Physical Activity Promotion: Prevention of Chronic Disease Morbidity

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Physical Activity Promotion Prevention of
Chronic Disease Morbidity Mortality

• Antronette (Toni) Yancey, MD, MPH, FACPM
• Associate Professor, Dept. of Health Services,
• Co-Director, Ctr. to Eliminate Health Disparities
• UCLA School of Public Health
• www.ph.ucla.edu/cehd
• www.toniyancey.com

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Unhealthy eating and inactivity are leading
causes of death in the U.S.
Leading Contributors to Premature Death1

• HHS estimates that unhealthy eating and
  inactivity contribute to 310,000 to 580,000
  deaths each year. Thats 5 times more than are
  killed by guns, HIV, and drug use combined.1
• The typical American diet is too high in
  saturated fat, cholesterol, salt, and refined
  sugar and too low in fruits, vegetables, whole
  grains, calcium, and fiber.
• Such a diet contributes to four of the seven
  leading causes of death and increases the risk of
  numerous diseases, including
• ?heart disease ?diabetes
• ?cancer ?high blood pressure
• ?obesity ?osteoporosis
• ?stroke
• 60 of Americans are at risk for health problems
  related to lack of physical activity (ie get
  less than 30 minutes of moderate activity 5 or
  more times per week). 2

Diet and Physical Inactivity 310,000-580,000
Tobacco 260,000-470,000
Alcohol 70,000-110,000
Microbial Agents 90,000
Toxic Agents 60,000-110,000
Firearms 35,000
Sexual Behavior 30,000
Motor Vehicles 25,000
Drug Use 20,000
Leading Causes of Death3 (Diet is a leading risk
factor for causes of death shown in bold or
green.)
1. Heart Disease 724,900
2. Cancer 541,400
3. Stroke 158,400
4. Chronic Obstructive Pulmonary Disease 112,700
5. Accidents 97,800
6. Pneumonia and Influenza 91,900
7. Diabetes 64,900
8. Suicide 30,500
9. Nephritis 26,200
10. Chronic Liver Disease/Cirrhosis 25,100
11. Septicemia 23,800
12. Alzheimers 22,700
13. Homicide and Capital Punishment 18,400
14. Atherosclerosis 15,400
15. High Blood Pressure 14,300
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DIABETES PREVENTION PROGRAM

• The goal was to study the reduction in incidence
  of Type 2 diabetes with lifestyle intervention or
  metformin
• All patients had impaired fasting blood sugars,
  but were not diabetic
• Their were randomized to placebo, metformin or a
  lifestyle modification with goal of at least 7
  weight loss, at least 150 minutes of exercise per
  week
• They were followed over 2.8 years

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DIABETES PREVENTION PROGRAM
Lifestyle intervention was much more effective
than either placebo or metformin
DPP Research Group. N Engl J Med.
2002346393-403.
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Fitness Mortality

• Low fitness is bad for health

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Walking CVD

• Walking as little as 5 mins. daily is beneficial
  for fitness
• 30 mins. daily provides best health benefit
  (heart disease prevention)
• 60 mins daily can cause reversal of heart disease

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Physical Activity Risk of Common Cancers

• Colon 30-40 decreased risk among active men
  women (Rectalno association)
• Breast substantial evidence for dec risk
  strength of assn--time period may be critical
• Prostate findings inconclusive
• Possible mechanisms
• 1. decreased GI transit time (dec carc expos)
• 2. enhanced immune function (moderate PA)
• 3. lowered levels of reproductive hormones

