, and
then provides considerations for future research and applied practice.
We have been working on the football and health agenda for 17 and 12 years,
respectively. Peter began his research in this area in 2003 through observational
pilot studies on the movement patterns, exercise intensity and fitness benefits of
football training in Danish low-level senior and veteran players, homeless men
and sedentary computer enthusiasts. In the latter study, 16 computer enthusiasts
came together as FC Zulu, and the pilot results demonstrated an average increase
in VO
2 max from 35 to 52 mL/min/kg over 2 years. This led to the first ran-
domised controlled trials (RCTs) in 2006–2009 comparing football training with
other popular exercise regimes like jogging, interval running and strength train-
ing for sedentary young men ( Krustrup et al., 2009 ; Krustrup et al., 2010a ) and
women ( Krustrup et al., 2010b ; Krustrup, Helge, Hansen et al., 2018 ; Ottesen
et al., 2010 ) and schoolchildren ( Krustrup et al., 2014 ). Later, Peter conducted
numerous RCTs incorporating football training in patient groups with hyperten-
sion, type 2 diabetes, osteopenia, prostate cancer and breast cancer ( Krustrup
et al., 2010a ; Krustrup et al., 2013 ; Milanovic´ et al., 2015 ; Uth et al., 2016 ; Krus-
trup, Williams, Mohr et al., 2018; Krustrup, Helge, Hansen et al., 2018 ; Skoradal
et al., 2018; Milanovic´ et al., 2019 ). Based on the results of these investigations,
which combined physiological, medical, psychological and sociological method-
ologies, Peter and his wife Birgitte developed a holistic Football is Medicine model
( Krustrup & Krustrup, 2018 ) ( Figure 0.1 ).
This model describes the cardiovascular, metabolic and musculoskeletal train-
ing components of recreational football training; training-induced adaptations in
fitness and health variables; and use of football training in the prevention, treat-
ment and rehabilitation of non-communicable diseases. The model also describes
the psychosocial elements of acute recreational football training as well as the
long-term psychosocial training-induced effects and the possibility of creating
adherence to an active lifestyle. Over the past decade, Peter and his team have
also been heavily involved in the practical application of their football for health
research, specifically the development, testing, adjustment and implementation of
evidence-based concepts using football as a tool for increasing fitness, health pro-
file, well-being and learning for children (FIT FIRST and 11 for Health), young
and older sedentary adults (Football Fitness), patients (Football Fitness ABC [After
Breast Cancer], FC Prostate and Football for the Heart) and socially deprived
people. This has been done in close collaboration with the Danish FA, the Dan-
ish Sports Confederation, Danish charities, and international football and sports
governing bodies.

Introduction 3
Figure 0.1 The Holistic Football is Medicine model.
Source: Adapted from Krustrup & Krustrup, British Journal of Sports Medicine , 2018.
Football training is all-in-one training
with broad-spectrum fitness and health effects:
aerobic high-intensity (HIIT), endurance and strength training
Football training, as per the Football Fitness concept, is social, fun,
variable, popular and adjustable, for participants of all ages and skill levels
Football training builds social relations in pair- and team-work
with positive effects on mental and social well-being
Football training elicits high ratings of enjoyment
with moderate ratings of perceived exertion
PREVENTION
HEALTHY
I, They, We stories We, I, They stories
Extrinsic motivation Intrinsic motivation
FUN SOCIAL
TREATMENT REHABILITATION
Training types Training categories Areas of fitness Measures Lifestyle diseases
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Metabolic
fitness
Muscle
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Type 2
diabetes
Cardiovascular
diseases
Risk of falls
and fractures
Osteoporosis
Glucose
tolerance
Fat per-
centage
Blood
pressure
VO2max
Postural
balance
Bone
mass
Cardio-
vascular
fitness
Musculo-
skeletal
fitness
Aerobic mode-
rate intensity
Endurance
training
HIIT
training
Strength
training
Aerobic
high intensity
Speed
endurance
Speed,
strength
Bone impact
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Krustrup and Krustrup, 2018
Dan began his research in 2006 examining the effectiveness of a football-
based community intervention delivered by an English Premier League football
club, Everton FC. The intervention examined the impact of a 16-week foot-
ball programme in primary-school children using a multi-method evaluation
which included pedometers, physical activity diaries, writing and drawing exer-
cises, interviews, focus groups and the principles of ethnography. The findings
pointed to a number of opportunities for strategic and operational changes to
improve the effectiveness of interventions (Parnell et al., 2013a). This interven-
tion, part of a broader action research project within the club, entailed Dan

4 Peter Krustrup and Daniel Parnell
shifting his focus from intervention evaluation towards helping manage positive
change in practice at Everton FC. Some of the areas of attention and focus over
the remaining years of his PhD were developing a clear strategic purpose and
objectives; recruiting appropriately skilled staff; providing relevant, continued
professional development opportunities to the coaching staff and practitioners;
promoting a culture of research and evaluation (i.e. understanding what works
and making practice more effective); and creating meaningful partnerships with
relevant higher-education departments with a clear focus on helping practitio-
ners improve their practice (i.e. engaging in action research) (see Parnell et al.,
2013a). Dan’s research then evolved in a collaborative partnership at Everton FC
through the creation of a community-facing facility to support activity for the
local community within the Everton Active Family Centre (Curran et al., 2014;
Bingham et al., 2014). He went on to establish a number of partnerships, working
with many clubs and organisations on initiatives primarily focused on evaluation
(Parnell et al., 2015), but also on providing genuine partnerships and professional
development for clubs and the staff involved (Parnell et al., 2013a). His current
interests include the impact of policy and politics on football, and the role of cor-
porate social responsibility in professional football (Parnell et al., 2013b; Parnell,
Curran and Philpott, 2016).
We are both fortunate to be able to exercise our passion for football through our
coaching practice and engagement with the sport. Moreover, we are committed to
understanding the role that football can play in health. As such, this book on Foot-
ball as Medicine brings together a culmination of extensive research in the field of
football and health. The 17 chapters of this edited collection aim to provide sharp,
critical analysis of key features and topics that underpin Football as Medicine.
Each chapter critically analyses its respective area and provides key considerations
and/or recommendations for the prescription of Football as Medicine, as well as
future research. The book should be an important addition for politicians, policy-
makers and analysts, researchers and academics, sports developers, educationists
and coaches, and the general public, who frequently assume that sport is good for
us and that participation in sport offers a range of public-health benefits. This
book collates the accumulated and extensive evidence to provide both the sub-
stance and rationale for Football as Medicine, providing a basis for the role that
football can play in promoting health. It provides the most comprehensive analysis
of the most recent and contemporary research in the field, with a broad variety
of research approaches, including sports physiology, training physiology, sports
medicine, sports psychology and sports management.
The first part of the book mostly focuses on the physiological response to
various types of recreational football and training-induced fitness adaptations in
relation to the cardiovascular, metabolic and musculoskeletal health profile. Simi-
larly, several chapters deal with the training-induced fitness and health effects of
football in specific target populations (children, cancer patients, socially deprived,
elderly), football training in specific settings (schools, sports clubs and work-
places) and injury-prevention strategies. The book also has several chapters on

Photo 0.1 The book editors, Peter Krustrup and Dan Parnell.
Source: Photo Credit: Bo Kousgaard, University of Southern Denmark.

