Johanna Ralston, CEO, World Heart Federation
When Member States met during September’s United Nations High Level Summit on Non-Comunicable Diseases (NCDs), one of the clear outcomes in the Political Declaration was their agreement to develop global targets to reduce the burden of NCDs by the end of 2012. Last week, the World Health Organization (WHO) Executive Board met here in Geneva and the commitments to targets and timeframes appeared in danger, as calls for more time and more targets threatened to undermine what Member States have committed to in the Political Declaration and further delay implementation with new deadlines for the creation of targets proposed for 2013 instead of 2012. Fortunately, leadership by key actors involved in negotiations and powerful statements by the NCD Alliance, other civil society organizations, and certain member countries, ensured that we will see those targets “completed” this year. Notably, Member States have agreed to “submit a substantive progress report on the development of a framework, including a set of indicators and targets, to the sixty-fifth World Health Assembly (May 2012) for consideration,” with “completion” committed to by the end of the year.
As the saying goes, “what gets measured gets done” and the discussions at the WHO Executive Board have brought us one step closer to being able to monitor and track progress made on NCDs. However, it is clear that controversy concerning how many and which targets will be presented at the World Health Assembly has not yet been resolved. The complexities include lack of a complete picture of available data and underlying surveillance systems that would be key in setting baseline measures against which to achieve targets. As well as limited and uncertain resources at a time when the major global organizations, including WHO and the Global Fund, are undergoing severe resource constraints and reform processes; and only an emerging recognition that achieving the commitments laid out in the Political Declaration and being debated in the targets process will require a different framework for policy, funding and partnership, what has been called a “new policy narrative.”
For the NCD and health community, this is the time to come together and build solidarity around which targets are needed to successfully reduce the global burden of cardiovascular disease and other NCDs. It is imperative that work on the global monitoring framework for NCDs is completed by the end of 2012, as agreed upon by member states at the WHO Executive Board last week. However, all of us will need to work together to ensure that the timeline laid out by last week’s resolution on NCDs is actually fulfilled.
The most critical goal included within the WHO proposed set of targets is one that has been championed by the NCD Alliance, that is to decrease the overall mortality from NCDs by 25% by the year 2025, using the mortality in 2010 as a baseline (and recognizing possible advantages in extending that goal to 2030 to align with development goals). In order to do this, all the major risk factors of NCDs must be addressed – including physical inactivity, which is noticeably missing from the current set of targets proposed by the WHO. There has been a push from many within the NGO community for the creation of a target for the reduction of physical inactivity, however some Member States feel that it does not sufficiently satisfy the WHO requirements regarding what should constitute a global target. A sticking point is an accurate indicator for physical activity. In other words, what measurement could governments use that would allow them to effectively monitor and track changes in physical activity levels? PAHO and GAPA have suggested legitimate and defensible indicators, as have many of our colleagues who submitted comments to the NCD Alliance prior to the Executive Board meeting, including the segmentation of targets based on age. The need for consistent data presents a legitimate challenge, yet to allow the targets process to continue without addressing physical activity seems a far greater problem.
Please weigh in: should physical activity be addressed in the global targets?
For more information
See the list of proposed WHO targets listed as table 2 in the following discussion paper
Download the statement made by the NCD Alliance at the Executive Board
Download the complete text of the WHO Executive Board Resolution on NCDs
Access full documentation from the 130th Session of the WHO Executive Board
Physical activity in all age groups must be measured and qualitatively reviewed as a global target. Because obesity and inactivity was not measured as health screening indicators in the past is why we have a global epidemic of NCDs now. Exercise or Physical Activity must start to be part of everyday lifestyles. How we measure it should be supported by technology and behavioral outcome indices to ensure that the public is supported on the best evidenced medical support.
Dr Mike Evans excellent video supports this notion in its simplest form: 23 and a half hours: http://www.youtube.com/watch?v=aUaInS6HIGo
Assessments for at risk groups such as children, obese teenage girls, those with modifiable risks such as Diabetes and heart disease should clearly be assessed for exercise as a ‘vital sign’.
In my opinion this should be clinician led, at every patient consultation and lifestyle check. It is because we have not included physical activity as an important contributor to health outcomes that we are facing the biggest global obesity, diabetes and mental health problem of our time.
Please feel free to contact me via the website, as I am passionate about helping ordinary people to get fitter and healthier through exercise.
Very best wishes
Ann Gates BPharm (Hons) MRPharmS , Founder: Exercise Works! Ltd
Thank you Johanna for posing this important question and raising awareness about the omission of physical activity in the latest presentation of global indicators from WHO.
Your specific question asks if there is a suitable measure for use by countries to monitor physical activity – and the answer is YES. Please see below for details.
Your overarching posting raises the omission of physical activity as a global indicator and questions whether it should be – the answer is yes and further below I provide a suggested indicator and target for debate.