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Population Attributable Fraction Cancer Mortality
Male Never Smokers
Population BMI Exposure RR PAR ()
25.0-29.9 42 1.1 4.0 30.0-34.9
21 1.4 6.8 gt35.0 13 1.3 3.4
14.2
NHANES 2000, men age 50-69
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Population Attributable Fraction Cancer Mortality
Women Never Smokers
Population BMI Exposure RR PAR ()
25.0-29.9 29 1.1 3.3 30.0-34.9
23 1.3 6.1 35.0-39.9 11 1.4 3.5 gt40.0
8 1.9 7.0
19.8
NHANES 2000, women age 50-69
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http//apps.nccd.cdc.gov/brfss/Trends/trendchart_c
.asp?state_cCAstateUSqkey10020SUBMIT1Go
YEAR Obese No LTPA 1991 10 23.3 1995 14.4
22.7 1998 16.8 25.5 1999 19.6 no
data 2000 19.2 26.5
BRFSS DATA
20 15 10 5
30 25 20 15
No LTPA
obese
1991 1995 1998 2000
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Lesser Effectiveness of Key Environmental
Interventions in Underserved Groups Example

• Posting of Signs Promoting Stair Usage
• (suburban Baltimore mall)
• Overall, stair use increased from 4.8 to 6.9,
  7.2, depending upon which of 2 signs used
• Among whites, increased from 5.1 to 7.5, 7.8
• Among blacks, changed from 4.1 to 3.4, 5.0
• Among nl wt, inc from 5.4 to 7.2, 6.9
• Among overwt, inc from 3.8 to 6.3, 7.8
• Andersen, Franckowiak, Snyder et al., Ann Int
  Med, 1998129363-369.

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Excess physical environmental risk in underserved
communities

• Pervasive targeted commercial marketing
• Distance to private fitness facilities
• Few worksite fitness opportunities
• Few/poor neighborhood recreation facilities
• Lesser neighborhood safety
• Poorer public/less reliable private
  transportation
• Poorly equipped facilities
• Poorly maintained sidewalks, e.g., cracks,
  litter, overgr. foliage
• Fewer traffic calming devices, e.g., speed bumps
• Ample car accommodation, e.g., parking, high-
  speed/multi-lane roads
• Move insecurity1, 2
• 1Jahns Jones, AJPM 200426186 2Yancey, AJPM
  200325(3Si)
• Adapted from Kumanyika S. Obesity in Minority
  Populations. In Fairburn G Brownell K, Eating
  Disorders and Obesity. A Comprehensive Handbook,
  2002.

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Which billboard(s) is (are) about physical
activity?
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Media Project five-city outdoor advertising
content analysis

• Funded by CA DHS, UT, Penn RWJF
• Cities LA, Philadelphia, Austin, Sacramento,
  Fresno
• Comparing high low SES predominantly black,
  Latino, white neighborhoods (all 6 categories
  not available in all cities, e.g., high SES black
  in Sacramento and Fresno)
• Utilizing secondary data from CHIS, LACHS,
  grocery store scanner (MOU with major supermarket
  chain) purchase data for correlational analyses

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Preliminary findings

• Absence of billboards and near-absence of other
  outdoor advertising in affluent white
  neighborhoodsexisting ads unrel. to weight
• Essentially no outdoor advertising of
  PA-promoting goods services in any community,
  but large amount sedentary entertainment
  transportation ads in low-inc. communities
• Pervasiveness of advertising in low-inc. white
  Latino communities, but more fast food,
  sugar-sweetened and alcoholic beverages in latter
• City of LA has moratorium on new billboards, but
  in low-inc. Latino comm., large of new side of
  building ads similarly framed
• Findings must be interpreted in light of
  historical covenants, fewer ads trad. In
  unincorp. areas

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Excess sociocultural environmental risk in
underserved communities

• Cultural attitudes about work, activity, rest
• Fears about safety
• Prevalent obesity/norms
• Female roles
• Cultural reverence for cars
• Hairstyle-related concerns about sweating
• Increased screen time, e.g., TV viewing,
  movie-going