6 Peter Krustrup and Daniel Parnell
the motivational and psychosocial climate during recreational football training
and the training-induced psychosocial effects of long-term football in relation to
wellbeing and mental health. The last part of the book mostly focuses on the
development and implementation of evidence-based football training concepts,
and how fan culture and fan programmes can influence population health. Last,
but not least, there is a discussion of how the evidence and concepts presented
on the potential use of football for global health promotion can be taken up and
applied by health workers and policymakers around the world. 
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Introduction 7
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Chapter 1
Football as Medicine against
cardiovascular disease
Magni Mohr , Peter Riis Hansen , Felipe Lobelo ,
Lars Nybo , Zoran Milanovic
´ and
Peter Krustrup
Exercise as treatment for cardiovascular disease
Cardiovascular disease (CVD) encompasses multiple pathological conditions for
which exercise may be a significant part of the treatment protocol, including cere-
brovascular disease, hypertension, coronary heart disease, heart failure and inter-
mittent claudication.
Cerebrovascular disease, including stroke, transient ischemic attack and cere-
bral bleeding, is clinically defined as a rapid onset disorder of brain function with
symptoms lasting more than 24 hours or causing death. The cause is likely to
be of vascular origin. Average age of the patients is 75 years, however 20% are
younger than 65 years. Parts of brain functions deteriorate, and symptomatic
stroke patients mainly have unilateral paresis of extremities. In addition, about
one third also experience aphasia. Some stroke patients may also display cognitive
and emotional impairment, and around 30% experience post-stroke depression
( Paolucci et al. 2006 ). Patients with prior stroke are therefore likely to be physically
inactive ( Rand et al. 2009 ). Physical inactivity is a major cause for atherosclerotic
disease and hypertension, which is supported by epidemiological findings demon-
strating that physical inactivity is a predictor of apoplexy ( Hu et al. 2007 ; Kra-
rup et al. 2007 ; Krarup et al. 2008 ; Sui, LaMonte, and Blair 2007 ; Boysen and
Krarup 2009 ). In contrast, stroke patients who have a high physical activity level
display comparatively fewer severe subsequent strokes and show superior recovery
results compared to their inactive counterparts ( Krarup et al. 2008 ).
Hypertension markedly elevates the risk of stroke, coronary artery disease
(CAD) such as acute myocardial infarction, heart failure and sudden death. Epi-
demiological reports indicate that regular physical exercise and a high fitness
level prevents hypertension ( Fagard 2005 ; Fagard and Cornelissen 2007 , 2005 ).
Lewington and colleagues (2002) demonstrated a linear relationship between a
reduced cardiovascular mortality rate and the lowering of arterial blood pressure
to a systolic blood pressure of below 115 mmHg and a diastolic blood pressure
of below 75 mmHg ( Lewington et al. 2002 ). A decline of 20 mmHg in systolic
blood pressure or 10 mmHg in diastolic blood pressure induced a 50% reduction
in risk of cardiovascular mortality. Thus, an individual with systolic blood pressure

Football as Medicine for CVD 9
of 120 mmHg has half the cardiovascular mortality risk of a person with systolic
blood pressure of 140 mmHg ( Pedersen and Saltin, 2015 ). Despite this, arterial
hypertension is still diagnosed as systolic blood pressure >140 mmHg and diastolic
blood pressure >90 mmHg. According to this definition, ~20% of the population
suffer from arterial hypertension or require blood pressure-lowering medication
( Burt et al. 1995 ). However, the definitions of optimal and normal blood pressure
and of mild, moderate and severe hypertension are arbitrary ( Burt et al. 1995 )
and the paradox of optimal and normal arterial blood pressure is highly complex.
CAD that impairs the blood flow supply to the myocardium cells will provoke
myocardial ischaemia. The principal cause is atherosclerothrombosis-induced
obstruction of the coronary arteries, but myocardial ischaemia can also develop
in patients with other heart conditions. Physical activity level and aerobic fitness
status are positively associated with adverse cardiovascular endpoints in healthy
individuals, as well as patients diagnosed with CAD ( Myers et al. 2002 ).
Heart failure patients have attenuated maintenance of blood flow to cover the
metabolic demands of the peripheral tissue ( Braunwald and Libby 2008 ). The
most common symptoms are fluid retention, breathlessness or tiredness when rest-
ing or exercising, and can relate to impaired systolic function of the left ventricle
(Pedersen and Saltin, 2015). Heart failure syndrome can be initiated by CAD, but
can additionally be provoked by hypertension or valvular heart disease ( Braunwald
and Libby 2008 ). Since the capacity for peripheral oxygen delivery and consump-
tion is deteriorated in heart failure patients ( Sullivan et al. 1989 ), they are likely to
encompass a low daily physical activity level, which may impair quality of life and
induce a negative impact on adaptability to exercise training. This may attenuate
myocardial function and peripheral complications in skeletal myocytes (Pedersen
and Saltin 2015). Heart failure patients may consequently also develop muscle
atrophy, tiredness and low muscle strength ( Anker et al. 1997 ; Harrington et al.
1997 ). Finally, heart failure patients experience a myriad of homeostasis dysfunc-
tions ( Bradham et al. 2002 ), including insulin resistance ( Paolisso et al. 1991 ). The
characteristic symptom of accelerated tiredness is likely to impair physical abili-
ties, creating a vicious circle that patients with heart failure may partly reverse by
regular exercise training ( Pedersen and Saltin 2015 ).
Lower limbs arterial insufficiency, such as symptomatic ischaemia in the legs, is
a chronic obstructive disease in the aorta below the outlet of the renal arteries, the
iliac artery and the arteries in the legs provoked by atherosclerosis (Pedersen and
Saltin 2015). Peripheral arteriosclerotic disease increases with increasing age, and
since conventional medical treatment of the condition has poor outcome exercise
training is a major component in the treatment ( TASC 2000 ). When the condi-
tion develops and becomes severe, the patients experience a marked impairment
in function level and deterioration of quality of life. Patients often have increasing
pain when walking and the exercise anxiety, may gradually cause physical inactiv-
ity and social isolation. This further leads to deterioration of physical ability and
the progression of atherosclerosis, reduced muscle strength and muscle atrophy.

