PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

Physical Activity and

Cardiovascular Disease
Prevention
in the European Union

The European Heart Network – December 1999

[1]
EUROPEAN HEART NETWORK

Report prepared by the European Heart Network’s

Expert Group on Physical Activity

Group members:
Professor Ilkka Vuori (Chairman), UKK Institute, Tampere, Finland
Professor Lars Bo Andersen, University of Copenhagen, Institute for
Exercise and Sports Sciences, Copenhagen, Denmark
Mr Nick Cavill, Programme Manager – Physical Activity, Health
Education Authority, London, UK
Professor Bernard Marti, Institute of Sports Science, Swiss Sports School
Magglingen, Magglingen, Switzerland
Dr Philippe Sellier, Chief, Cardiac Rehabilitation Department, Broussais
Hospital, Paris, France

Co-ordinator:
Susanne Løgstrup, Director, European Heart Network, Brussels, Belgium

Editor:
Carol Williams, Public Health Nutrition Consultant, Brighton, United
Kingdom

Getting Europeans to be more physically active offers the

greatest potential for reducing cardiovascular disease (CVD)
rates in the European Union (EU). Physical inactivity is now
established as a major risk factor for heart disease and
there is a new consensus that even small amounts of
activity confer a health benefit.
This paper is intended to draw attention to the importance
of physical activity for CVD prevention. It summarises the
evidence and the biological mechanisms which explain why
activity decreases CVD risk and outlines a series of policy
recommendations for creating an environment that fosters
a more physically active life. These require support from the
European Union’s action programmes in public health and
EU legislation that has an impact on environment,
transport, the workplace and leisure-time activities.

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

The European Heart Network (EHN)

The European Heart Network is a Brussels-based alliance linking 28

national heart foundations and other national non-governmental
organisations committed to the prevention of cardiovascular disease
(CVD), including coronary heart disease and stroke, in 24 countries across
Europe. It aims to achieve concerted action on cardiovascular disease
prevention within Europe and to promote the exchange of experience and
co-operation on CVD prevention between members.

Who should read this document?

Physical Activity and Cardiovascular Disease Prevention in the European

Union summarises the latest evidence relating a sedentary lifestyle to CVD
risk. It is intended to inform and update decision makers and health
professionals at European, national and local levels as to the implications
of new research findings on physical activity. These show the great value
for cardiovascular and general health of the promotion of even modest
levels of physical activity. The challenge now is for policy makers to work
together to create living environments that favour a more physically active
life, and for health professionals to put more emphasis on physical activity
in CVD prevention programmes. EHN makes a series of recommenda-
tions for action.

[3]
EUROPEAN HEART NETWORK

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

Contents

E xecuti ve SSu
umma
marr y 6

Sect ion 1: IIn

nt roduct ion – T he cco
ontext
1.1 A massive enemy: cardiovascular disease 10
1.2 Physical inactivity: a recently-accepted risk factor 13
1.3 Raising physical activity levels: the greatest potential for reducing CVD
in Europe 13
1.4 Europe’s inactive population 14
1.5 The health burden of physical inactivity in Europe 14

Sect ion 2: The E

Evv i dence
2.1 Epidemiological evidence 16
2.2 How physical inactivity influences CVD risk: biological
mechanisms 18
2.3 Summary 20

Secti on 3: R
Reecom menda datt ions ffo
or iin
ndiv idua
ualls –
Ho w mmuuch, hhoow ooff ten, hhoo w hha
ard aan
nd hhoow lloong?
3.1 Daily, moderate and accumulated 21
3.2 EHN recommendation 23
3.3 Adverse effects: they can be avoided 24
3.4 Implications: we can do better 25

Secti on 4: P olic y rreecom menda

Po datt ions –
Th e cch
halle nge aan
nd tth he ppoote ntia
iall ffoor cch
h ange
4.1 Recommendations for action at European Union level 26
4.2 Recommendations for action at national level 28
4.3 Conclusion: everything to gain 35