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LAs ESPN Radio 710 AM Ad

• Were the prime rib on a dial full of tofu
• --March 2006

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Cultural reverence for SUVs?
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AVERAGE ENERGY EXPENDITURE ESTIMATES
Hunter-gatherers 5000 cal
1 million yrs ago
Agriculture 6000 cal
10,000 yrs ago
Laborers 3000 cal
1915
Office Workers 1800 cal
NOW
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Physical Activity Levels, L.A. County Adults,
1999
District Sedentary (lt10 min/wk) Sedentary (lt10 min/wk)
County 41 1
Compton 45 6
South 50 9
Inglewood 46 6
Long Beach 37 5
West 31 3
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Physical Inactivity Levels TV viewing/computer
use, L.A. County Adults, 1999
Ethnic Group TV/Computer Use gt3 hrs/d (95 CI) TV/Computer Use gt3 hrs/d (95 CI)
County total 21.7 20.6-22.9
African Americans 36.5 32.4-40.5
American Indian 34.2 16.1-52.3
Asian/Pacific Isl. 21.1 17.6-24.6
Latino 15.8 14.3-17.3
White 24.3 22.4-26.2
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Self-Perceived Overweight by Ethnicity Gender,
LA County Adults
Female Male
AA Overwt 67 29
AA Nml wt 20 --
API Overwt 86 46
API Nml wt 28 10
Lat Overwt 80 41
Lat Nml wt 26 9
W Overwt 84 46
W Nml wt 21 4
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Influence of Self-Perceived Weight Status on
PA, LA County Adults

• Overall, regardless of BMI, those perceiving
  themselves as overweight more sedentary than
  those with average wt. self-perception (45 vs.
  30)
• Influence most pronounced for males and normal
  weight individuals
• Overwt. self-perception not assoc. with
  sedentariness among white women, the only one of
  the 6 ethnic-gender groups included in which
  BMIlt25 normative
• In multivariate analysis, self-perceived
  overweight, not BMI, predicts sedentary behavior
  (OR1.40, CI 1.19, 1.64)
• Yancey, Simon et al., Obes (Res) 200614980-8.
  Yancey, Wold et al., Am J Prev Med,
  200427146-52.

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Current Population Status

• Little change in leisure time physical activity
  (PA) during past several decades of obesity
  increases (1 in 5), but marked increases in
  sedentary entertainment, transportation, and
  other ADLs (Sturm, 2004)
• PA levels within increasingly sedentary,
  deconditioned, overweight population are unlikely
  to increase primarily through individual
  motivation and volitionrelatively little demand
  for goods services or political will to push
  for aggressive legislative policy change, e.g.,
  radical alteration in the built environment
  favoring bicycle, pedestrian, and mass transit
  over private automobile transportation

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Daily Dose (Rx) of Physical Activity

• 30-60 minutes/day on most (at least 5) days of
  the week
• At least moderate intensity (walking 1 ½ to 2
  miles in 30 minutes)
• Can be broken up into 10-minute stretches
  throughout the day
• Every calorie burned is one that doesnt end up
  around your waist!

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AFRICAN AMERICAN WOMEN HEART DISEASE DIABETES
PREVENTION PROGRAM

• The goal was to study the reduction in incidence
  of Type 2 diabetes with lifestyle intervention or
  metformin
• All patients had impaired fasting blood sugars,
  but were not diabetic
• Their were randomized to placebo, metformin or a
  lifestyle modification with goal of at least 7
  weight loss, at least 150 minutes of exercise per
  week
• They were followed over 2.8 years

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How much is enough?
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Population benefit estimates of risk factor
change PA

• 3-minute bouts of PA 10 times per day lowers
  serum triglycerides to same extent as 1
  continuous 30-minute bout of PA (Miyashita et
  al., 2006)
• Maintenance of moderate PA is assoc. with a 1/3
  to 2/3 lowering of Type 2 diabetes (DM) incidence
  over 4-14 yrs (Clark, 1997)
• Type 2 DM risk was 50 lower among individuals
  physically active at any level, and 66 lower
  among those at least moderately active (James et
  al., 1998)
• Sedentary behaviors (e.g., TV watching) as well
  as sub-optimal gtmoderate PA levels contributed to
  DM obesity risk over 6 yrs in women (Hu et al.,
  2003)