10 Magni Mohr et al.
Thus, exercise training should be applied to counteract this negative spiral and
target the pathogenesis of the condition by increasing training status and muscle
strength, changing pain perception, reducing the degree of exercise anxiety and
preventing the progression of the disease.
Aerobic exercise training for stroke patients has substantiated clear positive
effects on walking speed and CV function, and some evidence for reducing
mortality ( Pedersen and Saltin 2015 ). In relation to hypertension, meta-analyses
have concluded that physical exercise has a positive impact on blood pressure
in both normotensive and hypertensive individuals ( Fagard and Cornelis-
sen 2007 ; Cornelissen, Buys, and Smart 2013 ; Cornelissen and Smart 2013 ;
Huang etal. 2013 ). Meta-analysis evidence demonstrate an effect of both
aerobic and strength training ( Pedersen and Saltin 2015 ). Additionally, there
is strong documentation in favour of beneficial effects of exercise training on
patients with CAD. Exercise training increases survival rates and may have a
direct effect on the pathogenesis of the disease. Aerobic training at moderate
intensities is recommended for this patient group ( Pedersen and Saltin 2015 ).
Moreover, international guidelines recommend exercise training for patients
with heart failure since numerous studies demonstrated the beneficial effect
on central and peripheral factors, as well on function abilities and quality
of life without significant negative side-effects ( Hunt et al. 2005 ; Swedberg
et al. 2005 ). Indeed, the positive effects of exercise training on patients with
heart failure has been assessed in numerous meta-analyses ( Hwang and Mar-
wick 2009 ; Davies et al. 2010 ; Pedersen and Saltin 2015 ), interval training is
suggested as exercise treatment protocol for heart failure patients ( Pedersen and
Saltin 2015 ). Finally, there is strong evidence for the beneficial effect of exercise
training on patients with intermittent claudication. In a Cochrane review ( Lane
et al. 2014 ) analysing 30 trials and nearly 2000 participants with continuous leg
pain showed positive effects of different exercise regimes ranging from strength
to aerobic exercise. Collectively, there is clear scientific evidence that exercise
training should be deployed to treat a wide range of CVDs, though the train-
ing protocols differ. Thus, complex training protocols, such as football training,
can be suggested for targeting several of the pathophysiological mechanisms in
cardiovascular patients.
Effects of football on cardiac structure and function
CVD, e.g., CAD, stroke, arrhythmias and heart failure, account for approximately
1 in every 3 deaths, and in high-income countries, IHD remains the leading cause
of death, albeit IHD mortality has declined over the past decade ( Benjamin et al.
2017 ). Also, CVD rates are increasing on a global scale owing to, for example,
the aging population and increased urbanisation, with environmental pollution,
nutritional transition to more animal-source, processed and sugar-rich food, lack
of physical exercise and other factors fuelling the epidemic rise in major CVD risk
factors such as obesity, diabetes and hypertension ( Laslett et al. 2012 ). Although

Football as Medicine for CVD 11
exercise is a safe and effective intervention for primary and secondary prevention
of CVD, it is well recognised that it remains poorly implemented in clinical prac-
tice. Lack of time is a frequently cited barrier to exercise, and shorter-duration
high-intensity interval training may be a time-efficient way to achieve multifaceted
health benefits that can lead to reduction of CVD ( Karlsen et al. 2017 ; Weston,
Wisloff, and Coombes 2014 ). Also, there is ample evidence to suggest that team
sports, including football, offer a range of positive psychological and psychosocial
effects that promote participation in and adherence to the sport irrespective of the
subject’s age and the presence of chronic somatic or mental conditions ( Andersen,
Ottesen, and Thing 2018 ). On several parameters, the physiological load charac-
teristics of football training are similar to high-interval aerobic training, and here
we provide a short overview of the effects of football on the cardiovascular system
and circulating lipid levels ( Iaia, Rampinini, and Bangsbo 2009 ; Bangsbo et al.
2015 ; Krustrup et al. 2018 ).
Effects of football on the cardiovascular system and
circulating lipid levels
Myocardial structure and function
Physical inactivity is an important contributor to childhood obesity and is asso-
ciated with a clustering of cardiovascular risk factors that track into adulthood
and are linked with increased subclinical atherosclerosis in young adulthood and
increased risk of CVD in adults ( Andersen et al. 2011 ; Pahkala et al. 2011 ; Baker,
Olsen, and Sorensen 2007 ). There are limited studies of the effects of football
training on myocardial structure and function in children, but significant increases
in left-ventricular posterior-wall thickness and right-ventricular systolic function
have been demonstrated by echocardiography after football training in obese chil-
dren, and discrete cardiac adaptations were found in normal-weight, school-aged,
football-playing boys and children of both genders in response to a school-based
football intervention ( Barczuk-Falecka et al. 2018 ; Krustrup et al. 2014 ; Larsen
etal. 2018 ; Hansen et al. 2013 ). 
In randomised controlled studies with football as the intervention, favour-
able changes in left-ventricular dimensions and systolic and diastolic functions
have also been reported, as well as amelioration of right-ventricular function
in untrained premenstrual women, hypertensive men, men with type 2 diabetes
and elderly men, respectively, compared to control subjects ( Andersen et al. 2010 ,
2014; Schmidt et al. 2013 , 2014 ). In addition, a cross-sectional study showed that
left-ventricular systolic function was increased in veteran football players com-
pared to untrained elderly healthy men ( Schmidt et al. 2015 ). Intriguingly, foot-
ball was not associated with changes of echocardiographic variables in elderly
men with prostate cancer undergoing androgen deprivation therapy, suggesting
that the latter may diminish the myocardial effects of football training ( Schmidt
et al. 2015 , 2017 ).

(a)
Photo 1.1 Testing the aerobic fitness (a) and cardiac function and structure (b) before
and after 16 and 64 weeks of recreational football training for sedentary 20- to
45-year-old women.
Source: Photo Credit: Lizette Kabre.
(b)

Football as Medicine for CVD 13
While overall changes in myocardial structure and function following football
training, e.g., increases in left- and right-ventricular systolic function, may con-
fer reduced risk of CVD and improved prognosis, the long-term consequences
of football training for cardiovascular morbidity and mortality await further
study and the potential of football training to add to cardiac rehabilitation pro-
grammes, e.g., in patients with IHD and heart failure, is unknown. However, it is
notable that positive results are accumulating for high-intensity interval training
in various patient subsets, and high-intensity training comparable to football is
increasingly advocated for the primary and secondary prevention of CVD ( Iaia,
Rampinini, and Bangsbo 2009 ; Bangsbo et al. 2015 ; Krustrup et al. 2018 ; Price
et al. 2016 ). Moreover, favourable psychosocial effects of team sports that pro-
mote the subject’s participation and adherence appear to be independent of the
presence of a range of chronic diseases, indicating that football may be a winning
ticket for cardiac rehabilitation exercise programmes ( Andersen, Ottesen, and
Thing 2018 ).
Arterial function
Arterial function and characteristics, e.g., arterial stiffness and flow-mediated
endothelial-dependent vasodilatation, contribute importantly to myocardial
afterload and regulation of tissue perfusion ( Mitchell 2009 ). It is therefore hardly
surprising that measures of arterial function carry prognostic information and
are increasingly utilised as preclinical surrogates of CVD ( Mitchell 2009 ; Flam-
mer, 2012). By using peripheral arterial tonometry, we found that, in hyperten-
sive men, the augmentation index (a measure of arterial stiffness that predicts
CVD) was lowered after football training, whereas the reactive hyperaemia
index (a correlate of endothelial function that is also a predictor of CVD) was
unchanged ( Krustrup et al. 2013 ). Similar findings were observed after football
training in premenopausal women, and here the decrease in the augmentation
index was tied to an 18% increase in leg muscle capillarisation ( Krustrup, Han-
sen et al. 2010 ). Indeed, a comparable increase in the number of capillaries per
muscle fibre was reported after football training in untrained men ( Krustrup et
al. 2009a ). In addition, the reactive hyperaemia index was significantly higher
in veteran football players compared to elderly healthy controls ( Schmidt et al.
2015 ). Level of physical activity is also directly associated with flow-mediated
vasodilatation and measurable changes of the retinal microvasculature in chil-
dren and adolescents ( Pahkala et al. 2011 ; Gopinath 2011). Evidence for the
effects of football training on vascular function in children is limited, but we
found no significant changes in the reactive hyperaemia index measured by
peripheral arterial tonometry after a 10-month school-based football interven-
tion compared to controls ( Larsen et al. 2018 ). However, for children, microvas-
cular function develops with age, masking the effects of physical exercise in this
age group ( Radtke et al. 2012 ).

