Lack of exercise is contributing to a burgeoning health crisis. To get back in shape, we need to remodel not just our bodies, but our cities and workplaces.
It is difficult to believe today but in the relatively recent past, medical experts believed vigorous exercise might be bad for our health and that elite athletes risked an early death.
Ironically, just as it was becoming accepted that we are biologically designed for movement and that physical activity, without overdoing it, is absolutely crucial for our mental and physical health, the human race was starting to become less active.
The constant invention of more labour-saving devices means that now even minor exertions, such as getting off the sofa to change the TV channel or walking around a video store to choose a movie, are unnecessary. We have created what medical journal the Lancet described as a "pandemic of physical inactivity".
“We are the undermuscled generation,” University of Auckland nutrition professor David Cameron-Smith told the Listener after research at the university’s Liggins Institute in 2018 sounded the alarm about “an epidemic of frailty”. “We are puny compared with previous generations.”
The loss begins early and for many years we hardly notice. But weakness matters. "It's staggering how frail some otherwise healthy 50-year-old men are," Cameron-Smith said. "At some point in your life, the hardest thing you will have to do is get up out of your chair or get yourself up off the floor after a fall, and your maximum strength determines whether you can or can't do that … or whether you're stuck on the toilet and can't get up. "Weak people at 50 are going to be the weakest people at 70, unless we shift ourselves dramatically."
And we’re not. The statistics make grim reading. One in eight New Zealand adults is active for less than 30 minutes a week. Only 7 per cent of children meet the Ministry of Health guideline of at least one hour of moderate to vigorous activity a day. And we are not alone – when Public Health England asked people how much cumulative time in an average month they spent walking briskly, 44 per cent ticked less than 10 minutes. In the meantime, the fitness industry has boomed. With more options than ever before, revenue for the sector is set to surge by more than $430 billion by 2028, growing at an average of 30%.
So, what’s going on? And more importantly, what can we do about it? That was what Peter Walker wanted to know when he set out to research his book, The Miracle Pill.
Walker isn't a scientist; he is a political correspondent for UK newspaper the Guardian. He was disturbed by the way everyday physical activity has disappeared from our lives and convinced of the "near-magical benefits" of moving more.
There hasn't been a sudden global outbreak of idleness, he says. The real problem is that disincentives to move are to be found almost everywhere we go.
"One of the more obvious examples is going into an office block, hotel or any big building," he says. "There will almost certainly be a set of gleaming lifts as you walk through the door. But if you try to find the stairs, you have to hunt down a corridor and then risk setting off an alarm, or getting locked on the stairwell."
Walker gets his own dose of daily activity cycling from his home in Camberwell, South London, to his job in the House of Commons, but concedes that cycling is not for everyone.
"There aren't enough safe bike routes and a lot of people quite reasonably feel that sharing a road with cars driving fast isn't much fun," he says.
Better than nothing
It all sounds like we are doomed but, encouragingly, Walker doesn't think so. In fact, he describes The Miracle Pill as a story of hope.
"Before I started researching the book, I knew how bad it was for you in the long term to be inactive," he says. "But what I didn't realise was how quickly things could turn round. The US Centers for Disease Control says that on the same day that you're vigorously physically active you will have this whole list of benefits: your body will cope with glucose better, you will sleep better, your mental state will be better and your blood pressure will be lower. That is all from one bout of exercise, so the dose response curve is incredibly steep. And that is a hopeful thing. People don't have to aim for running a marathon or doing 10,000 steps a day, because virtually anything is better than nothing."
Elite sport has seen a lot of investment. Walker cites the UK Olympic budget, which rose from £59 million in 1996 to £274 million by 2016. In New Zealand, the Government contributed $19 million towards hosting the recent FIFA Women’s World Cup.
There is no evidence that this kind of thing boosts the numbers of ordinary people taking part in sports. In fact, in this country, there is a downward trend, according to data collected by Sports New Zealand, with fewer eight- to 14-year-olds belonging to sports teams or clubs outside school and 18- to 24-year-olds spending less time being physically active.
