How About Some Really Out-of-the-Box Thinking?
Many of the comments responding to our disparities postings have reflected a certain cynicism and skepticism about our calls to address the public’s health using intervention approaches that fall outside of the health care or even traditional public health arena.
Let’s take physical activity, my favorite example of non-pharmacological, non-surgical, non-psychotherapeutic “medicine.” Physical activity is one of the most potent and grossly underutilized tools in our prevention arsenal. The data supporting the effectiveness of modest “doses” of exercise in preventing, managing and, on occasion, even curing a host of chronic disease maladies is overwhelming. Participation in doses as modest as 50-60 minutes of moderate-to-vigorous intensity physical activity per week confers some health benefits; engaging in at least 150 weekly minutes is associated with a full spectrum of protection across most health and wellness domains, and augmentation of disease management and rehabilitation—from A to Z, academic achievement, Alzheimer’s disease and depression, to obesity, stroke and other vascular diseases. Yet, a recent study of data from the National Health and Nutrition Examination Survey (NHANES) gathered from objective monitoring of activity levels revealed that Americans participate in an average of only 6-10 minutes of at least moderate intensity physical activity each day. A study of ours a few years ago [PDF] found that more than 40% of Los Angeles County’s more than 10 million residents is completely sedentary, engaging in fewer than 10 minutes per week of continuous activity.
An early and concerted emphasis on physical activity should assume primacy in any comprehensive effort to promote health and well-being, prevent chronic disease and contain medical care costs. Preventing weight gain, much less achieving healthy weight status is highly unlikely to be sustainable at the low levels of physical activity in which most Americans engage. Yet we constantly look elsewhere for solutions, rather than looking for delivery vehicles for this “miracle drug.” So here are three focused strategies for achieving sufficient increases in physical activity across the entire population to realize meaningful health and wellness benefits. This will not only ease the strain on the medical care system but also on the overall economy by increasing productivity, decreasing injury and workers’ compensation liability, and improving student and employee morale and retention:
1) Adopt “opt-out” or “push” organizational practices and policies that make the physically active choice the default option or path of least resistance, and the sedentary choice difficult, in schools and workplaces, especially government-run and government-regulated agencies, e.g., exercise breaks at a certain time of day or reserving parking within a 5-minute walk of the workspace for people with disabilities. (See this NPR story for more.) This includes setting day care, pre-school and after-school standards for minimum amounts of physical activity per hour spent in child care. Legislators and other policymakers have wide spheres of influence and this is a “mirror” strategy—rather than instructing others, what can you do within your own decisional latitude? Incentives, e.g., tax rebates, for workplace wellness programs not built on these opt-out strategies will not produce a sustainable return on investment. That’s because the people most likely to take advantage of on-site fitness facilities or programs are healthier and more active than most employees—and willing to spend their own discretionary time and income on active pursuits. Poor structuring of workplace wellness tax breaks will merely shift costs now borne by these individuals to employers and taxpayers.
2) Improve the quality of physical education (PE) by investing resources to increase the number of PE teachers, training of all elementary school teachers in PE, activity-focused PE implementation support materials and equipment), even before much-needed efforts to increase PE duration. We conducted a statewide assessment of PE and physical activity in California public schools [PDF] a few years ago, and found that kids in low-resource schools typically spend only 4-6 minutes being moderately-to-vigorously active (walking, running or jumping) during a 30-minute PE class. More PE time without quality improvement translates only into more time spent sitting or standing around.
3) Impose an excise tax on sedentary behavior-promoting goods and services, e.g., movie tickets, inactive video game consoles and software, private automobiles and cable TV packages. Like tobacco excise taxes, not only would this provide a funding stream for ramping up and scaling up public health coordination of physical activity promotion, but price elasticity would also decrease consumption among adolescents. The revenues might also permit the redress of the inequities in park space in low income communities and communities of color, so kids have someplace to bounce a real ball!
Out-of-the-box thinking? Maybe once we’re strong enough to punch our way out!
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3 Responses to “How About Some Really Out-of-the-Box Thinking?”
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how about leaving the box dimension altogether, and end the cultural taboo against insisting on personal lifestyle change, by spending one cent for ink (zero cents for electronoc medical records), to add three lines to everyone’s medical chart, ahead of the present entries for blood pressure, cholesterol, and weight (all symptoms – 20 years too late). The new lines are: hours per week of lifelong vigorous exercise, eating only unprocessed, mainly plant-based food, and freedom from chronic stress.
These would be quantified as a percent of the ideal. These scores would be given equal weight to symptom scores, or missed medications. Incentives for compliance are limitless, such as zero co-payments; non-compliance ( or lack of improvement) could result in a mandatory group class before the next doctor visit.
85% of all health costs result from chronic conditions, almost all of which are easily avoidable with a healthy lifestyle. Is not the genetic expression from innoculations against infectious disease similar in nature to lifestyle “innoculations” against chronic diseases? And further, does not a poor lifestyle “infect” one with chronic disease, just as surely as introducing viruses or germs into the body?
Perhaps you can explain how my website, freehealthreform.com, is not correct.
If it is right, the current health care model is completely outdated.
Thanks, donald wilhelm, III
The article states:
“t kids in low-resource schools typically spend only 4-6 minutes being moderately-to-vigorously active (walking, running or jumping) during a 30-minute PE class.”
Huh? Then what are they doing the rest of the time? Putting on their uniforms? Roll call?
Although I agree whole-heartedly that regular exercise and control of one’s weight is more powerful than most of the “preventive care”services we physicians provide and certainly preferable to treatment after opportunities for prevention have passed…
Let’s keep these lifestyle change incentives out of the doctor-patient relationship. People fudge the truth about these matters even when there are no increased copays.
I’m intrigued that a tax on sedentary behavior-promoting goods and services could be used to increase access to physical exercise opportunities such as parks, exercise classes, etc.
a primary care physician with mostly diabetic and hypertensive patients.