14 Magni Mohr et al.
Circulating lipid levels
Football training is associated with favourable changes in circulating lipid levels,
and a recent meta-analysis of randomised controlled trials of recreational foot-
ball in men and women with or without hypertension found that football training
achieved a reduction in low-density lipoprotein (LDL) cholesterol levels of 0.21
(95% CI, 0.06–0.36) mmol/L compared to non-active control groups ( Milanović
et al. 2019 ). This effect size was considered to be ‘possibly beneficial’ for reducing
long-term cardiovascular risk, whereas smaller decreases in total cholesterol and
triglyceride levels, as well as minor increases in high-density lipoprotein (HDL)
cholesterol levels, were observed and deemed ‘likely to be trivial’ ( Milanović etal.
2019 ). The influence of football training on less-traditional lipid parameters
related to cardiovascular risk, e.g., lipoprotein(a), oxidised LDL and HDL choles-
terol function, is unknown at present.
Effects of football on maximal oxygen uptake,
blood pressure and resting heart rate
Recreational football training, and in particular the high-intensity periods observed
in both small-sided matches/exercises and 11v11 matches, stimulates a broad spec-
trum of physical fitness components, including maximal oxygen uptake (VO
2 max).
Previous studies confirmed larger improvements in VO
2 max after recreational
football compared to continuous moderate-intensity endurance running, strength
training and no-exercise groups ( Milanović et al. 2015 ; Krustrup et al. 2009 ).
VO
2 max increases by an average of 3.5 mL/kg/min during a recreational foot-
ball training programme in comparison with other training types ( Milanović et al.
2015 ). Overall improvement is equivalent to a 10.3% increase in VO
2 max after
short- to medium-term recreational football training, which is enough to prevent a
decrease of 5–10% in VO
2 max per decade caused by physiological aging ( Hawkins
and Wiswell 2003 ). According to current evidence, recreational football is suitable
for VO
2 max improvement in healthy males and females, regardless of age or fit-
ness level, as well as untrained patients with mild-to-moderate hypertension, type 2
diabetes patients, men with prostate cancer and untrained elderly people.
Interestingly, recreational football and continuous endurance running pro-
duced similar increases in VO
2 max at the beginning of a training intervention
(first month), equivalent to 7% and 6%, respectively ( Krustrup et al. 2009 ).
However, further increases during the next 8 weeks were much higher in par-
ticipants who performed recreational football compared to their peers who were
involved in continuous endurance running because the stimulus of factors affect-
ing VO
2 max during the running training was not large enough for additional
increases ( Bangsbo et al. 2006 ; Midgley, McNaughton, and Wilkinson 2006 ). In
contrast, typical patterns of cardiovascular adaptations and stimuli elicited during
recreational football training have similarities to interval training. Marked and

Football as Medicine for CVD 15
frequent changes in exercise intensity when playing recreational football, despite
the fact that average heart rate is the same in football and continuous endur-
ance running groups (~80% HRmax), lead to larger improvements in VO
2 max.
During recreational football, ~20% of the total training time usually comprises
activities with intensity above 90% HRmax, compared to only 1% for continuous
running ( Krustrup et al. 2009 ).
Lack of time is often given as a barrier to participation in regular physical
training. However, investigations involving previously inactive participants com-
pleting short-term intervention studies involving 2–3 sessions of recreational
football per week demonstrate that the effects are similar to, or even higher than,
the improvements in VO
2 max observed for a control training group following
the recommendation of the American College of Sports Medicine (ACSM) of
5 training sessions per week ( Milanović et al. 2015 ). Recreational football could
therefore be considered a time-efficient form of exercise training for VO
2 max
improvement.
As aforementioned, hypertension is one of the most common CVDs in both
men and women, and it is predicted that the prevalence of hypertensive adults
will be more than 1.56 billion by the year 2025 ( Kearney et al. 2005 ). However, a
short-term recreational football programme (40–60 min, 2–3 sessions per week) is
Photo 1.2 Testing the blood pressure before and after 16 and 52 weeks of football training
for 65- to 78-year-old men.
Source: Photo Credit: Mikal Schlosser.

16 Magni Mohr et al.
most likely beneficial for systolic and diastolic blood pressure, with the magnitude
of reduction in pre- to mildly hypertensive adults observed at 11 and 7 mmHg,
respectively ( Milanović et al. 2019 ). Moreover, recreational football reduces sys-
tolic and diastolic blood pressure by 2.9% and 8.6% in overweight children ( Cvet-
kovic et al. 2018 ). The aforementioned improvements are comparable to the acute
effect of taking one standard dose of a blood pressure-lowering drug ( Law, Mor-
ris, and Wald 2009 ) and are of clinical importance given that a blood pressure
reduction of such a magnitude corresponds to a lowered risk of sudden cardiac
stroke by 20–30% in hypertensive individuals ( Law, Morris, and Wald 2009 ). Rec-
reational football is an adequate stimulus to upregulate a multitude of physiologi-
cal parameters associated with CVD ( Hansen et al. 2013 ; Andersen et al. 2010 ).
These cardiovascular system adaptations, which are the consequence of frequent
high-intensity movements performed during recreational football, also lead to a
moderate decrease in resting heart rate, with a magnitude of 4–12 bpm depend-
ing on aerobic fitness at baseline ( Milanović et al. 2019 ) 
Prescription of football training for cardiovascular patients
Given the well-documented and broad-spectrum beneficial effects of recreational
football training on several central and peripheral components of cardiovascular
health in patients with cardiovascular deficiencies ( Milanović et al. 2015 , 2019 ),
we suggest the prescription of this training modality as part of the treatment for
this patient group. In the vast majority of the studies presented above, 2–3 weekly
sessions lasting 1 hour were applied for 3–6 months ( Krustrup, Aagaard et al.
2010 ; Bangsbo et al. 2015 ; Krustrup and Krustrup 2018 ). Thus, clinically relevant
beneficial effects on numerous physiological parameters of importance for treating
a number of CVDs were attainable within this timeframe when the training was
organised and supervised by researchers.
In relation to patients with stroke, aerobic exercise is recommended ( Pedersen
and Saltin 2015 ). Football training has been demonstrated to be an aerobic train-
ing form, including for weak patient groups, since average heart rate responses of
75–80% HRmax have been determined in patients with hypertension, prostate
cancer and type 2 diabetes ( Randers et al. 2010 ; Mohr et al. 2014 ; Uth et al.
2016 ; Skoradal et al. 2018 ). Since stroke patients normally have a poor physical
status ( King et al. 1989 ), it is suggested to start the training at low to moderate
intensity. In order to control the exercise intensity and avoid excessive workload
in the early phase of training during rehabilitation from stroke, the pitch size can
be reduced ( Randers et al. 2014 ) or walking football ( McEwan et al. 2018 ) can
be deployed.
As previously stated, football training combines aerobic, anaerobic and strength
training ( Krustrup and Krustrup 2018 ), and since several training forms are rec-
ommended for patients with arterial hypertension, football could be an efficient
treatment protocol for mild and moderate hypertension ( Pedersen and Saltin
2015 ). In support of this, meta-analysis evidence confirms that the deployment of

