Global health agenda on non-communicable diseases: has WHO set a smart goal for physical activity?BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h23 (Published 21 January 2015) Cite this as: BMJ 2015;350:h23
All rapid responses
In response to recent comments in BMJ by Leandro M.T.Garcia, I would like to refer to four conclusions from my forty years of research.
In 1975 it was generally thought that sedentary workers didn’t do anything physical so their illnesses must be due to such factors as stress.
However I identified that repeatedly leaning forward to read and write was compressing the chest and abdomen, and while considering those aspects I eventually developed The Posture Theory in 1980.
In 1976 I had a lot of problems with fatigue so I enrolled in an exercise class at a medical research organisation in North Adelaide.
The standard method of improving fitness was to gradually increase the level of exercise each week but when I tried to do that the symptoms became worse so I slowed down and continued at my own pace.
Six years later the head of that organisation asked me to design a project to help other patients, and I was able to scientifically prove and reprove the effectiveness of the method between 1982 and 1983.
That method is now widely recommended and used under the name of PACING.
In 1994 I began experimenting with writing onto pages after placing them on benches on top of desks, and on tall platforms and lecterns, and I eventually invented the Standing Computer Posture in 1998, with the screen just below eye height, and the keyboard at elbow height, and I have been producing essays like that ever since.
In 1997 I modified and simplified the Pritikin Diet to treat angina caused by coronary artery disease.
It is salts, sugars, and fats which caused the problems, and which are added during food processing methods and included in packaging such as bottles, cans, and boxes which have complicated lists of ingredients on the back, so I discarded all such items from my cupboards and refrigerator and began eating fresh fruits and vegetables.
It is the diet that humans would have eaten before civilisation evolved so I called it the Tribeman's Diet.
The pain ceased to be a problem after six months.
I have recently published more detailed accounts of those ideas in the BMJ, and have included the essays as references.
1. Garcia Leonardo M.T. 2015 (February 5th), Recommendations for physical activity: moving beyond minutes and dose-response, BMJ 2015;350:h23, Actual page of response is http://www.bmj.com/content/350/bmj.h23/rr-0
2. Banfield M.A. 2014 (March 30th), The Posture Theory as an explanation for many previously unexplainable symptoms, BMJ 2008;336:1124, (Online Rapid Responses), Actual page of response for 30-3-14 is http://www.bmj.com/content/336/7653/1124/rr/692354
3. Banfield M.A. 2014 (April 6th), The biomechanics of writing, typing, and computing, and it’s relation to recurring abdominal pain, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page of response is http://www.bmj.com/content/336/7653/1124/rr/693338
4. Banfield M.A. 2014 (January 8th), A 1982-3 research paper on the effects of regular exercise on chronic fatigue, BMJ 2013;347:f5731, (Online Rapid Responses),http://www.bmj.com/content/347/bmj.f5731/rr/680738
The attachment which contains the PDF for the paper is here
5. Banfield M.A. 2014 (June 25th), The value of population studies in determining the cause and treatment of disease, BMJ 2014;348:g3617,(Online Rapid Responses), Actual page of response is http://www.bmj.com/content/348/bmj.g3617/rr/703395
Competing interests: No competing interests
We congratulate Barreto for bringing to discussion the current World Health Organization’s (WHO) physical activity recommendations and Global Action Plan and its implications. Papers like this help us to appraise and debate the assumptions and consequences of what we are doing and, when required, reorient our research and advocacy plans.
The current WHO’s recommendation and Global Action Plan have the merit of advancing the global physical activity promotion effort. This needs to be acknowledged. However, as Barreto, we also doubt whether they are the best approach to promote physical activity aiming to mitigate the burden of non-communicable diseases. Nevertheless, instead of focusing our actions on a specific subgroup as he suggested, since the difficulty in meeting the recommendation goals is not peculiar only to those physically inactive, we think the effort should be in establishing an easily understandable, achievable, and inclusive physical activity recommendation, a challenge still open.
