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
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. That’s 5 times more than are killed by guns,
HIV, and drug use combined.1
Diet and Physical Inactivity
310,000-580,000
Tobacco
260,000-470,000
Alcohol
70,000-110,000
Microbial Agents
Toxic Agents

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
cancer
obesity
stroke

90,000
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
diabetes
4. Chronic Obstructive Pulmonary Disease
112,700
high
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. Alzheimer’s
22,700
13. Homicide and Capital Punishment
18,400
14. Atherosclerosis
15,400
15. High Blood Pressure
14,300
blood pressure
osteoporosis
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
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
DIABETES PREVENTION PROGRAM
Lifestyle intervention was much more effective than either placebo or metformin
DPP Research Group. N Engl J Med. 2002;346:393-403.
Fitness & Mortality
•Low fitness is bad
for health
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
Physical Activity
& Risk of Common Cancers
Colon: 30-40% decreased risk among active
men & women (Rectal—no 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

Population Attributable Fraction Cancer
Mortality – Male Never Smokers
Population
Exposure*
RR†
25.0-29.9
42%
1.1
30.0-34.9
21%
1.4
>35.0
13%
1.3
BMI
PAR (%)
4.0%
6.8%
3.4%
14.2%
*NHANES 2000, men age 50-69
Population Attributable Fraction Cancer
Mortality – Women Never Smokers
BMI
Population
Exposure*
RR†
PAR (%)
3.3%
6.1%
25.0-29.9
29%
1.1
30.0-34.9
23%
1.3
35.0-39.9
11%
1.4
8%
1.9
>40.0
3.5%
7.0%
19.8%
*NHANES 2000, women age 50-69
http://apps.nccd.cdc.gov/brfss/Trends/trendchart_c.asp?state_c=CA&state=US&qkey=10020&SUBMIT1=Go
BRFSS DATA
%
obese
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%
20
30
15
25
10
20
5
15
1991
1995
1998
2000
%
No
LTPA
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 n’l 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, 1998;129:363-369.
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/multilane roads
=“Move insecurity”1, 2

1Jahns
& Jones, AJPM 2004;26:186 2Yancey, AJPM 2003;25(3Si)
Adapted from Kumanyika S. Obesity in Minority Populations. In Fairburn G & Brownell K, Eating Disorders and Obesity. A Comprehensive Handbook, 2002.
Marketing Expenditures, CMR, 2005
(in millions)
$123.4
$43.9
$35.7
$22.8
$17.5
$10.5
$0.0
Coca Cola
Diet Coke
Odwalla
Minute Maid
Dasani
Powerade
Sprite
Which billboard(s) is (are) about
physical activity?
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
Preliminary findings




Absence of billboards and near-absence of other outdoor
advertising in affluent white neighborhoods—existing 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
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

LA’s ESPN Radio 710 AM Ad
“We’re the prime rib on a
dial full of tofu”
--March 2006
Cultural reverence for SUVs?
AVERAGE ENERGY EXPENDITURE ESTIMATES
1 million
yrs ago
Hunter-gatherers
5000 cal
10,000 yrs
ago
Agriculture
6000 cal
1915
Laborers
3000 cal
NOW
Office Workers
1800 cal
Physical Activity Levels, %
L.A. County Adults, 1999
District
Sedentary (<10 min/wk)
County
41
+1
Compton
45
+6
South
50
+9
Inglewood
46
+6
Long Beach
37
+5
West
31
+3
Physical Inactivity Levels:
TV viewing/computer use, %
L.A. County Adults, 1999
Ethnic Group
TV/Computer Use
>3 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
Self-Perceived Overweight by
Ethnicity & Gender,
% LA County Adults
AA Overwt
AA Nml wt
API Overwt
API Nml wt
Lat Overwt
Lat Nml wt
W Overwt
W Nml wt
Female
67
20
86
28
80
26
84
21
Male
29
-46
10
41
9
46
4
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 ethnicgender groups included in which BMI<25 normative
In multivariate analysis, self-perceived overweight,
not BMI, predicts sedentary behavior (OR=1.40, CI
1.19, 1.64)
Yancey, Simon et al., Obes (Res) 2006;14:980-8. Yancey, Wold et al., Am J Prev Med, 2004;27:146-52.
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
volition—relatively 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
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 doesn’t
end up around your waist!