Football as Medicine for CVD 17
1-hour sessions of football training 2–3 times per week for 12–16 weeks reduces
mean arterial pressure by ~8 mmHg ( Milanović et al. 2019 ).
For patients with CAD, aerobic training at moderate intensities should be pre-
scribed ( Pedersen and Saltin 2015 ). Thus, football training with small pitch sizes
combined with walking football may be deployed to maintain the intensity at a
moderate aerobic level. Football training has been shown to have beneficial effects
on central as well as peripheral factors ( Krustrup, Aagaard et al. 2010 ; Krustrup
and Krustrup 2018 ), which is essential for CAD patients.
On the other hand, interval training should be deployed for patients with heart
failure ( Pedersen and Saltin 2015 ). As football training is a high-intensity inter-
mittent training form, if may be highly relevant for heart failure patients. These
patients have lower fitness statuses, maximal oxygen uptakes and muscle strength,
and a greater degree of skeletal muscle atrophy ( Pedersen and Saltin 2015 ), so
broad-spectrum training modalities, such as football training, should be deployed
for this patient group.
Football training may have some limited application for patients with intermit-
tent claudication, depending on the severity of the disease. Football training has,
for example, been shown to increase muscle capillarisation in m. vastus lateralis
( Krustrup, Aagaard et al. 2010 ) in untrained individuals, as well as arterial func-
tion in hypertensive subjects ( Krustrup et al. 2013 ), which is beneficial for patients
with intermittent claudication. Generally, both strength training and aerobic exer-
cise for upper or lower limbs is suggested ( Pedersen and Saltin 2015 ). Football
training is also an alternative form of strength training ( Krustrup, Aagaard et al.
2010 ). It has been shown to improve the oxidative capacity in both arms and legs
( Nordsborg et al. 2015 ), and may therefore be applied to patients in this group.
It is recommended that the training should be administered in a progressive and
individualised manner, possibly starting with walking football and slowly increas-
ing the volume and intensity.
Since the prevalence of most CVDs increases with age, it is essential to apply
exercise as medicine in a manner that can also be used by elderly patient groups.
Several studies have tested football training in elderly populations ( Schmidt et al.
2014 ; Schmidt et al. 2015 ; Bangsbo et al. 2015 ; Mancini et al. 2017 ; Skoradal
etal. 2018 ), with similar outcomes to those obtained in younger populations.
In summary, football training can be integrated into the treatment strategy
for numerous cardiovascular patient groups due to its broad-spectrum effects
with beneficial impact on cardiac and peripheral components. The Football
Fitness concept has now been implemented in hundreds of football clubs in
Scandinavia, where it is organised to a greater or lesser extent by the clubs
in cooperation with the national football associations ( Bennike, Wikman, and
Ottesen 2014 ). Furthermore, in 2016 we conducted a national intervention in
the Faroe Islands with around 2% of the adult population taking part ( Flotum
et al. 2016 ). Several of these clubs and original participants are still active,
which from an organisational point of view indicates that this is a sustainable
exercise training method.

18 Magni Mohr et al.
Directions for future studies of recreational football and
cardiovascular patients
The promising health effects of football training both for lowing cardiovascular
risk factors (prevention) and improving CVD (treatment) calls for further opti-
misation and understanding of the associated mechanisms. These may include
combination with other health interventions, e.g., nutritional optimisation of diet
to support weight loss in obese individuals or further lowering of blood pressure
potentially via reduced dietary sodium content, albeit the overall health effects of
lowering habitual dietary salt intake are debated ( Rust and Ekmekcioglu 2017 ).
This may be relevant for patients with heart failure. Given the average size effect
for CVD reduction as a result of lowering blood pressure, it is clear that an overall
decrease of 6–8 mmHg would have a marked effect on public health. But, for
the individual with severe hypertension, combinations of interventions may of
course be required and it will be attractive to evaluate the incremental effects of
such strategies in the future. Analogously, for patients with very high plasma lipid
levels, combination with pharmacological and nutritional interventions may be
required, and in terms of glucose tolerance, the interaction of physical exercise
with muscle metabolic adaptations and improved insulin sensitivity in patients
with CVD is an area of importance. Also, studies combining football training
with the administration of conventional pharmacological agents may provide new
treatment perspectives. We encourage future studies to evaluate the size effects of
physical exercise interventions on cardiovascular endpoints as well as explorations
of the physiological mechanisms involved.
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bjsports-2013-092576.

Chapter 17
A closing comment on
the policy and politics of
implementing Football as
Medicine
The English context
Daniel Parnell , Søren Bennike , Laila Ottesen
and Paul Widdop
Background
Football is one of the most popular sports in the world and given its mass youth
appeal and global reach, it provides a potentially invaluable vehicle for promoting
health ( Smith and Westerbeek 2007 ). The participative nature of football (whether
as a leisure activity, exercise or competitive sport) (see Bennike et al. 2014 ), as an
event and place to attend; or as a hook to engage people appears to be a prudent
consideration for policymakers and practitioners who aim to deliver health out-
comes ( Krustrup and Krustrup 2018 ; Parnell et al. 2016 ). Despite the burgeoning
evidence that supports Football as Medicine, this chapter argues that in order to
capitalise on this evidence, greater consideration must be placed on the policy and
politics of countries. This chapter focuses on England in the United Kingdom
(UK), given that football is a prominent sport of the country and should prove
excellent territory to deliver and lead the Football as Medicine agenda. Follow-
ing this, a brief analysis is provided on the football context in Denmark. These
two countries and policies have been chosen given their respective adoption of
different welfare models. England having an Anglo-Saxon model and Denmark
having a Scandinavian model. This chapter concludes with a call to arms for those
involved in Football as Medicine research.
Between the 1970s and 1980s, England engaged in a range of recreation and
welfare policies ( King 2009 ). In the 1990s, greater political acclaim was attached
to sport endorsing its potential to impact social welfare and regeneration ( Coal-
ter 2007 ). Sport was lauded as an instrument to deliver upon multiple agendas,
such as increasing income and jobs, improving education, health and social inclu-
sion ( Coalter 2007 ; King 2009 ). Given the widespread appeal and reach of sport,
some authors have acknowledged that it may provide a more effective vehicle in
reaching those at risk who may not be reached by traditional political or civic
activities ( Mellor 2008 ; Bloyce and Smith 2010 ; Collins and Kay 2014 ; Parnell
and Richardson 2014 ; Parnell et al. 2015a ). In contrast, several authors chal-
lenged the social impact of sport, claiming a lack of empirical evidence ( S mith