The current WHO’s recommendation does not transmit an easy message. For adults, it includes three equivalent possibilities to achieve the aerobic physical activity volume, which should be accumulated in bouts of at least 10 minutes, plus muscle-strengthening activities on at least 2 days/week. For elderly, it is also recommended at least 3 days/week of physical activity to enhance balance and prevent falls. For children, the recommendation is rather different. Such complication leads to shortening of the message to “at least 150 min/week of moderate-to-vigorous physical activity” (420 for children and adolescents) and do not consider all aspects even when monitoring population physical activity levels. Such difficult message undermine its range and adoption.
We can do better. For instance, the second edition of the Dietary Guidelines for the Brazilian Population (DGBP), published in 2014, is a groundbreaking example of paradigm shift in the nutrition field: it does not bring any parameter for amounts, doses or frequencies of calories, macro- or micronutrients intake. Instead, it simply focus on the type of processing used in food production, condensed in a golden rule: prefer natural or minimally processed foods and freshly made meals to ultra-processed foods. Importantly, the message is the same for everyone. Similarly, the main message of a physical activity recommendation could be something like “move more, in your pace; rest when needed” or “whenever is possible, prefer sitting less and moving more”.
Other aspect of the current WHO’s recommendation is its focus on how much physical activity we should do, instead of how we include it in our daily lives, based on a day-long approach. We think this is the central point to increasing the amount of people the recommendation influences and to achieving the Global Action Plan aim. For instance, the new DGBP devotes the same importance of how choosing foods to offering guidance about preparing meals, the context of eating, and overcoming barriers.
We believe a good physical activity recommendation and global aim should also not focus on any particular subgroup, but be inclusive. We agree with Barreto that the current Global Action Plain fails in this aspect, once the recommendation goal is too high or even a barrier for some, disregarding small volumes and increments that can be beneficial to mitigate the burden of non-communicable diseases. However, focusing on those physically inactive is not inclusive either, considering that less than 1/3 of the global population is in this situation. Therefore, better recommendation and global aim to prevent non-communicable diseases should work to move the entire population distribution of physical activity level rather than focusing in any subgroup, even the high-risk individuals.
Lastly, we believe that physical activity plays a fundamental role in our daily lives, embodied in several human practices, and that goes far beyond just the prevention of non-communicable diseases. Therefore, we should challenge ourselves to develop a different recommendation and global aim taking into account the physical activity relevance in larger societal and individual contexts, consequently promoting health and preventing diseases for everyone.
1. Barreto PS. Global health agenda on non-communicable diseases: has WHO set a smart goal for physical activity? BMJ 2015;350:h23.
2. World Health Organization. Global recommendations on physical activity for health. 2010. www.who.int/dietphysicalactivity/factsheet_recommendations/en.
3. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. 2013. www.who.int/nmh/events/ncd_action_plan/en.
4. Sparling PB, Howard BJ, Dunstan DW, Owen N. Recommendations for physical activity in older adults. BMJ 2015;350:h100.
5. Brazil. Ministry of Health. Dietary Guidelines for the Brazilian Population. 2014. http://nupensusp.wix.com/nupens#!__english/new-brazilian-dietary-guidelines.
6. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U; Lancet Physical Activity Series Working Group. Lancet 2012;380(9838):247-57.
7. Rose G, Khaw KT, Marmot M. Rose’s strategy of preventive medicine. 2nd ed. Oxford, UK: Oxford University Press; 2008.
Competing interests: No competing interests
We welcome the recent focus on whether current international physical activity targets are appropriate given that the largest health benefits are derived from increasing activity among the most sedentary [1,2] . In the discussion of how to increase physical activity however, walking and cycling for travel (commonly referred to as active travel) received only a perfunctory mention.
