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01.05.2010
1
determinantsdeterminants ofof ((leisureleisure time) time) physicalphysical activityactivity andand in in consequenceconsequence
desirabledesirable policypolicy strategiesstrategies
determinantsdeterminants ofof ((leisureleisure time) time) physicalphysical activityactivity andand in in consequenceconsequence
desirabledesirable policypolicy strategiesstrategies
PD Dr. med. Susi Kriemler
FMH Pediatrics, FA Sports medicine
Swiss Tropical and Public Health Institute & Institute of Exercise and Health Science
University of Basel
SecularSecular trendstrends ofof obesityobesity in in adultsadultsin CHin CH
Staub 2010 BMC Public Health
BMI-shift:
Median shift 20.5 -> 22P90 shift 23 -> 27Overweight 1.5 ->23%
Jahr ∼∼∼∼1880Jahr 1930Jahre 2005-6
SecularSecular trendstrends ofof obesityobesity in in childrenchildren in CHin CH
7.4
19.90
0
5
10
15
20
25
Übergewicht Adipositas
%
1960-1965
1980-1990
2002
Zimmermann 04 Swiss Med Wkly
……whowho andand whatwhat isis decidingdeciding……
01.05.2010
2
overviewoverview
1. determinants of PA
• Children, adolescents, adults We don‘t let him play, but we won 4 games
by forfeit!
overviewoverview
2. what has been done to change PA habits
and what worked best
overview3. keys of an effective Public Health approach for policy
Social Ecological Model of Physical Activity
Davison & Birch 2001
PHYSICALACTIVITY
INDIVIDUALGender Age
Enjoyment
SOCIOCULTURAL
DIETARY
HABITS
SEDENTARY
BEHAVIOR
Beliefs Social capital
Physician
influence
Urban planning
policiesSocial support
friends
Social norms
Social isolation
Social support
family
Ethnicity
ENVIRONMENTAL/POLICY
Seasonality
Area-level SES
Crime rates &
neighborhood
safety
Walking/cycling tracks
Aesthetics of
environment
Active
transport
policies
Access to
recreational facilities
Someone to
be active with
Self-efficacy
Education
level SES
Barriers
Parental PA c
Peer & sibling
interactions c Children same
age live nearby c
Family rules
PA c
Cultural norms
Perceptions of
safety
Access to parks/
playgrounds
Connectivity of
streets
Topography
Organizational PA
policies
determinantsdeterminants ofof PAPA
11
The environment
Macro environment
Physicalenvironment
Individual behaviour
Economicalenvironment
Socio-culturalenvironment
Micro environment
Adapted from Egger&Swinburn 97 BMJ
1. 1. DeterminantsDeterminants ofof PA in PA in childrenchildrenandand adolescentsadolescents
• Reviews with separate results for children
(aged 3-12) and adolescents (aged 13-18)
• ∼200 studies reveiwed including ∼ 50
variables for children and adolescents
• % of univariate associations with
significant vs. non-significnat findings
• + clear evidence, +/- inconclusive, - no
evidence
Sallis 00 MSSE, van der Horst 07 MSSE
01.05.2010
3
DemographicDemographic//biologicalbiological variablesvariables
Children Adolescents
Males + Males
Parental education +/- Parental education +
Age, ethnicity - Age, ethnicity +/-
BMI/skinfolds - BMI, SES
single parent
Sallis 00 MSSE, van der Horst 07 MSSE
Psychological variables Psychological variables andand PAPA
Children Adolescents
Self-efficacy +self-efficacy, attitude, goal
orientation/motivation
Intention, perceived barriers, sport competence +/-
Self perception, enjoyment, barriers
towards PA-
self-perception, perceivedbenefits, fun/enjoyment,
depression
Sallis 00 MSSE, van der Horst 07 MSSE
