1. World-Wide Physical Inactivity: Scope of the Problem and What to Do about It Moscow, Russia Russia-U.S.A. Scientific Forum November 17, 2011 Steven N. Blair Departments of Exercise Science & Epidemiology/Biostatistics University of South Carolina

2. Non-Communicable Diseases (NCDs) Changing patterns in leisure and work have led to a health crisis NCDs cause 65% of all deaths worldwide 36.1 million deaths from CVD, Stroke, Diabetes, Cancer & Respiratory diseases. Physical inactivity causes 3.2 million deaths/year WHO. Mortality and burden of disease estimates for WHO Member States in 2008. Geneva: World Health Organization, 2010.

3. NCDs: Key Risk Factors Beaglehole et al., Lancet 2011; 377: 1438–47   Direct Causal Factors Tobacco use Physical Inactivity Poor Nutrition   Intermediate Risk Factors Obesity Hypertension Hyperglycemia Hypercholesterolemia

4. Mortality in millions (total 58.8 million) Leading risk factors for mortality by income group (estimates from 2004) © World Health Organization 2009 (http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.html)

5. Self-reported Physical Activity Underestimates the True Effect 31,818 men and 10,555 women 1492 deaths in men during average follow- up of 14.6 years, and 230 deaths in women during average follow- up of 12.8 years PA mortality trends not significant after adj for CRF CRF trends significant after adj for PA Phys Act CRF Lee DC, et al. BJSM 2011; 45:504-10

6. Aerobics Center Longitudinal Study

7. Design of the ACLS 1970 More than 80,000 patients 2005 Mortality surveillance to 2003 More than 4000 deaths Cooper Clinic examinations--including history and physical exam, clinical tests, body composition, EBT, and CRF 1982 ‘86 ‘90 ‘95 ’99 ‘04 Mail-back surveys for case finding and monitoring habits and other characteristics

8. All-Cause Death Rates by CRF Categories—3120 Women and 10 224 Men—ACLS Blair SN. JAMA 1989

9. Does Changing Cardiorespiratory Fitness Reduce Mortality Risk?

10. Fitness Change Categories Unfit was defined as the least fit 20% of men in each age group Men were classified as fit or unfit at both examinations Change categories unfit at both examinations = never fit unfit at first, fit at second = improvers fit at both examinations = always fit Blair SN et al. JAMA 1995; 273:1093-8

11. Age-Adjusted Death Rates by Fitness Change Groups, Men, ACLS Blair SN et al. JAMA 1995; 273:1093-8

12. CRF and Other Health Outcomes

13. CRF and Risk of Incident Hypertension, ACLS Women 4,884 healthy women examined at the Cooper Clinic, 1970-1998 157 women developed hypertension during average follow-up of 5 years Risk adjusted for age, exam year, alcohol intake, smoking, BP, family history of hypertension, waist girth, glucose, & triglycerides Fitness Groups Risk of Developing Hypertension Barlow CE et al. Am J Epidemiol 2006; 163:142-50 P for trend <0.01

14. CRF and Breast Cancer Mortality 14,551 women, ages 20-83 years Completed exam 1970-2001 Followed for breast cancer mortality to 12/31/2003 68 breast cancer deaths in average follow-up of 16 years Odds ration adjusted for age, BMI, smoking, alcohol intake, abnormal ECT, health status, family history, & hormone use Odds Ratio p for trend=0.04 Sui X et al. MSSE 2009; 41:742

15. Activity, Fitness, and Mortality in Older Adults

16. Cardiorespiratory Fitness and All-Cause Mortality, Women and Men ≥60 Years of Age 4060 women and men ≤60 years 989 died during ~14 years of follow-up ~25% were women Death rates adjusted for age, sex, and exam year All-Cause death rates/1,000 PY Age Groups Sui M et al. JAGS 2007.

17. Cardiorespiratory Fitness and Health Outcomes in Various Population Subgroups Such as People Who Are Overweight or Obese or Those with Chronic Disease

18. Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men, ACLS # of risk factors Risk Factors current smoking SBP >140 mmHg Chol >240 mg/dl Cardiorespiratory Fitness Groups *Adjusted for age, exam year, and other risk factors Blair SN et al. JAMA 1996; 276:205-10

19. CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men with Diabetes, 179 CVD Deaths Church TS et al. Arch Int Med 2005; 165:2114 *Adj for age and examination year p for trend <0.0001 p for trend <0.002

20. Controlled HTN Stage 1 HTN Stage 2 HTN Severity of HTN P <.001 P <.001 P =.048 CRF: Age and exam year adjusted rates of total CVD events by levels of CRF and severity of HTN in 8147 hypertensive men Sui X et al. Am J Hyptertension. 2007 CVD incidence/1000 man-years

21. Summary

22. 40,842 Men & 12,943 Women, ACLS Attributable Fractions (%) for All-Cause Deaths 40,842 Men & 12,943 Women, ACLS Blair SN. Br J Sports Med 2009; 43:1-2.

23. Getting People to Be Physically Active

24. Behavioral Approaches to Physical Activity Interventions Theoretical foundations Social Learning Theory Stages of Change Model Environmental/Ecological Model Methods Problem solving Self-monitoring Goal setting Social support Cognitive restructuring Incremental changes Manipulating the environment Marcus & Forsyth. Motivating People to Be Physically Active, 2 nd edition. 2009. Human Kinetics (www.hkusa.com

25. Track Record of Lifestyle PA Interventions Successfully implemented in many different populations and settings Men and women of all ages African-American men and women, Hispanic women Prostate cancer survivors Worksites, YMCA’s, public heath departments, recreation facilities, senior centers, churches We can get a substantial proportion of inactive people to become active

26. Using Modern Technology to Promote Healthful Lifestyles

27. Promoting PA via PDA 37 healthy, inactive adults, ≥50 years of age 8-week RCT PDA intervention (93% had not used PDAs) Questions about amount and type of PA Alerted at 2 PM and 9 PM to complete PA assessment Gave motivational and behavioral tips Controls—standard written materials King AC et al. Am J Prev Med 2007; 34:138-42

28. Promoting PA via PDA Intervention participants completed 68% of the 112 PDA entries available After adjusting for baseline differences PDA group reported 310.6 minutes of moderate to vigorous PA/week Control group reported 125.5 minutes/week p=0.048 for group comparison 78.6% of PDA group reported enjoying using the device King AC et al. Am J Prev Med 2007; 34:138-42

29. The SenseWear Armband (SWA)  The SenseWear TM Armband (BodyMedia, Pittsburgh, PA)  Lightweight monitor worn on the upper left arm  Four sensors (skin temp, galvanic skin response, heat flux, tri-axial accelerometer)  Estimates energy expenditure  Physical activity – duration & intensity

30. Effects across time for weight. Estimates adjust for age, gender, race, education, and wave. Standard Care GWL GWL=Group Weight Loss SWA=SenseWear Armband Shuger S et al. 2011 IJBNPA

31. Where Do We Go from Here?

32. All countries should develop a national physical activity plan

33. What is a Physical Activity Plan? A comprehensive set of strategies including policies, practices, and initiatives aimed at increasing physical activity in all segments of the population.

34. Mass Media Public Health Education Healthcare Volunteer and Non-Profit Organizations Transportation, Urban Design, Community Planning Business and Industry Parks, Recreation, Fitness, and Sports

35. Prevention of NCDs Prevention is essential to reduce immediate burden and protect future generations NCDs threaten health and social systems and hinder economic performance A 2% reduction in NCD death rates will achieve an increase in economic growth of 1% per year within a decade Cecchini et al. The Lancet 2010; 376:1775-84

36. Thank you Questions?