The same research shows that, across the board, females spend less time than males being active. And people from high-deprivation areas participate in fewer sports and activities than others each week.
As for gym-going, it is estimated that about 400,000 New Zealanders hold memberships but, as one fitness industry analyst admitted to Walker, the business model of gyms is built on a good proportion of members being “sleepers”, who pay but don’t bother to go.
"Studies have shown again and again that not enough people manage to do formal sport," he says. "Maybe they work long hours or they've got young kids, but it doesn't work. Governments have to realise that it's not just about saying sport is great, do it. If you really want physical movement to embed in someone's life, it has to be in the form of incidental activity."
What particularly shocked Walker was how sedentary kids are these days. The tendency is to blame screen-time, but when he fitted a high-tech fitness tracker to his nine-year-old son, he found that the child's weekend was full of movement. School days, conversely, were mostly spent in a chair. There, his son was sitting for six hours a day, three times as much as on the weekend.
"I don't want to criticise the school, because they do an amazing job of teaching kids with a wide range of abilities," says Walker. "But I think it's possible to have the same amount of education and to integrate more movement into it."
Activity is particularly crucial in childhood because that is when we build strong bones and cardiovascular systems, but hopefully it also sets up good habits for life. There is no mandate for a minimum level of activity in the school curriculum, but a research paper from the University of Otago recommended introducing one, stressing that the situation was urgent.
Walker’s story of hope visits some of the places where the problem is already being addressed. In Scotland, he met former school principal Elaine Wyllie who, appalled by the lack of physical fitness shown by many of her pupils, introduced what came to be called the Daily Mile.
“Every day, the kids are taken out for a mile run,” Walker explains. “They wear their normal school clothes, so don’t have to change into their sports gear. It always takes place outside and they can chat as they go.”
Initially, the kids were exhausted, but then they started to enjoy their 15 minutes of fresh air and freedom, and the initiative has now spread to more than 7000 British primary schools and beyond to other countries. "The studies they've done in schools that have the Daily Mile show that apart from physical fitness, their concentration tends to be better and there's some evidence that even academic attainment improves, and it's just running round chatting to your mates, which is what kids are supposed to do."
Meanwhile, Finland has a national action plan called Finnish Schools on the Move, which most of its schools participate in. They implement individual plans to increase activity, which involve the way kids travel to school, physical activity breaks and active learning – getting them up and out of their chairs during normal lesson time.
Snackable exercise
It isn't news that prolonged, uninterrupted sitting is bad for us. But for many it has become the way we have to spend our work time and choose to spend our leisure – five to nine hours sitting in a day is normal, according to various surveys.
This affects so much about the way our bodies work. Resting muscles produce fewer of the proteins that break down triglycerides – a type of fat found in the blood that is released for energy. The absence of muscle contraction isn't helpful for the correct processing of blood glucose, either. Being sedentary is bad for our health in a dizzying array of ways. One US study, which tracked a large group of people over a long term, found that those who sat for more than six hours a day were more likely to acquire a long list of conditions ranging from Alzheimer's to type 2 diabetes, cardiovascular problems and cancer.
There are solutions such as standing desks, walking meetings, Swiss balls, and phones and watches that sound an alarm reminding us to get up and move around every 30 minutes.
Even insurers are getting in on the act; with some offering discounts and other incentives to encourage physical health.
But many of us are still sitting for too long. Covid lockdowns left their mark.
In New Zealand, there were winners and losers in the exercise stakes during the national Level 4 hard lockdown, according to a survey by the University of Otago. Overall activity decreased, but some people who were only moderately active before did manage to exercise more and maintained the change.
Walker has taken up running for the first time in his life, encouraged by a 2017 study that showed that although regular activity brings greater benefits, so-called weekend warriors are still 30 per cent less likely to die than people who are inactive, even when they don’t meet minimum-activity guidelines.
Walker may also want to take up energetic fidgeting as, remarkably, it has real benefits, according to leading authority on obesity James Levine, author of Get Up! Why your chair is killing you and what you can do about it. He calculated that toe tappers and arm swingers expend considerably more energy than someone who sits motionless in a chair.