A closing comment on Football as Medicine 249
and Waddington 2004 ; Bailey 2005 ; Collins and Kay 2014 ). Despite this lack of
evidence, policies continued to endorse sport as a vehicle to attend to social agen-
das and change ( Coalter 2007 ).
Football is considered the national game in England and has been a prominent
vehicle in the health agenda. Whilst successive governments have used sport policy
to deliver policy goals, including youth justice, social inclusion and public health,
with limited evidence of effectiveness ( Coalter 2007 ), it is now beyond doubt that
regular physical activity during childhood and adolescence is an important part
of the foundation of a happy, healthy and longer life. The serious dangers associ-
ated with inactive lifestyles are equally clear, such as heart disease, diabetes and
obesity (see Bailey et al. 2015 ). As such, football has been employed in a variety of
contexts to deliver public health outcomes for various populations.
Tackling inactivity through a public health position is of particular impor-
tance, given its role in the major causes of death and disability, through non-
communicable diseases like obesity, heart disease and stroke, cancer, chronic
respiratory disease and diabetes. Estimations from the World Health Organization
claim the annual worldwide tally of 35 million people per year dying of these
chronic diseases, which is double the number dying from all combined infectious
diseases, like HIV/AIDS and malaria ( WHO 2005 ). This extends beyond the
human cost. In the UK, around 20 million adults are physically inactive, which
costs an estimated £7.4bn per year ( N ICE 201 8 ). As such, sport has increasingly
featured as a vehicle for public health ( Bailey et al. 2015 ).
Despite this, Kohl et al. (2012 ) suggest that contrary to evidence on the ben-
efits of physical activity being available since the 1950s, it is only recently that
government action has developed. One of the reasons for this lack of action is
the cross-cutting nature of sport development, which makes it difficult to man-
age. Indeed, whilst there is now an acknowledgement of the link between sport,
physical activity and health, strategies to address these issues are underdeveloped.
Yet, the importance of football (sports and physical activity) for most policymakers
and politicians lies in its status as the least expensive and most effective preven-
tive treatment for combating the increasing worldwide problem of obesity ( Bailey
etal. 2015 ). Given the widespread appeal of football, it would be remiss for poli-
cymakers and governments not to explore the potential of the game as a vehicle
of public health.
Football has received much attention in recent years for its contribution to
society via corporate social responsibility strategies, which have been delivered
through a variety of methods. One approach in England has been Football in
the Community (FitC) programmes, the community arms and often registered
charities of professional football clubs. Some examples of interventions delivered
by FitC programmes include those engaging hard-to-reach groups ( Curran et al.
2014 ), social inclusion ( Parnell et al. 2015a ) and health ( Parnell and Richardson
2014 ) across the lifespan and with men and women ( Parnell et al. 2013 ; Bingham
et al. 2014 ; Parnell et al. 2015b ) and in football stadia as a setting to promote
health ( Parnell et al. 2016 ). Football has even entered educational domains and
is now seen as a major contributor to the delivery of Physical Education and

250 Daniel Parnell et al.
School Sport, as sport policy in England ultimately encouraged schools to out-
source this aspect of the curriculum ( Parnell et al. 2016 ). Despite this, football is
under enhanced scrutiny for what has been observed as grassroots and community
failure (see O’Gorman et al. 2018 ).
To understand the present context, it is worth offering a brief historic perspec-
tive. Evidence suggests that there has been a historic mismanagement of sport
facilities, most notably playing fields – and resultantly football pitches, which are
a vital resource for community participants to play the game ( King 2009 ). This
previous policy disorganisation has resulted in lost playing fields and lack of main-
tenance, certainly over the past six decades. Subtle changes over times such as
shifting the protected area from 6 hectares to 0.2 hectares at present can have a
significant impact on practice (see King 2009 ). This would suggest that despite the
political hyperbole around sport in England, little genuine value has been placed
on sport locally and nationally, historically and geographically over time.
Evidence points towards a combination of both an absence of collaboration
between central government, national governing bodies for sport, Sport England,
other major stakeholders and local government, alongside the absence of (real)
power nationally to prevent local decisions. Ultimately, local government can
make local agreements to sell playing fields ( King 2009 ). This exists due to the
absence of rigid, coherent and extensive statutory laws related to playing fields,
a manifestation of political devolution. This decline in playing fields has devel-
oped overtime, despite many local governments previous support for football (and
sport). Indeed, many local governments remain inclined to support the benefits of
football today. However, in England, the current political and fiscal climate sug-
gest that over the past decade this decline has heightened and worsened the state
of play for community and grassroots football, despite the best intentions of some
local governments.
In May 2010, a Conservative Party-led coalition government assumed political
leadership of the UK. This was in response to (real and perceived) debt incurred
by the previous Labour administration, so the new government initiated consider-
able cuts to public spending, including a raft of austerity measures in its ‘Com-
prehensive Spending Review’, which outlined £81 billion cuts to government
departments. This meant that public spending was reduced on a national scale,
leaving few government departments untouched. By the end of 2013, almost
three and a half years after the introduction of austerity-driven policy measures, it
was estimated that £64 billion had been wiped from public expenditure. Austerity
was rolled out across the UK, spreading to all tributaries of public spending. Later,
the then Chancellor scheduled a further 20% expenditure cut between 2014 and
2018 ( Croucher 2013 ). The cuts impacted upon provision including services being
reduced, reorganised or disposed of. This included services such as libraries and
clubs for disabled children, to leisure centres and community sport facilities ( Blyth
2013 ; Parnell et al. 2015 ; Parnell et al. 2018 ). Importantly, these cuts were primar-
ily focused on social benefits and local government budgets.

A closing comment on Football as Medicine 251
Local governments were charged with delivering these expenditure reductions
( Audit Commission 2011 ). The Department of Communities and Local Govern-
ment’s funding was cut by 51% between 2010 and 2015, resulting in grants to
local government falling by 27%. As a consequence, discretionary services, such
as sport, leisure and culture faced funding uncertainty ( Collins and Haudenhuyse
2015 ; see Parnell et al. 2018 ).
During 2015, David Cameron, the Prime Minister of the UK at the time,
stated that there is a need for ‘a leaner, more efficient state’ in which ‘we need
to do more with less. Not just now, but permanently’ (quoted in Krugman 2012 ),
ensuring austerity would continue. Indeed, in the UK, the economy was set to face
a continued period of what scholars would describe as ‘super austerity’ (i.e. further
cuts upon already financially constrained services) ( Lowndes and Gardner 2016 ).
In terms of local government expenditure, the annual spending commitment
to services categorised by the Chartered Institute of Public Finance and Account-
ability as ‘sport development and community recreation’ are important to con-
sider, as these services primarily aim to raise and widen participation among
socio-economic groups considered to be the most excluded and tend to be subsi-
dised in order that income is not a barrier to participation ( King 2009 ). It is recog-
nised that the Chartered Institute of Public Finance and Accountability category
for expenditure on ‘indoor and outdoor facilities’ is also critical for participation
as is the expenditure on ‘parks and open spaces’. In fact, research undertaken by
the Association of Public Service Excellence ( A PSE 201 2 ) noted that although
reductions in expenditure on maintaining and servicing facilities have occurred
and were likely to continue, it is community-based programmes that have been
disproportionately affected, whether these services are a component of direct local
authority provision, funded from local budgets and delivered by local authority
staff, or are funded by central government agencies and delivered in a partnership
arrangement locally.
The impact of these funding cuts is relatively under-researched in scholarly
circles. However, recent evidence of the impact on a range of contexts and ser-
vices is starting to emerge, including the third sector ( Walker and Hayton 2017 ,
2018 ; Kenyon et al. 2018 ; Parnell et al. 2014 ; Parnell et al. 2018 ), public sector
services ( Ramchandani et al. 2018 ; Reid 2018 ) and sports participation ( Widdop
et al. 2018 ). This is of particular importance for football, as playing fields and
football pitches often fall under the leadership of local government or third sector
organisations. Moreover, football, as the nation’s game, is an important contribu-
tor to sport participation and physical activity, but its grassroots facilities are often
at the mercy of local governments working in an environment of austerity.
Widdop et al. (2018 ) noted that sport participation among socio-demographic
groups defined as ‘hard to reach’ has not altered significantly by comparing the
Active People data in 2008–09 with 2013–14. The study revealed that only mar-
ginal differences can be identified across the 5-year timespan (during the period
of intense austerity), which is perhaps unsurprising given the difficulties of raising