An n exes
1 The health benefits of regular physical activity 37
2 Examples of strength of association between moderate physical
activity and various health outcomes 40
3 Physical activity and physical fitness: explaining the differences 42
4 Physical activity readiness questionnaire 43

Refer ence s 44

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EUROPEAN HEART NETWORK

Executive Summary

A continuing threat
threat: Cardiovascular disease (CVD) is the number one
killer in Europe, accounting for nearly half of all deaths. Based on current
disease trends and the growing number of elderly people in the European
population, CVD is expected to continue to be the major killer disease in
Europe well into the next millennium.
Double the risk
risk: Physical inactivity is now established as a major risk
factor for coronary heart disease and cerebrovascular disease. Inactive
populations have around twice the risk of CVD compared with active
populations (Relative Risk ~2). This is of the same order as the risk of
smoking, high blood pressure and raised blood-cholesterol levels.
A best buy
buy: Raising physical activity levels amongst the general population
has been described as ‘today’s best buy in public health.’ This is because
physical activity has such a strong effect on CVD risk and because activity
levels in the European population are so low. Inadequate physical activity
is more common at the community level than any of the classic risk factors
for CVD – smoking, hypertension, raised blood cholesterol and
overweight. The proportion of CVD incidences that could theoretically be
prevented if the European population were more physically active – the
Population Attributable Risk (PAR) – is estimated to be around 30–40%.
Changing lifestyle
lifestyle: Taking up a more physically active lifestyle, even in
middle or older age, is associated with lower rates of death from coronary
heart disease (CHD) and all causes. The decrease in risk is of the same
order as cessation of smoking.
Low activity is better than none, but more is always better: The
relationship of physical activity to health is continuous – the more a
person does, the lower their risk, whatever the existing level of activity.
Most studies have found the greatest difference in CVD rates between the
completely sedentary and those being moderately active. There is a new
consensus that even low intensity physical activity may reduce risk of CVD
without having any notable influence on fitness. The public health message
is that any physical activity exceeding a completely sedentary lifestyle will
produce health benefits.
Accumulated activity
activity: Another new conclusion is that short bursts of
physical activity accumulated throughout the day can also be health
enhancing. Short-duration activities, such as climbing stairs or walking up
a hilly street, can be included in health promotion programmes.

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

EHN recommends 30 minutes most days:

EHN recommends that every European adult should accumulate 30
minutes of moderate intensity physical activity most, and preferably
every, day of the week. The activity should be of sufficient intensity to
leave the participant slightly out of breath, but still able to talk. The
actual intensity of the exercise will depend on the existing fitness level
of the participant: a moderate-intensity brisk walk for a fit person will
be much faster than for an unfit person. Physical activity needs to be
habitual, current and lifelong. Young people (aged 5–18) should
accumulate at least an hour a day of moderate-intensity activity to
promote optimal growth and development and to help foster
appropriate activity patterns into adulthood.

Daily, moderate and accumulated: The new recommendations for daily

moderate accumulated activity mean that physical activity needs to be part
of everyday life, and not necessarily vigorous activity in a sports centre.
This is a shift from heart-health recommendations of the 1980s. It provides
a new direction for health policy and planning to foster greater
opportunities and to encourage people to engage in physical activity as
part of daily life. This strategy offers the best hope that at least the
minimum requirements of regular health enhancing activity can be met by
the largest possible proportion of the population in the most economic
and ecological way.
2% of the day
day: Substantial increases in regular physical activity among
people of all ages throughout the EU are called for to improve both
cardiovascular and general health. There has been a progressive
elimination of physical activity from normal daily living. Estimates of
current levels in EU countries suggest that the majority of adults (66%) are
physically active for less than the recommended 30 minutes a day – that is
just 2% of the day. The widespread inactivity of Europeans has broad
health implications on, for example, cancer, diabetes, osteoporosis,
arthritis and psychological aspects as well as on CVD. Getting Europe
active promises to become a public health necessity to counteract the
health problems of the EU’s ageing population.