Although no one is denying that vigorous exercise is the ideal, it seems that so called "exercise snacking" – small bursts of activity throughout a day – is better than nothing. Even the first minute of exercise improves your health, just getting out of a chair and walking a few steps.
"The message that can't be stressed enough is that there are remarkably few circumstances in which being physically active for even slightly longer or a bit more vigorously will not do you some good," says Walker.
None of that is remotely contentious nowadays. One theory that is more controversial, however, is that it is better to be heavy and healthy than skinny and inactive. Some studies say yes, but others have claimed it not to be the case.
"Much cleverer people than me have been arguing about this for years," says Walker. "But the one thing they agree on is that whatever your BMI [body mass index], being active is almost always going to be much better for you, whether or not you end up losing weight.
“A lot of governments are focused on obesity and it’s a really important public-health issue. But losing weight in the long term is extraordinarily difficult. So I think it’s important for people to just be active anyway. If you lose weight, that’s brilliant, and if you don’t, you’ll still get some benefits.”
Reshaping cities
We have known since workplace studies in the 1950s that there is a connection between better health and being more active. Bus conductors on double-deckers who were climbing and descending 500 to 750 steps a day were healthier than their sedentary bus-driver colleagues. Postal workers who delivered mail by bike or on foot had half the incidence of heart disease of their desk-bound fellow workers. But despite health campaigns such as Push Play, most of us move less today than we would have back then. Walker is hopeful that the post-pandemic era will be the time when finally we do something about it.
"Certainly, in the UK, a lot of the political discourse is seeing the world after Covid as an almost post-1945 mood," he says. "In the UK, after World War II, you had the establishment of the National Health Service and the welfare state. There were some very big changes because the attitude was, we've suffered enormously for six years, so we want the world to be better now."
Covid has shown what governments can do, says Walker. If you can effectively shut down an economy to save 200,000 lives, then you can introduce some robust public-health policies to save the lives of the 100,000 people who die each year in the UK as a result of inactivity. In New Zealand, a 2015 statement from the College of Public Health Medicine said that a lack of physical activity caused 12.7 per cent of all deaths. To solve this problem will require long-term planning from reasonably interventionist governments to re-engineer our built environments, says Walker, making it easier for people to cycle to wherever they need to go, or walk up stairs rather than take the lift.
"It can be done; it just takes time," he says. "There are lots of cities around the world that are reshaping themselves and making it easier for people to move. But the ones where things are getting notably better are where they've had this slightly nanny-state approach.
"The Dutch have got the highest cycling levels in the world; something like 25 per cent of all trips are done by bike there. In the 50s and 60s, they had similar city layouts to most other countries. There was the rise of the car and they built highways in cities. Then, from the 1970s, they had this coherent policy of trying to change it. For my previous book, Bike Nation, I talked to the head of the Royal Dutch Cycling Union and asked what countries such as Britain could do and, basically, she said, 'Well, I'd start 30 or 40 years ago.'"
Late is better than never, says Walker. In fact, he believes we don't have a choice.
“If we keep with current activity levels then health services as we know them are not going to be viable in 20 or 30 years’ time, and that’s going to concentrate a few minds. No prime minister is going to want to be known in retrospect as someone who could have acted but didn’t.”
The long game
Empowering people to stay active is the key to avoiding a downward spiral in health among the elderly.
And it’s not just the young who need to focus on fitness. Naturally, there is a tendency for the elderly to become more and more sedentary. Very quickly they start losing muscle strength and stamina, then balance suffers and the risk of falls increases.
“With exercise, frequency is important, and even more so for older people,” says Marya Hopman, a personal trainer and corrective-exercise specialist. “If younger people have a gap, then it doesn’t take them long to get back on track. For those who are older, it takes much longer and sometimes they can’t regain the level of strength and fitness they had before. The less you do, the less you are capable of doing. And the longer you leave it, the harder it’s going to get. It can just take one event to start that downward spiral.”