SocialSocial//behaviouralbehavioural variables variables andand PAPA
Children Adolescents
Parental support +Parental and peer support ,
help from parents
+ Siblings PA
+ PE/school sports
Parental PA +/- Parental PA +/-
TV time - Smoking, TV time
Sallis 00 MSSE, van der Horst 07 MSSE
Environmental variables Environmental variables andand PAPA
Children Adolescents
Program/facility access + Opportunities for PA
Time outdoors +
Perceived access tofacilities/play space/sporting
equipment-
Perceived access tofacilities/play
space/sporting equipment
Sallis 00 MSSE, van der Horst 07 MSSE
CorrelatesCorrelates ofof PA in PA in adultsadults
Correlates Association
Personal Age, male, good health, lack of time
Psychological Intention, self-efficacy, perceived benefits
Environment Supportive physical environment:accessible facilities, presence of
sidewalks/bike paths, safe streets,
good lightening etc
Sherwood 00 Ann Rev Nutr, Pan 09 BMC PH, Dishman 85 Pub Heath Rep, NcNeill 06 Soc Sci Med, Sallis 02, Humpel 02 AJPM, Duncan 05 Int J Behav Nutr PA
CorrelatesCorrelates ofof PA in PA in adultsadults
Correlates Association
Social SES, social inequalities
Social support and networksSocial environment:
companionship, encouragement,
assistance from friends/family
members, tangible aid and servicefrom community,
advice/suggestions/information
from professionals
Sherwood 00 Ann Rev Nutr, Pan 09 BMC PH, Dishman 85 Pub Heath Rep, NcNeill 06 Soc Sci Med, Sallis 02, Humpel 02 AJPM, Duncan 05 Int J Behav Nutr PA
01.05.2010
4
SummarySummary ofof PA PA correlatescorrelates
• Children: gender, self-efficacy, outdoors, parental PA, parental parental supportsupport
• Adolescents: gender, parental education,
attitude, self-efficacy, goal orientation/motivation, physicalphysical educationeducation//schoolschool sportssports participationparticipation,
familyfamily andand friendsfriends supportsupport
• Adults: age, gender, intention, self-efficacy, socialsocial supportsupport andand environmentenvironment, supportive
physicalphysical environmentenvironment
……somesome moremore toto considerconsider
100‘000 y
Homo sapiens
„„survivalsurvival ofofthethe fittest“fittest“
5-8‘000 y
Human societies
Economic successleads toto betterbettersurvivalsurvival
500-3‘000 y
HealthHealth promotionpromotionthroughthrough PAPA
• 776 first olympicgames
today
industrialisation
Elimination Elimination ofof PA PA asasstrategystrategy ofofsurvivalsurvival
-->>developmentdevelopmentofof chronicchronicdiseasedisease
Bouchard, Blair&Haskell 2007
….….moremore passive passive travellingtravelling ……lessless pedestrialpedestrial commutingcommuting
……moremore sedentarysedentary leisureleisure timetime ….….lessless domesticdomestic activityactivity
01.05.2010
5
EffectEffect ofof changingchanging distributiondistribution ofofactivitiesactivities andand energyenergy costcost
EffectEffect ofof changingchanging distributiondistribution ofofactivitiesactivities andand energyenergy costcost
EffectEffect ofof changingchanging distributiondistribution ofofactivitiesactivities andand energyenergy costcost
2% positive energy balancecan lead to overweight
This is about 125 kJ/day or 15 min PA
abnormal reaction to a normal environment?
normal reaction to anabnormal environment?
Egger&Swinburn 97 BMJ
2. 2. whatwhat hashas beenbeen donedone toto changechange PA PA habitshabits andand whatwhat workedworked bestbest??
?