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
How much is enough?
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 suboptimal >moderate PA levels contributed to DM & obesity
risk over 6 yrs in women (Hu et al., 2003)
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 & 24Hour Fitness, stand to benefit from success of efforts
(vs. “Big Food” losing $ because can’t as readily
induce over-consumption of H2O, whole grains,
legumes, F+V)
 Cheaper & easier—10 min. supply 1/3 of PA “RDA”
 May positively influence food preferences
Population Obesity Control:
Early stage in development
To avoid exacerbating health risk/disease
burden disparities, push strategies (skipstop/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
approaches—make it easier to do it than not to do it!
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 created—need 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
Spectrum of Prevention:
Health 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
Spectrum of Prevention:
Shift in health promotion field
The most effective and sustainable PH
intervention approaches of the past two
decades are the more “upstream” ones
(structural/environmental vs. individuallevel), involving social norm change:
 Tobacco control
 Alcohol consumption and driving
 Breastfeeding
 Littering and recycling
Spectrum of Prevention
nd
(2 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
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
Spectrum of Prevention
th
(5 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
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)
Translating Evidence-Based
CDC/ACSM Recommendation into
Culturally-Targeted Intervention
Integrating 10-’ PA into organizational routine:





Movement to music integral to African-American,
Latino culture—dancing 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, $
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/day—BP, 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
LAC Fitness & Wellness Study:
design



Randomized, controlled, post-test only,
intervention trial testing the effects of
incorporation of a 10-min exercise break into staff
meetings & training seminars lasting > 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
LAC Fitness & Wellness Study:
Results (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 (r=0.59) than controls (r=0.38, z=-2.32,
p=0.02)
Among sedentary participants:
 Intervention participants’ self-perceived health
status ratings were significantly lower than
controls (OR=0.17; 95% CI=0.05, 0.60; p=.0003

Yancey, McCarthy, Taylor et al. 2004;38:848-856
Fuel Up/Lift Off! LA
Video/audio (DVD/CD) excerpt:
movement break (Lift Off) demonstration
www.ph.ucla.edu/cehd
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
Community Health Council’s (CHC’s) 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 2003;18:1-8
CHC’s African Americans Building
a Legacy of Health:
Process evaluation
Measures: Primary dependent measure–level
of organizational support for physical activity
integration, as reflected in intensity of
interventions selected for participation;
Results: Nearly half (>100) of the 220
participating organizations demonstrated
active support for physical activity integration,
with >25% committed at the highest level of
support.
Yancey, Lewis, Sloane et al., J Pub Health Mgmt Prac, 2004;10(2):118-123
CHC’s African Americans Building
a Legacy of Health:
Organizational wellness outcome evaluation
Participants: 35 organizations, >700 staff/
members/clients, 1o overwt./obese black women
Measures: Primary dependent—BMI; Secondary—
affect, F+V intake, PA level
Results (post-intervention f/u):
12-week intervention—dec. feelings of sadness/depr.
(p=0.00), inc. F+V (+0.5 svgs, p=0.00),
marginally dec. BMI (-0.5 kg/m2 , p=0.08)
6-week intervention (re-tooled)—inc. #days in which
participated in vigorous PA (+0.3 days, p=0.00)
Yancey, Lewis, Guinyard et al., Health Prom Prac, 2006;7(3):233S-246S
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
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 children’s play area, carrying a basket
vs. pushing a grocery cart)
 Empowerment thru provision of tools, e.g.,
videos, audiotapes, bands, pedometers
WIC Staff Wellness Training
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%, p<.02)
 Increased self-reported counseling behaviors
with WIC parents promoting physical activity
(64 vs 35%, p<.05) & sensitivity in handling
weight-related issues (92 vs 58%, p<.01)
Crawford, Gosliner, Strode et al., Am J Public Health, 2004
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”)
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)
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
Community “Cost-Sharing”
“We must become
the change
we wish to see in
the world.”
--Mahatma Gandhi