Hopman has joined forces with fitness instructor Rebekah Charlton to form SuperCue, a Hawke’s Bay social enterprise that aims to make exercise accessible and fun for all older adults. SuperCue offers community sessions, but also DVDs and online classes for at-home workouts.
It is never too late to start exercising, say the pair, but often the fear of injury leads to underestimating what seniors are capable of.
“Someone may be in a wheelchair because of the risk of them falling, but we can still challenge them in a safe way,” says Hopman. “They can do strong moves, lifting and kicking their legs. It’s amazing what they can manage.”
A typical session targets the whole body, using body-weight exercises and resistance bands. People can choose whether to stand or sit, and a lot of the movements link to activities they may need to do in everyday life, such as walking up stairs, putting on clothes or getting out of a chair confidently.
The starting point is always posture. Rather than sitting slumped with knees to one side and feet tucked under the chair, people are established in a better position.
“We want them to have their feet hip-width apart and flat on the floor,” says Hopman. “Then we ask them to roll up on to their sitting bones and lift up their chest. Straight away the tummy engages, they’re using their back muscles to hold themselves up and they’re able to breathe better, so they feel better.”
‘Bang for buck’
By Donna Chisholm
Auckland exercise physiologist Matt Wood, who manages the Auckland University of Technology’s exercise science clinic and runs fitness programmes for heart and cancer patients, cannot stress this enough: “Walking from A to B will get you only so far, and so far is not bad, but it’s not great. Intensity matters.”
Getting stronger doesn’t mean you have to go to the gym. You can achieve the same results doing push-ups, sit-ups and squats at home, carrying children or heavy bags of shopping, or doing activities such as aqua aerobics, hill walking, climbing stairs or digging in the garden.
The AUT exercise programme, although individually tailored for participants, combines structured strength/resistance exercises with physical activity, ideally taking the least time to achieve “bang for buck”.
“We’re not trying to give people traditional, slow, long-distance training because 95% of people don’t like that stuff,” says Wood. “Usually, we’re not prescribing more than eight repetitions of an exercise.” The basic regimes involve 10 minutes of resistance work with 20 minutes of cardio.
People referred to the programme typically have one or more heart risk factors, and are often in sedentary jobs and overweight, but Wood says weight loss is not a focus. “The primary focus on obesity is, psychologically, one of our biggest problems. BMI has no predictive ability for cardiovascular fitness.
“There’s nothing worse than saying to someone, ‘Your BMI is this’, and they lose 2kg and think they’ve failed. The recommendations for weight loss involve 60 minutes [exercise] five days a week. Well, who the heck is going to do that? Setting people up for failure is not going to solve the problem.”
Programme participants are often surprised to discover that as a risk factor for coronary disease, cardiorespiratory fitness is more important than hypertension, smoking, cholesterol, diabetes or obesity. It’s measured by the amount of oxygen consumed during exercise – the less consumed, the less fit you are. A person in their eighties in a rest home, for example, would likely consume about a fifth of the oxygen of a moderately fit middle-aged person.
Muscle up
Exercise physiologist Matt Wood has advice to keep up muscle strength:
- Strength training and aerobic exercise have to go together – brisk walking won’t do much to improve your muscle strength.
- Don’t focus on weight loss when starting an exercise programme. Fitness is much more important to your overall health.
- Do exercises you enjoy or can incorporate into your daily life, for example, cycling to work, but at an intensity that means you can’t hold a conversation.
- Don’t overdo it in an exercise session – building up to two sets of eight repetitions of each strength exercise is all you need for health benefits.
- If time is an issue, don’t waste it on isolated muscle resistance exercises that are more for looks. When choosing strength training workouts, opt for four or five multi-joint resistance exercises that relate to everyday activities.
- Many exercises can be adapted to your home, for example, modified push-ups, squats, lifting dumbbell weights.
- Find a family member, friend or colleague to work out with to keep you motivated.
- Yoga and similar workouts can be great for fundamental strength, balance, flexibility, relaxation and enjoyment. However, they shouldn’t be used in isolation. Research hasn’t shown large improvements in cardiorespiratory fitness compared with traditional methods of training.