252 Daniel Parnell et al.
and widening participation among the low-income and socially excluded in a con-
text of disinvestment through austerity policies.
Furthermore a recent government strategy ( Cabinet Office 2015 ) has specifi-
cally focused on ‘social and community development’, implying that a commit-
ment of resources to raising and widening participation among ‘hard-to-reach’
groups is needed. However, in a period of austerity and public spending reduc-
tions, it appears that investment has not followed these policy aspiration to date, in
that participation has not increased in these priority groups ( Widdop et al. 2018 ).
Indeed, central government has a commitment to, ‘distribute funding to focus
on those people who tend not to take part in sport, including women and girls,
disabled people, those in lower socio-economic groups and older people’ ( Cabinet
Office 2015 , p.10). In order to achieve this, local governments are viewed as criti-
cal in delivering policy in this respect. However, it appears investment needs to
follow policy statements for any tangible change of participation to result.
As a consequence of funding cuts (whether austerity policy-related directly or
not), discretionary services such as sport have faced uncertain times and ultimately
an uncertain future, especially as trends suggest further regression of funding for
local authority services up until 2020 ( Collins and Haudenhuyse 2015 ). This has
created challenges for community sport facilities who have had to manage both
their financial viability and sustainability during this fiscal constraint ( Parnell et al.
2018 ). An Association for Public Service Excellence report ( 2 01 2 ) anticipated fall-
ing revenue budgets, staff cuts, increased charges, reduced opening hours, facility
closures and reduced commitments to parks and pitches utilised for organised
and casual participation in the light of changes to public funding levels. Some of
these predictions have been reported through case studies on reductions to sport
and leisure services and its impact on a range of sports from swimming facilities
to municipal golf courses. The question remains how this may impact upon the
potential for football to deliver upon the health agenda.
Despite austerity, football remains one of the most popular sports in England,
with a reported 1.8 million participants on a weekly basis ( Sport England 2017 ).
Whilst there is an absence of longitudinal data, evidence suggests a decline in
the number of people playing 11-aside competitive football ( T he FA 200 4 , 2 01 5 ;
Lusted 2009 ) . The data suggests that this decline accelerated between 2005 and
2015, showing the number of people playing affiliated 11-aside football fell by
180,000 ( T he FA 201 5 ). A recent analysis on contemporary issues in grassroots and
community football suggests we should anticipate a further reduction in the qual-
ity of football playing facilities, increased costs, overuse of pitches, more matches
cancelled, and potentially poorer experiences for players and, subsequently, less
players involved in the game ( O’Gorman et al. 2018 ).
Given the cost of lifestyle-related diseases and inactivity alongside the abun-
dance of evidence for the role football can play towards the health agenda, it
would make a reduction in funding for grassroots and community football appear
questionable. Given the relatively low estimated costs for community football
pitch development, whether grass or artificial grass surfaces, it appears to offer an

A closing comment on Football as Medicine 253
opportunity to design and deliver programmes to reduce inactivity and increase
sport participation. The cost of upkeep and enhancing grassroots and community
football could be argued as insignificant when compared to the potential public
health benefits of football, especially when compared with the financial burden of
inactivity. Given the potential ongoing threat of austerity-driven policies in Eng-
land, alongside the absence of rigorous protection for sport and leisure services
and playing fields, it would appear that we may be missing out on an opportunity
to capitalise on the evidence for Football as Medicine.
In the spirit of this book, and beyond merely the geography of the co-editors,
it appears pertinent to offer a comparison with a European neighbor country,
Denmark. Both countries adopt quite different approaches to a welfare model,
which stimulates interest and analysis. Moreover, Denmark is a country in which
the national football associations are specifically incorporating football for health
in their strategy and activity profile.
Denmark has a population of 5.7 million citizens and a GDP of $286 billion,
operating as a universal welfare state, also referred to as the Scandinavian or Nor-
dic model ( Esping-Andersen 1990 ; see also Ibsen 2017 ). It is beyond the scope of
this short text to further unfold the complex model of governance you will find in
Denmark. The country is among the healthiest countries in the European Union
with a high level of sports participation. According to the Eurobarometer ( Euro-
pean Commission 2014 ), Denmark is the 2nd most ‘active’ country and the 2nd
most ‘sport club active’ country. The total number of sport clubs in Denmark is
estimated to be around 16,000, corresponding to one per 350 inhabitants ( Ibsen
et al. 2015 ), making Denmark among the countries in the world with the highest
number of sports facilities per capita ( Rafoss and Troelsen 2010 ). In this case,
Ibsen and Ottesen highlighted in 2003 that there is a football pitch for every 1,000
people. According to the national database of facilities, Denmark has, at present,
approximately 4600 pitches, most of which are grass outdoor pitches, funded by
the government ( IDAN and LOA 2019 ). In terms of activity, a national survey
estimates 61% of the adult (16+) population is active, of which 39% are active
in sport clubs ( Pilgaard and Rask 2016 ). The latter is more than doubled when
considering children (age 7–15), as 83 % are active, of which between eight and
nine out of every ten children will have participated in sports in a sport club set-
ting ( Laub 2013 ; Pilgaard and Rask 2016 ). The same survey concludes that 7%
of the adult population (16+) and 37% of children (7–15) regularly play football,
of which a majority play in local clubs under the wings of the Danish Football
Association (DFA), making football the most popular sports-club-based activity in
Denmark.
An important aspect of understanding the relative success in sports participa-
tion numbers, and more specifically participation in sport clubs, is the relation
between the state and voluntarily organised sport clubs functioning as associa-
tions, being formal (formal democratic structures), private (self-governed) and
non-profit. Building on these characteristics, the clubs are placed in the voluntary
(third) sector ( Pestof 1992 ), which plays a unique role in the Scandinavian welfare

254 Daniel Parnell et al.
state model ( Klausen and Selle 1996 ). Overall, Denmark has been progressive
with their prioritisation of sport, which is delivered through a state-supported
model in which the sport clubs holds a relatively strong autonomy. Please note that
this autonomy is not functioning clearly separated from the state, on the contrary
it is sphere of social life dependent on the state ( Kaspersen and Ottesen 2001 ).
Of great importance to the development of sport clubs is the School Law of
1937, which required the municipalities to provide public schools of a certain size
with a playing field ( Ibsen and Ottesen 2003 ). And more importantly, to make
these facilities available to local sport clubs after school hours. This secured avail-
able and playable football pitches to football clubs all over the country, which
before that time stood as a major issue. Furthermore, in 1948, the Danish parlia-
ment adopted a State Football Pool, which secured the Sports Confederation of
Denmark (SCD) a relatively large part of the national monopolistic betting prof-
its (including the national lottery profits in 1989), bringing funding to the DFA.
Importantly, this funding is earmarked for activities related to grassroots football
alone (including the ‘football for health’ initiatives). In 1968, another law was
passed, the Danish Leisure Act, which provided favorable conditions for the clubs,
as it obligated the municipalities to support all leisure-time activities organised in
associations, including football, by means of grants and access to facilities. By this
time, a subsidised structure was created that remains within grassroots football
today; the state supports the work of the DFA, and the municipalities support
the work of association-based football clubs functioning relatively autonomously
on democratic principles. And lastly, the citizens pay membership fees to clubs,
and many are involved with voluntary work (see Bennike et al. 2017 ). Ibsen et al.
(2015 ) argues for the volunteers to be the resource securing the survival of sport
clubs, of which especially football clubs have a high number of volunteers. In rela-
tion to sport clubs, and thereby also football clubs, about half the income (facilities
included) of the sport clubs are based on local government support ( Ibsen and
Ottesen 2003 ). In addition, membership fees do likewise stand as a strong finan-
cial income for sport clubs ( Ibsen et al. 2015 ). The financial support and state
recognition of sport clubs creates an ‘associative democracy’ as a parallel form
of government to ‘representative democracy’, forming a dual strategy called ‘the
double democratic principle’ ( Kaspersen and Ottesen 2001 ).
Building on the above it becomes clear that the sport clubs of Denmark, includ-
ing the ones organizing football, are deeply dependent on the government hav-
ing favorable conditions. Further Ibsen and Eichberg (2012 ) argue that the sports
organisations of today have become a sector in the government intervention. The
perspectives in this book stand as an important point to understand how and why
the health outcomes of football are receiving an increased focus from politicians
and administrative policymakers. In the present time in Denmark, the welfare
state does not have the same amount of financial capacity as in previous times,
due to numerous factors related to expenditures and the global economic reces-
sion. As a result, in a time of austerity policy, the support for sport club activities
is being questioned and challenged under a lens of greater scrutiny (see KUM