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EUROPEAN HEART NETWORK

Recommendations for the European Union

Pan-European initiatives
initiatives: Support pan-European initiatives designed to
facilitate the uptake of and regular participation in physical activity and to
raise awareness of the health benefits of physical activity.
EU policy
policy: Develop an EU policy on health that enhances physical activity
and develop a broad strategy for implementation in a range of sectors. This
should be linked to other policies that affect opportunities for physical
activity, such as economy and finance, employment, transport,
environment, regional policies, education and tourism.
EU surveys
surveys: Monitor EU citizens’ participation in physical activity
through regular surveys.
Research into special groups
groups: Conduct pan-European research on
physical activity patterns and identification of effective promotion among
children, women, the elderly and lower socio-economic groups.
Information exchange
exchange: Encourage information exchange on the
effectiveness of physical activity intervention programmes among relevant
pan-European networks in areas such as health, education and training,
environment, and transport.

Recommendations for action at a national level

Information: Raise awareness among key professionals of the importance
of physical activity as a risk factor for CVD.
A new message
message: Raise public awareness of the modern health message that
even low levels of physical activity are beneficial and that these can be
achieved through the activities of daily life.
Environment and transport
transport: Encourage changes in infrastructure and
policy that increase the opportunities for physical activity as part of daily
life.
Facilities: Increase opportunities and facilities for appropriate sport and
active recreation for individuals and families.
Workplace: Promote physical activity through the workplace and
encourage commuting on foot or by bicycle.
Education and physical activity skills
skills: Develop school and teacher-
training programmes that emphasise enjoyable non-competitive physical
activity and that foster the acquisition of essential sports and leisure skills
and a lifelong physical activity habit.

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

Older people
people: Promote appropriate physical activity for older people that
emphasises the development of social networks and enhances quality of
life and independence.
Community involvement
involvement: Encourage whole-community approaches to
the promotion of physical activity to all sectors of the population.
Access for the disabled
disabled: Develop clear well-structured physical-activity
programmes for disabled people.
Equal access
access: Reduce the inequality in provision that affects black and
minority ethnic groups, the long-term unemployed, and people from
lower socio-economic groups.
Challenge or opportunity
opportunity: Getting Europeans to be more physically
active not only promises to produce health-enhancing effects for the
individual and the community, it is also fully in accordance with parallel
initiatives aimed at creating a greener and more ecologically-aware society.
Raising physical activity levels needs to be seen not as a challenge, but as an
opportunity waiting to be seized. The EHN hopes that this document will
help to put physical activity higher up the political agenda in the transport,
planning, social and employment spheres as well as in public health.

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EUROPEAN HEART NETWORK

Section 1:
Introduction – The Context

1.1 A massive enemy: Cardiovascular disease

During the last half century, CVD has been the number one killer in
Europe accounting for nearly half of all deaths. Today, CVD is
overwhelmingly the most common disease in the countries of the
European Union (Table 1) and causes nearly twice as many deaths as
all cancers put together (Figure 1). On the basis of current trends in
the prevalence of different diseases and the growing number of
elderly people in the European population, CVD is expected to
continue to be the major killer in Europe for many years to come
(Table 1).
Trends in deaths from CVD show a striking pattern (Figures 2 & 3).
In many western and northern European countries, which originally
had the highest rates of CVD, there has been a sharp decline in CVD
deaths in people under 75, especially in men. This follows favourable
changes in risk-factor behaviour which are largely the result of
concerted long-term health promotion programmes. There has been
a substantial increase in CVD rates in eastern European countries
where trends in risk-factor behaviour are the reverse. Even amongst

Figure 1: Causes of death in the European Union according to main

groups of causes (in thousands) in 19911

% Total Women Men Legend

100
482 217
267 All other causes
90
158 83 Diseases of the digestive system
80 75 119
159 70 External causes
70 268 120 148 Respiratory disease

