Physical Activity and Sport: What Should We Recommend?

In his final annual report On the State of Public Health before retiring from the role of Chief Medical Officer (CMO) in 2010, Sir Liam Donaldson highlighted the health benefits of physical activity, including sport, suggesting that “If a medication existed which had a similar effect, it would be regarded as a ‘wonder drug’ or ‘miracle cure’”.  However, Sir Liam also noted that “Over the last 50 years, activity levels, particularly amongst the young, have fallen”.  So why have public health recommendations promoting “nature’s finest cure” been so unsuccessful?

1) What physical science says: Since 2004, the UK Chief Medical Officer (CMO) has recommended that for general health adults should take part in 30 minutes of moderate intensity exercise at least five times a week (5x30mins), whilst children should accumulate 60 minutes of moderate intensity exercise every day.  In the report that underpins these recommendations, these levels are promoted as being the minimum “necessary” for general health according to the scientific evidence.  Related to this evidence, Sport England’s policy goal is to increase participation in sport for thirty minutes at a time at least three times a week (3x30mins), based on the reasonable assumption that people taking part in sport at this level are likely to get another 2x30mins exercise in other ways.  More recently, however, there has been an increasing volume of research on the health benefits of short duration high intensity exercise. Reports of such research have been around for five years or so, but the volume of evidence is now increasing, and a recent University of West of Scotland Study was featured in the media last week.  The UWS study suggests that as little as four bouts of 30 seconds maximum effort exercise, interspersed with 30 second rest periods, on only three occasions each week (3x 4x30secs), may have equal, if not greater, health benefits  than the CMO’s recommendations of 5x30mins.

2) What behavioural science says: We know people can be motivated to be physically active and participate in sport in a number of ways.  There are external motivations such as reward (eg, payment or praise), external motivations that can become internalised (eg, the health benefits, sense of achievement or sociability of exercising or sport), and the truly intrinsic motivation of enjoying the physicality or movement of performing the activity itself (see the SPEAR Model in this report to Sport England, pp. 30-34). In many cases, internalised motivations are wrongly thought to be intrinsic motivations. Exercising to be healthy is not an intrinsic motivation – one does not need to enjoy the physical activity or sport itself to be motivated in this way.  Turning to aims around changing behaviour; we know that behaviour changes require two broad steps: firstly the development of a positive attitude towards a behaviour (thinking about change), and secondly a change in behaviour itself (see stages of change models in SPEAR’s report to the Department of Health, pp. 45-46). The problem group for physical activity and sport promotion is the proportion of the population who don’t even think about change.  These people can be put off physical activity and sport for many reasons: they may think that what is promoted as “necessary” for general health (5x30mins) is beyond their capabilities (this is called a competence gap), they may not be motivated by or value general health as an outcome, or they may react negatively to health messages that they perceive to be threats of consequences (eg, “if you don’t exercise you’ll have a heart attack”).

3) Why do we promote Physical Activity & Sport Participation? This is the vitally important question.  For the CMO and the Department of Health, physical activity and sport is not promoted for intrinsic reasons, but for its health benefits.  However, the sport community promotes sport as being important for intrinsic reasons of enjoyment, but also for a range of externalities such as health, the economy, sociability and socialisation, achievement, national pride and so on.   Now here’s the key: physical activity and/or sport can be valued by individuals for health outcomes, but still be regarded as a chore that isn’t enjoyable.  So, for those who are not yet even thinking about physical activity or sport participation, should we promote physical activity and sport on the basis of health benefits or on the basis of being an intrinsically and socially enjoyable activity?

4) Should we recommend what we can’t sell?  Given what we know about the underpinning physical and behavioural science, can the CMO’s recommendations that it is “necessary” to exercise at moderate intensity for at least 30 minutes at least five times a week for general health benefits be sold to those who are not even considering becoming more physically active or participating in sport?  If 5x30mins can’t be sold to this audience (and the relatively static participation figures across the UK suggests that it can’t) then, regardless of the physical science and medical evidence, the recommendations are pointless.

So, what can be done? Two alternative (or perhaps parallel) strategies suggest themselves.  On one hand, we could accept that doing physical activity and/or sport for health benefits is always likely to be regarded as an unpleasant chore (almost like taking medicine) for many people who are not active, and so we should make the pill as “un-bitter” to swallow as possible.  This is where the growing volume of research into the benefits of short duration high intensity exercise is important.  Performing four 30 second bouts of exercise with 30 seconds rest in between each (a total time of four minutes) three times a week (3x 4x30secs) is a much less bitter pill to swallow for those who do not like exercise than the CMO’s recommendations of 5x30mins exercise per week.  On the other hand, we could accept that health benefits do not appear to be working as motivations to engage those who are not physically active, and that they may even be off-putting to some audiences.  Alternative messages without any health references but focusing on, for example, enjoyment and sociability (eg, “Enjoy 30 Active Minutes”) or on green values in relation to active transport or the natural environment (eg, “Actively Save the Planet”) could be more widely used to capture those who, for whatever reasons, do not respond to health-related promotions of physical activity and sport.  What is clear, though, is that 3x 4x30secs will never be saleable as anything other than the least-bitter exercise for health option, whilst 5x30mins may be too much of a commitment to sell on the basis of health benefits alone.  For physical activity and sport promotion, it seems: For health or not for health…that is the question!

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