- Exercise intensity matters. You’ll need to spend some time exerting yourself pretty hard to get the most out of your cardiovascular exercise – your fitness will plateau pretty quickly with moderate walks, but thrashing yourself can be detrimental.
- If you have a chronic health condition – cancer, cardiovascular disease, diabetes or high blood pressure, you’ll benefit from an exercise physiology assessment for individualised guidelines.
Take a load off
Exercise can significantly reduce the inflammation and pain caused by osteoarthritis.
‘Anything that gets worse as you get older gets better when you exercise,” according to Ralph Paffenbarger, an epidemiologist, professor and exercise authority who took up marathon running at 45 and lived to a ripe old age.
Paffenbarger must have had good knees. Because if you suffer from the aches of arthritic joints in midlife, even going for a brisk walk can be off-puttingly painful, never mind running a marathon.
There is no cure for osteoarthritis; the best you can do is manage it to prevent further deterioration. Exercise is a part of that process, even if it does hurt a bit, says Dr Stephen Messier, director of the JB Snow Biomechanics Laboratory at Wake Forest University, North Carolina. He has spent a career drilling down into exactly what activity or exercise is best and has come to this conclusion: it really doesn’t matter.
“For people with knee osteoarthritis, no matter what you do, whether it’s strength exercise or walking, it has a modest effect. It’s about a 30% decrease in pain, which is what you get taking anti-inflammatories.”
Messier’s latest study looked at a group of people in their sixties who had been taking no more than 30 minutes of exercise a week. They were divided into three groups. Over 18 months, one group did high-intensity strength training, the other low-intensity, and the control group had 14 sessions learning about the benefits of weight loss, healthy living and activity but no supervised exercise. Initially, the results surprised Messier, because each group reduced pain by about 30%, including the control group.
“It was a little difficult to swallow in the beginning,” he says.
Then he took a closer look at the control group. This was the most education any participants in a trial had ever been given. “And they took to heart what we told them, which doesn’t usually happen. Their physical activity matched what the two strength-training groups did.”
Messier had proved what other studies have shown – when people feel they are getting guidance and attention, it makes them more likely to achieve their goals, whether that is losing weight or getting fitter.
“Our take-home message is that if an adult with osteoarthritis of the knee doesn’t do anything, then they’re going to decline,” he says. “And if you want to get more than a modest reduction in pain, you need to add weight loss to exercise. That’s the best non-pharmacological and non-surgical intervention.”
A study he published in 2013 showed that moderate exercise, mostly walking with a little bit of strength training, plus 10% weight loss, takes the load off the knee, decreases inflammation and results in a more than 50% decrease in pain.
However, Messier hasn’t found any evidence that if you build strong muscles they will act as a shock absorber for knee joints, which is a widely held belief. And he is still working on the science that will show whether exercise can prevent osteoarthritis developing in the first place.
Even if you don’t have arthritis, from midlife onwards, chances are you will notice that sitting still for too long results in stiffness, backache and neck pain. In her 50 years as a physiotherapist in rural New Zealand, Barbara Mawson met a lot of people with postural problems caused by prolonged sitting, and she produced a book about it: Becoming the Shape of the Chair You Sit In. Self-care is the best option, she says, but there are no quick fixes.
“You need to get up every half hour or so, have a stretch, lean over backwards a few times, walk a bit,” she advises. “And as you get older, if you sit a lot in your job, then it pays to choose active pursuits in your free time – dancing, walking, gardening, something that will be the opposite of what you do during the day.”
If you have back pain when you stand up, that’s a red light, she says, and you need to change something. And when relaxing in the evening, don’t slump into a recliner or sit like a banana hunched over a gadget, head bent and neck forwards – a common position for many screen-addicted younger people.
“When I first started as a physio, I saw no one under the age of 32 with back pain,” says Mawson. “By the time I finished, I was getting sent 14-year-olds from the paediatrics department with back and neck pain.
“There’s been a huge change over the years. I notice the stature and posture changes in our young people on the streets, which is worrying me. You’ve got the poking-out tummy and the overextended back happening. I really fear for the future.”
This article was originally published on 10 April 2021.