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Population Obesity Control Early stage in
development

• Strategically, why focus on PA promotion first?
• Less controversy, conflict, stigma than
  surrounding diet/nutrition
• Deep pocket business interests, e.g., Nike
  24-Hour Fitness, stand to benefit from success of
  efforts (vs. Big Food losing because cant as
  readily induce over-consumption of H2O, whole
  grains, legumes, FV)
• Cheaper easier10 min. supply 1/3 of PA RDA
• May positively influence food preferences

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Population Obesity Control Early stage in
development

• To avoid exacerbating health risk/disease burden
  disparities, push strategies (skip-stop/slowed
  hydraulic elevators, restricted proximal parking,
  non-discretionary time exercise breaks, walking
  meetings) should be prioritized over pull
  strategies (building trails parks, offering gym
  membership subsidies/discounts) at this early
  stage of development of environmental and policy
  approachesmake it easier to do it than not to do
  it!

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Population Obesity Control Early stage in
development (cont.)

• Synergy will occur when supply (physical
  environmental access appeal) meets demand
  (individual/ sociocultural motivation,
  prioritization, valuation, skills/interests,
  political will)
• Demand must be createdneed to structure in
  unavoidable experiences which increase aerobic
  conditioning, build skills self-efficacy,
  foster enjoyment, elevate mood energy, increase
  taste for water-bearing foods less
  highly-sweetened beverages

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Spectrum of PreventionHealth behavior change
model

• Level 1 Strengthening individual knowledge and
  skills
• Level 2 Promoting community education
• Level 3 Educating service providers
• Level 4 Fostering coalitions and networks
• Level 5 Changing organizational practice
• Level 6 Influencing policy and legislation

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Spectrum of PreventionShift in health promotion
field

• The most effective and sustainable PH
  intervention approaches of the past two decades
  are the more upstream ones (structural/environme
  ntal vs. individual-level), involving social norm
  change
• Tobacco control
• Alcohol consumption and driving
• Breastfeeding
• Littering and recycling

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Spectrum of Prevention(2nd level)
Level of Prevention Definition of Level Examples of Obesity Prev. Efforts
Promoting community education Reaching groups of people with information and resources to promote health Community walkathons / fitness events Media campaigns Neighborhood canvassing for healthy food options Community gardens
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ROCK! Richmond

• Community-level fitness promotion initiative of
  Richmond City DPH/Medical College of Virginia
• 3 major components (1) free fitness instruction
  in CBOs in underserved areas (2) environmental
  changes in conduct of city business (e.g.,
  low-fat/ high-fiber food choices at city
  functions) (3) social marketing effort to
  reinforce norms supporting PA healthy eating
• Successful in recruiting disproportionately among
  population segments at highest risk for chronic
  disease (older, black, female, family hx of CA,
  CVD)
• Yancey, Jordan, Bradford et al., Health Prom
  Practice, 2003

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Spectrum of Prevention(5th level)
Level of Prevention Definition of Level Examples of Obesity Prev. Efforts
Changing organizational practice policy Adopting regulations and shaping norms to improve health Protocols for MD assessment, sliding fees, counseling referral Worksite policies (movement breaks, vending, refreshments) School PE content delivery
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Translating Evidence-Based CDC/ACSM
Recommendations into Culturally-Targeted
Intervention

• Integrating 10- PA bouts into organizational
  routine
• Minimal intensity environmental intervention,
  e.g., stair prompts
• Short bouts accommodate higher proportion
  sedentary individuals (incremental change)
• Variable (max moderate) intensity, low-impact PA
  accommodates higher proportion overweight/obese
  and disabled individuals (higher perceived
  exertion, discomfort, functional limitations)
• Passive (push) strategy relies less on
  individual motivation facility access (early
  adopters scarce)