Sparling et al  recommend activities such as pacing while on the phone, which have not to our knowledge been studied in terms of contributions to levels of activity or health benefits. They also suggest walking rather than driving for short trips – which has a more developed evidence base. In the UK people who walk, cycle or take public transport to work have lower adiposity than those who drive to work [3,4]. Public transport is often overlooked as a contributor to activity levels, but walking to and from transport access points contributes to achieving recommended physical activity levels . Active travel has also been found to increase physical activity in such as older people, who are at high risk of having sedentary lifestyles . For example, recent work suggests that the provision of subsidised bus travel for older people in England was associated with increased walking and lower weight gain [7,8].
Active travel is increasingly recognised as an important component of physical activity in low and middle income countries. One third of Brazilian adults walk or cycle on a regular basis, a figure that can reach up to 50% in some regions of the country . Research from 22 African countries has found that 46% of overall physical activity came from transport related activities . However, increasing levels of car use, linked to economic development, have been associated with increasingly sedentary lifestyles and adiposity in both India and China [11,12]. This evidence suggests that it may be easier to protect high levels of active travel in these settings than to wait until levels of motorisation increase. Interventions which address the environmental, structural and financial barriers to active travel should be prioritised to make it easier for people to build physical activity into their everyday lives . These interventions have great potential to increase population levels of physical activity both in developed and developing countries  and have larger potential to increase population levels of physical activity than the health sector alone. In addition to the potential benefits of getting the sedentary active, increased active travel provides the added benefit of reducing levels of carbon released into the atmosphere and lowering the risk of catastrophic anthropogenic climate change.
1. Barreto PdS (2015) Global health agenda on non-communicable diseases: has WHO set a smart goal for physical activity? British Medical Journal 350.
2. Sparling PB, Howard BJ, Dunstan DW, Owen N (2015) Recommendations for physical activity in older adults. Briish Medical Journal 350.
3. Flint E, Cummins S, Sacker A (2014) Associations between active commuting, body fat, and body mass index: population based, cross sectional study in the United Kingdom. British Medical Journal 349.
4. Laverty AA, Mindell JS, Webb EA, Millett C (2013) Active Travel to Work and Cardiovascular Risk Factors in the United Kingdom. American Journal of Preventive Medicine 45: 282-288.
5. Besser LM, Dannenberg AL (2005) Walking to public transit: steps to help meet physical activity recommendations. Am J Prev Med 29: 273-280.
6. King AC, King DK (2010) Physical Activity for an Aging Population. . Public Health Reviews 32: , 401-426.
7. Webb E, Netuveli G, Millett C (2012) Free bus passes, use of public transport and obesity among older people in England. J Epidemiol Community Health 66: 176-180.
8. Coronini-Cronberg S, Millett C, Laverty AA, Webb E (2012) The impact of a free older persons' bus pass on active travel and regular walking in England. Am J Public Health 102: 2141-2148.
9. Sa TH, Pereira RD, Ana Clara; Monteiro, Augusto. C (2015) Socioeconomic and spatial differences of active commuting in Brasil. Revista de Saude Public Under consideration.
10. Guthold R, Louazani SA, Riley LM, Cowan MJ, Bovet P, et al. (2011) Physical Activity in 22 African Countries: Results from the World Health Organization STEPwise Approach to Chronic Disease Risk Factor Surveillance. American Journal of Preventive Medicine 41: 52-60.
11. Bell AC, Ge K, Popkin BM (2002) The road to obesity or the path to prevention: motorized transportation and obesity in China. Obes Res 10: 277-283.
12. Millett C, Agrawal S, Sullivan R, Vaz M, Kurpad A, et al. (2013) Associations between Active Travel to Work and Overweight, Hypertension, and Diabetes in India: A Cross-Sectional Study. Plos Medicine 10.
13. NICE (2012) Walking and cycling: local measures to promote walking and cycling as forms of travel or recreation. National Institute of Health and Clinical Excellence.
14. Woodcock J, Edwards P, Tonne C, Armstrong BG, Ashiru O, et al. (2009) Public health benefits of strategies to reduce greenhouse-gas emissions: urban land transport. Lancet 374: 1930-1943.
Competing interests: No competing interests