Intermediate
outcomes
health
outcomes
INTERVENTION AEROBIC CAPACITY
modifiable
determinants
PHYSIOLOGICAL MEASURES
(anaerobic capacity,
muscular strength,
endurance, HR, BP, capillary
density, stroke volume)
INFORMATION
BODY COMPOSITION
(muscle mass ↑, fat mass ↓)
BEHAVIOUR-SOCIAL
SKILL-BASED FITNESS
(balance, coordination)
ENVIRONMENT/POLICY
METABOLIC FITNESS
(bone density, lipid profile,
insulin, coagulation,
immunologic function)
MOOD
(anxiety, depression)
other modifiable determinants
(genetics, nutrition, co-
morbidities)
PA
BEHAVIOUR
Measures of
Mortality/Morbidity
and QoL
1°/2° prevention
suggested
osteoporosis,
depression, stroke,
PAVK, cholelithiasis
Measures of
Mortality/Morbidity
and QoL
1°/2° prevention
established
CHD, hypertension,
Diabetes, colon cancer,
falls with fracture,
health-related QoL
MODEL to look at INTERVENTION STUDIES
Kahn 02 Am J Prev Med
01.05.2010
6
Information Information approachesapproaches
• Designed to increase PA by providingprovidinginformationinformation necessary to motivate and enable
people to change their behaviour, as well as to
maintain change over time
• Focus on cognitive skills
• Use of primarilyprimarily educationaleducational approachesapproaches
• Interventions: point-of-decision prompts,
community-wide educational campaigns, mass media campains, classroom-based health
education
Kahn 02 Am J Prev Med
EffectivenessEffectiveness ofof informationinformation
InformationResults of intervention
trials
Point-of-decision prompts(placement of a sign)
recommended
Community-wide campaigns recommended
Mass media campaigns insufficient evidence
Classroom based healtheducation
insufficient evidence
www.thecommunityguide.org
InformationalInformational interventionintervention
� ‘point-of-decision’-signs on elevator doors
� motivational texts in staircases
� slim making mirrors in staircases
� routing of people to the stairs
Engbers 07 Prev Med
PointPoint--ofof--decisiondecision signssigns
Routing Motivational texts
1 mars = 27 min of stair walking
Engbers 07 Prev Med
Food Food labellinglabelling
• Food labelling: caloric values of products translated into number of minutes of a certain activity
1 orange = 55 Kcal
≈ 6.9 minutes cycling
1 mars = 270 Kcal
≈ 30 minutes stair walking
≈ 2.5 hours sitting in a meeting
Engbers 07 Prev Med
ResultsResults
• Effects generally modest
• Effects on LDL- and HDL-chol signficant in favour of the intervention group
• Effects higher in men and those with BMI<25
Engbers 07 Prev Med
01.05.2010
7
BehaviouralBehavioural andand socialsocial approachesapproaches
• Teaching widely applicable behaviouralbehavioural
managementmanagement skillsskills and by structuringstructuring thethe
socialsocial environmentenvironment ot provide support for
people trying to initiate or maintain
behavioural change
www.thecommunityguide.org
BehaviouralBehavioural//socialsocial interventionsinterventions
ChangeResults of intervention
trials
School-based PE recommended
Classroom health educationto reduce TV
insufficient evidence
Family-based social supportinterventions
insufficient evidence
Social support interventionsin communities
recommended
Individually-adapted healthbehaviour change
recommended
www.thecommunityguide.org
……oneone thoughtthought aboutabout thethe socialsocialsystemsystem....