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Translating Evidence-Based CDC/ACSM
Recommendation into Culturally-Targeted
Intervention

• Integrating 10- PA into organizational routine
• Movement to music integral to African-American,
  Latino culturedancing normative for adults
• Short bouts minimize perspiration, hairstyle
  disturbance
• Social support conformity desires drive
  participation (collectivist vs. indiv.
  orientation)
• Addresses less activity conducive outdoor
  environments (safety, utility, aesthetics)
• Designed for organizational settings for work,
  worship, other purposes--less disposable t,

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Lift Offs Work! the Rapidly Growing Evidence
Base

• Documented individual and organizational
  receptivity to integrating PA on paid work time
• Contribute meaningfully to daily accumulation of
  MVPA
• Motivational teachable moment linking
  sedentariness to health status for inactive folks
• Improvements in clinical outcomes from as little
  as one 10-min. break/dayBP, BMI, waist circ.,
  mood, attention span, cumulative trauma disorders
• Spill-over or generalization to inc. active
  leisure
• Favorable cost-benefit ratio, eg, L.L. Bean mfg
  plant

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LAC Fitness Wellness Studydesign

• Randomized, controlled, post-test only,
  intervention trial testing the effects of
  incorporation of a 10-min exercise break into
  staff meetings training seminars lasting gt 1 hr
• Outcome measures (1) participation by
  sedentary/overweight individuals (2)
  mood/affect (3) satisfaction with health
  status/fitness level
• 26 meetings (11 intervention, 15 control) with
  449 county employees, mostly women of color

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LAC Fitness Wellness StudyResults (cont.)

• More than 90 of meeting attendees participated
  in the exercises
• Among relatively sedentary participants
• Intervention participants satisfaction with
  fitness levels more highly correlated with PA
  stage of change (r0.59) than controls (r0.38,
  z-2.32, p0.02)
• Among sedentary participants
• Intervention participants self-perceived health
  status ratings were significantly lower than
  controls (OR0.17 95 CI0.05, 0.60 p.0003
• Yancey, McCarthy, Taylor et al. 200438848-856

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Fuel Up/Lift Off! LA

• Video/audio (DVD/CD) excerpt
• movement break (Lift Off) demonstration
• www.ph.ucla.edu/cehd

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Pausa para tu salud
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Propuesta de colaboración Implementación de la
pausa para la Salud

• Evaluar los factores de riesgo cardiovascular
  previo a la intervención de actividad física.
• Promover de 15 a 20 minutos de actividad física
  dentro de la jornada laboral, iniciando con 10
  minutos hasta alcanzar máximo 20 minutos.
• Promover la orientación alimentaria dentro de la
  jornada laboral.
• Logros alcanzados en un año 0.4 kg/m2 menos de
  BMI (1 kg) y 1.6 cm menos de cintura promedio en
  los trabajadores en un año.
• Lara A, Yancey A, Tapia-Conyer R et al., in
  preparation, 2006

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Community Health Councils (CHCs) REACH 2010
demonstration project--African Americans Building
a Legacy of Health

• Intervention Multi-component, centered around
  modeling the behaviors promoted (walking the
  talk)(1) incorporation of fitness breaks into
  meetings, events and other gatherings (2)
  provision of wellness training focused on
  changing the norms of organizations to
  incorporate PA healthy food choices into their
  regular conduct of business (organizational
  wellness) (3) provision of a personal training
  experience to key organizational leaders (4)
  development of a small grants program for
  ID/creation/promotion of PA opportunities.
• Sloane, Diamant, Lewis et al., J Gen Int Med
  2003181-8

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CHCs African Americans Building a Legacy of
HealthProcess evaluation

• Measures Primary dependent measurelevel of
  organizational support for physical activity
  integration, as reflected in intensity of
  interventions selected for participation
  Results Nearly half (gt100) of the 220
  participating organizations demonstrated active
  support for physical activity integration, with
  gt25 committed at the highest level of support.
• Yancey, Lewis, Sloane et al., J Pub Health Mgmt
  Prac, 200410(2)118-123