Over the last decade the agenda of measuring and monitoring physical activity has been a priority of leading academics and WHO and the result of combined work is two self-report measures, namely the International Physical Activity Questionnaire (IPAQ) and the Global Physical Activity Questionnaire (GPAQ) – various publications are available on request. They sound similar and indeed have some common characteristics. IPAQ SHORT (not long version) was developed specifically for population surveillance and as its name suggests, it is short in length providing estimates of walking, vigorous and moderate intensity activity which summed provide an estimate of total activity in the past week. GPAQ is structured to capture moderate (including walking) and vigorous activity as well but the items are structured to provides estimates of work-related (including domestic activity), transport related and leisure (recreation) activity; when summed this also provides an estimate of total activity in the past week. For clarity – both instruments collect activity across multiple domains, not just leisure/sports and both instruments provide an estimate of total activity in the past week; they differ in number of items and item structure. Most importantly, both instruments have been tested for reliability and validity in a large number and diverse set of countries – including low and middle income countries. Their performance has been recognized as acceptable with some evidence to suggest that GPAQ has stronger properties, likely due to its item structure. Some readers may be aware of some concerns with over reporting in the IPAQ, likely due to the item order and item structure. Of particular importance is the fact that GPAQ provides countries with estimates of activity by domain and as transport patterns (more car use) and employment patterns (work involving less activity and more sitting) are rapidly changing in LMIC, this characteristic is particularly useful for monitoring and influencing policy and practice – particularly in relation to urban design and development.
To date IPAQ and GPAQ have been used in over 130 countries – please see the WHO Global Status Report 2010 for reporting of the global estimates and the Appendix and available excel tables for access to available country estimates. This is a dramatic increase from 10 years ago when data were available from less than 35 countries and these were mostly high income countries (ref available). The chosen reporting metric in 2010 report is the % not meeting recommendation – that is, the % inactive and this is defined in line with the WHO 2010 Global Physical Activity Recommendations.
Other measures:
In addition to these two established and ready to use self-report instruments, there is much work underway using new technologies, namely pedometers and better still accelerometers, to assess population level of physical activity and sedentary behavior. These devices are worn on the hip for a number of days and clearly this has notable respondent burden and logistical complexity. Nonetheless, this has been tested for feasibility in the USA, France, Sweden, the UK and possibly elsewhere. Moreover, there is work underway exploring the feasibility of use in Chile as part of their National Health Monitoring program and much more research and development work like this should be supported in other LMIC. Cost is prohibitive in the near future for use in LMIC but demand can change this factor.
Thus, the short answer to your question is that there most certainly is known, ready to use and previously demonstrated instruments for assessing physical activity. The self-report items, say of GPAQ, could be used within the WHO STEPS surveillance program or inserted into an existing national health survey. This could start tomorrow! Moreover, there is techincal support and analysis tools available.
GLOBAL INDICTOR FOR PHYSICAL ACTIVITY- what should it be?
May I use this opportunity to further the debate and propose that along with the need to defend and advocate for the importance of including PA as a global indicator, and the need to inform that there are viable methods, there is also the need to present a proposal for a global indicator and target. GAPA [Global Advocacy for Physical Activity, a Council of the International Society of Physical Activity and Health] has presented to the NCD Alliance and its members, as well as to WHO, the following which has received broad support from those in the physical activity field and which are consistent within the policy context and scientific evidence:
Target: 10% relative reduction in the prevalence of insufficient physical activity in adults (defined as less than 150 minutes of moderate physical activity per week or equivalent)
Indicator: Age-standardized prevalence of insufficient physical activity adults (defined as less than 150 minutes of moderate physical activity per week or equivalent)
May I encourage all those engaged in the discussion about global indicators to raise concern about the omission of Physical Activity given the gross inconsistency of including indicators for the other 3 leading and common risk factors; and to counter arguments that we do not know how to measure physical activity (we do, see above and we know the strengths and limitations of these measures just like any other risk factor) and also to indicate that there are clear actions for countries to adopt and implement. I refer all interested in these actions to the recent publication “Seven Investments that Work for Physical Activity” available from the GAPA website – http://www.globalpa.org.uk/investments/. Other useful material is also available from this site.
I would be happy to provide further support or information on physical activity to further this debate and the development of the NCD Global Indicators.
Professor Fiona Bull
Chair: Global Advocacy for Physical Activity (GAPA) http://www.globalpa.org.uk
School of Population Health
The University of Western Australia
fiona.bull@uwa.edu.au
Dear Johanna, we should also recommend the measurement and monitoring of physical inactivity at national and regional levels. A realistic way to do it is through collecting data on TV/monitor viewing during discretionary time. The target: <2 hrs/day.
Manuel Ramírez Zea, MD PhD
Coordinator, INCAP Comprehensive Center for the Prevention of Chronic Diseases – CIIPEC
Institute of Nutrition of Central America and Panama – INCAP
Dear Johanna,
I have something very important to discuss with you in terms of NCD, esp CVD epidemic in India. Need your help to address the cause of concerns to ensure we curb the growth of these chronic diseases in India.
Please send me your mail ID to get connected and we can discuss in details.
Regards,
Pranjit Konch
Bangalore – India