• http://content.nejm.org/content/vol357/issue4/images/data/370/DC2/
NEJM_Christakis_370v1.swf
Chrisdakis 07 NEJM
The The closercloser thethe relationshiprelationship thethemoremore riskrisk
Chrisdakis 07 NEJM
SummarySummary
• A person‘s chance of becoming obese
increased
• by 57% if he/she had a friend who became
obese
• by 40% with an adult obese siblings
• by 37% with an obese spouse
A A behaviouralbehavioural//socialsocialinterventionintervention thatthat worksworks
• We therefore implemented a school-based PA intervention aiming at
• ↑ PA (accelerometry)
• ↑ aerobic fitness (shuttle run test)
• ↑ quality of life (child health questionnaire)
• ↑ percent body fat (skinfolds)
• ↓ a cardiovascular risk score (BP, waist circumference, HDL-cholesterol, triglycerides, glucose)
• Use of a behavioral and social approach by focussing
on increasing PA by structuring the social environment (school)
Zahner,Puder&Kriemler BMC Public Health 06
01.05.2010
8
KISS KISS populationpopulation
• Cluster-randomized, controlled trial
• 2 provinces (ca 10% ofSwiss population)
• N=504, 28 classes
• 1st and 5th grade
• equally distributed rural-urban
• 10-30% migrants
Zahner,Puder&Kriemler BMC Public Health 06
KISS KISS interventionintervention (1 (1 schoolyearschoolyear))
• Daily physical education (3+2 lessons) withcompensation of 2 academic lessons
• Short activity breaks during academic lessons
• Physical activity home work
• Play tools during recess
• Education of classroom teachers and parents
Dartfit
Short PA Short PA breaksbreaks PAPA homeworkhomework
Playtools Playtools forfor recessrecess
Cleven - Becker Foundation
-0,3
-0,2
-0,1
0,0
0,1
0,2
Deltas z-Score
-12
-7
-2
3
8
ResultsResults
Zahner&Kriemler BMC Public Health 06, Kriemler&Zahner 10 BMJ
28 classes (n=502)
ShuttlerunCardiovascular
Risk ScoreSum of 4 skinfolds
MVPA in school&whole day)
Qualityof life
* ***
RCT [15360785]RCT [15360785]
Intervention
Controls
**
Del
tas
skin
fold
s (m
m),
M
od
erat
e-vi
go
rou
s P
A (
min
/day
)Q
ual
ity
of
life
(Sco
re)
01.05.2010
9
……whywhy successfulsuccessful
• Change of the social environment
• Inclusion of everybody
• Expert physical education teachers
• „mandatory“ approach
• Playful and fun
Kriemler&Zahner 10 BMJ
Environmental Environmental oror policypolicyapproachesapproaches
• Efforts of worksites, coalitions, agencies,
and communities to createcreate accessaccess toto
placesplaces where people can be active
www.thecommunityguide.org
Environmental Environmental andand policypolicy
ChangeResults of intervention
trials
Community-scale urban design and land use policies
Recommended
↑access to places for PA Recommended
Street-scale urban design/land use policies
Recommended
Transportation and travelpolicies and practices
insufficient evidence
www.thecommunityguide.org
PuttingPutting all all togethertogether: : EPODEEPODE
• Community-based childhood obesity prevention program in France
• Global effort of the whole community including shop owners, teachers, doctors, pharmacists, caterers, restaurant owners, sport
associations, media, scientists and the town government
www.epode.fr
01.05.2010
10
……whywhy isis thisthis so so geniousgenious
• Global work of the whole community
• everybody takes part
• Costs: 2 Euros per year and inhabitant
……andand itit worksworks !!! !!!
Romon 08 Public Health Nutr
3. 3. KeysKeys ofofan an effectiveeffective Public Public HealthHealth approachapproach
Focus on :Focus on :
•• 11°°prevention
•• childrenchildren where habit change is still doable
• the socialsocial systemsystem and environmental environmental changechange
…. …. PossiblePossible nightmarenightmare
Politicians:
politicans.mpeg
…. …. dreamdream
with know how and a long-term view
Politicians:
…. …. mymy dreamdream
http://youtube.com/watch?v=XQcVllWpwGs
know how
Vision:Politicians:
01.05.2010
11
…. …. mymy dreamdream
http://youtube.com/watch?v=XQcVllWpwGs
know how
Vision:Politicians:
He will never forget….
thanksthanks !!
…. but…. but
1 000
1 500
2 000
2 500
3 000
1960 1965 1970 1975 1980 1985 1990 1995 2000
Cig
are
ttes/
gra
ms
per
adult
First tobacco law
New tobacco law
Tobacco and Health
Reports
Statistics Finland 1998
…. but…. but
1 000
1 500
2 000
2 500
3 000
1960 1965 1970 1975 1980 1985 1990 1995 2000
Cig
are
ttes/
gra
ms
per
adult
First tobacco law
New tobacco law
Tobacco and Health
Reports
Statistics Finland 1998
perhaps a more draconic action is needed….
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