A closing comment on Football as Medicine 255
2014; Bennike et al. 2017 ). This holds a tendency in which the support for sport
clubs is debated according to criteria of cost-utility ( Ibsen and Ottesen 2003 ). In
this case, policymakers are increasingly recognizing the value of advocating sport
and football as a means of enhancing the overall health of the population ( Thing
and Ottesen 2010 ; Bennike 2017 ). In the public health programme ‘A healthier
life for all’ (Danish Government 2014), the government sets the scene for increas-
ingly involving the voluntary sector, such as football clubs, in addressing issues
‘normally’ expected to be a state or municipal responsibility. This applies to tack-
ling issues such as health. This goal can be pursued either through infrastructural
power (as is currently the case) or through despotic power ( Mann 1990 ). Central
to infrastructural power is the state’s ability and desire to exercise its power in dia-
logue with society’s institutions, such as sports organisations (e.g. the DFA). Con-
versely, despotic power is used by the state when it intervenes directly in society
without entering into dialogue with the society’s agents ( Mann 1990 ). If the state
chooses to keep working in the infrastructural way, it will entail that the DFA and
the clubs are able and willing to voluntarily participate in working with health.
Bennike (2016 ) shows how health has progressed to a relatively central position in
the latest strategy of the Danish Football Association ( DFA 2012 ). The creation
and introduction of Football Fitness, which is an initiative coming from the DFA,
is an illustrative example. If the concept proves sustainable in the long-term, it will
become self-governing as an activity managed by local clubs and with state fund-
ing pursuant to the legislation benefitting the associations, especially in regard to
facilities.
This short commentary is intended to stimulate the similar yet contrasting
aspects of the welfare state model. For a fuller insight, we recommend that readers
examine Bennike et al. (2017 ), which helps reveal the evidence-based collaborative
policymaking and strategic support of Denmark against a more splintered and
under-funded approach in England. This should serve to stimulate considerations
for policy and practice transfer.
In summary, England has seen a historic mismanagement of sporting facilities,
which has resulted in lost playing fields and lack of maintenance. There has been
little political power or will nationally to prevent local decisions – ultimately, to
sell playfields, a strategy which requires greater scrutiny. Austerity has appeared to
heighten the decline in football participation and the general experience, resulting
in people turning away from the sport. This could be a false economy given the
need to get the nation active. It appears important for collaboration across football
stakeholders and government departments to tighten legislation and turn the tide
on declining playing fields, football pitches and declining football participation – if
football is to play a part in creating an active and healthy nation.
The state-funded model observed in Denmark offers a perspective of consid-
eration for researchers, practitioners and policymakers not only in the UK but
globally. It prompts us to reflect on the Football as Medicine model (see Krustrup
and Krustrup 2018 ; Figure 17.1). In doing so, we have adapted the Krustrup and
Krustrup model to go beyond our current focus on personal and interpersonal

Figure 17.1 An expanded version of the Football is Medicine model, emphasising that the policy, community and institutional levels are
important when using the football as a vehicle to promote world health.
Source: Adapted from Krustrup & Krustrup, BJSM, 2 018 .
Football training is all-in-one training
with broad-spectrum fitness and health effects:
aerobic high-intensity (HIIT), endurance and strength training
Football training, as per the Football Fitness concept, is social, fun,
variable, popular and adjustable, for participants of all ages and skill levels
Football training builds social relations in pair- and team-work
with positive effects on mental and social well-being
Football training elicits high ratings of enjoyment
with moderate ratings of perceived exertion
PREVENTION
HEALTHY
Extrinsic motivation Intrinsic motivation
FUN SOCIAL
TREATMENT
POLICY
REHABILITATION
R
e
c
r
u
i
t
m
e
n
t
A
d
h
e
r
e
n
c
e
Aerobic low
intensity
Football
training
Metabolic
fitness
Muscle
mass
Type 2
diabetes
Cardiovascular
diseases
Risk of falls
and fractures
Glucose
tolerance
Fat per-
centage
Blood
pressure
VO2max
Postural
balance
Bone
mass
Cardio-
vascular
fitness
Musculo-
skeletal
fitness
Aerobic mode-
rate intensity
Endurance
Training
HIIT
Training
Strength
training
Aerobic
high intensity
Speed
endurance
Speed,
strength
Bone impact
F
O
O
T
B
A
L
L
I
S
M
E
D
I
C
I
N
E
F
o
o
t
b
a
l
l
i
s
M
e
d
i
c
i
n
e
–
F
o
o
t
b
a
l
l
i
s
f
o
r
A
l
l
–
F
o
o
t
b
a
l
l
i
s
f
o
r
L
i
f
e
COMMUNITY
INSTITUTIONAL
INTERPERSONAL
AND
INDIVIDUAL
Training types Training categories Areas of fitness Measures Lifestyle diseases
Osteoporosis
I, They, We stories We, I, They stories

A closing comment on Football as Medicine 257
examination in greater detail. To do this, we have incorporated aspects of ecologi-
cal theory, i.e., institutional, community and policy to develop the model. Despite
evidence that football is medicine (and does work for health promotion and deliv-
ering on public health outcomes), broader forces are at play in enabling what we
know to be implemented.
Canadian medical sociologist Arthur Frank stated that new evidence does
not necessarily help us make better, more ethical decisions for our communities:
‘More knowledge may be less important than a clearer sense of value’ ( Frank
2000 , p.363). As many scholars operate in the knowledge economy of universities
on a day-to-day basis, exchanging and discussing new findings and analysis, evi-
dence in England points to either lack of information, willingness to listen and/or
action. Our rally call would be for Football as Medicine scholars to take on these
bigger policy and government challenges. To work with politicians and policy-
makers to crow bar the evidence into decisionmaker narratives. Ultimately, this
case serves to highlight that despite growing evidence for football’s potential role
in the health agenda, evidence alone pales in significance against public policy.
More needs to be done within policy domains if we are to aspire to share the evi-
dence to strengthen communities and society to be resilient to attend to the health
(and social) challenges we face. 
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