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CHCs African Americans Building a Legacy of
HealthOrganizational wellness outcome evaluation

• Participants 35 organizations, gt700 staff/
  members/clients, 1o overwt./obese black women
• Measures Primary dependentBMI
  Secondaryaffect, FV intake, PA level
• Results (post-intervention f/u)
• 12-week interventiondec. feelings of
  sadness/depr. (p0.00), inc. FV (0.5 svgs,
  p0.00), marginally dec. BMI (-0.5 kg/m2 ,
  p0.08)
• 6-week intervention (re-tooled)inc. days in
  which participated in vigorous PA (0.3 days,
  p0.00)
• Yancey, Lewis, Guinyard et al., Health Prom Prac,
  20067(3)233S-246S

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California Fit WIC Staff Wellness Training

• AIMS
• To provide skills and tools to influence
  workplace organizational practices and cultural
  norms to promote physical activity healthy
  eating among staff
• To provide skills and tools to influence staff to
  promote physical activity healthy eating among
  WIC clients/families

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California Fit WIC Staff Wellness Training

• Training sessions included
• Engagement around ubiquitous nature of the
  problem (toxic environment surrounding us)
• Skills training in workplace practice change
  (e.g., movement breaks, walking meetings, leading
  co-workers to stairs vs. elev., healthy
  refreshments identifying practical strategies
  to integrate PA (parking farther away, walking
  around childrens play area, carrying a basket
  vs. pushing a grocery cart)
• Empowerment thru provision of tools, e.g.,
  videos, audiotapes, bands, pedometers

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WIC Staff Wellness Training
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California Fit WIC Staff Wellness Training

• Significant findings
• Increased perceived workplace support for staff
  PA (96 vs 58, p.002) and healthy food choices
  (85 vs 28, p.001)
• Change in types of foods served during meetings
  (72 vs 24, p.002) PA priority in workplace
  (96 vs 71, plt.02)
• Increased self-reported counseling behaviors with
  WIC parents promoting physical activity (64 vs
  35, plt.05) sensitivity in handling
  weight-related issues (92 vs 58, plt.01)
• Crawford, Gosliner, Strode et al., Am J Public
  Health, 2004

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Community Cost-Sharing

• 1. Leverage funder and/or regulatory roles
  (foundation, especially government) to mandate
  healthy/fit workplace practices, with added
  resource allocation (e.g., 5)
• 2. Change internal organizational culture (social
  norms) to create healthy/fit health social
  services agency workplaces (Walking the Talk)

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Community Cost-Sharing

• Healthy/fit organizational PA promotion
  practices include core elective components,
  e.g., 10 movement (or walking) breaks in
  meetings/ functions at certain time(s) of day
  walking meetings stair prompts leading employee
  groups to stairs in moving between work
  activities restricted near parking incentives
  for distant parking model reward fidgeting and
  lifestyle PA integration (e.g., less high heel
  tie wearing, more pedometer wearing, formal
  recognition/kudos to those who jog or swim during
  lunchtime)

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Community Cost-Sharing

• 3. Encourage local school officials to
• a. Train teachers of PE in SPARK-type models
  emphasizing coop. vs. compet., engaging all kids
• b. Move student drop-off location as far away
  from door as possible, e.g., behind playing
  field, to maximize distance youth must walk to
  attend class
• c. Incorporate Take 10!, Lift Off! or other
  exercise breaks into academic curriculum 2x/day,
  eg, math
• d. Incorporate structured exercise breaks into
  PTA meetings, school board meetings, community
  dialogues, staff meetings other gatherings to
  raise visibilty/priority of PA promotion in
  addressing childhood obesity

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Community Cost-Sharing
We must become the change we wish to see in the
world. --Mahatma Gandhi