60 382 Cancer
862
480
50
40
Cardiovascular disease
30 833
1525
44% of all deaths in the EU
20 692 are attributed to
cardiovascular disease
10
0

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

Table 1: Ranking of the five leading clusters of disease/conditions in

the European Region (selected years, indicative list, WHO 1998)2
Disease category 1960 1980 1997 2025
predicted

Circulatory system 1 1 1 1

Malignant neoplasms 2 2 2 2
Respiratory system 3 4 4

All external causes 4 3 3 3

Infectious and parasitic 5 5 5

Mental and behavioural 5 4

countries of western, northern and southern Europe, and between

different sectors of the population, great differences in CVD death
rates remain. The fact that trends in CVD death rates match trends
in risk factors suggests that changing risk-factor behaviour can
reduce CVD mortality and morbidity.

Figure 2: Time trends in mortality of men aged 45–74

from all causes in selected countries, 1970–92 3

Mortality rate per 100 000 Mortality rate per 100 000
3200 1500
Rus
3100
2900 1400
Hun
2800 Hun
1300 Rus
2700 Fin Rus Cze Hun
2600
1200 + Fin
Por
Rus
2500 Cze ++
Cze
2400 1100 E&W
++ Cze
E&W Den ++
2300
Hun +
2100 1000 + Den
2000 ++ + + + + + Spa +
Por
+
1900 ++ 900 **** +
Gre ++
1800 Spa
+ *** +
+
E&W
+
+++ 800 ** * + + ++
1700
+ * ** + + Por
1600 Den ++ ++
Fin ****
++ Den
Por
700 ** Fin
1500
* **
1400
*Gre
* * * ** * * * *
E&W
600 * Gre
1300 ******** Spa Spa
1200
***** Gre 500

year 70 72 74 76 78 80 82 84 86 88 90 92 year 70 72 74 76 78 80 82 84 86 88 90 92

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EUROPEAN HEART NETWORK

Figure 3: Annual percent change in mortality rates of men & women

aged 45–74 from all causes in European countries, 1970–923

Men Women
Hungary ««« Hungary
Poland ««« Poland
Bulgaria ««« Denmark
Romania ««« Romania «
Ex-Czechoslovakia Bulgaria «««
Yugoslavia Ex-Czechoslovakia ««
East Germany ««« East Germany «««
Denmark ««« Scotland «««
Greece ««« Yugoslavia «««
Norway ««« Norway «««
Ireland ««« England & Wales «««
Sweden ««« Iceland «««
Netherlands ««« Netherlands «««
Scotland ««« Sweden «««
Portugal ««« N. Ireland «««
Iceland ««« Greece «««
N. Ireland ««« Ireland «««
Spain ««« Finland «««
Italy ««« Portugal «««
Switzerland ««« Austria «««
England & Wales ««« Italy «««
France ««« Switzerland «««
West Germany ««« West Germany «««
Austria ««« Belgium «««
Belgium ««« France «««
Finland ««« Spain «««

Percent per year -4 -3 -2 -1 0 1 2 3 4 Percent per year -4 -3 -2 -1 0 1 2 3 4

« P<0.01, «« P<0.001, ««« P<0.0001

Causes of cardiovascular diseases

By far the most common and lethal cardiovascular diseases are ischaemic
or coronary heart disease and cerebrovascular disease that causes stroke.
These are characterised by a gradual obstructive process – atherosclerosis –
usually ending in an obstruction of the arteries that bring nutrients and
oxygen to the heart and brain respectively. Atherosclerosis is caused by
many factors; some genetically determined, many based on lifestyle habits
and some related to the environment. The power of a few of these factors
to induce the development of atherosclerosis, particularly of the coronary
arteries, is so great that the probability or risk of developing CVD can be
predicted by measuring these factors. Traditionally the three ‘major’ risk
factors are cigarette smoking, high blood pressure, and high serum
cholesterol concentration and other blood lipid abnormalities. Over the
years, the role of a number of other factors contributing to the risk of
developing atherosclerotic arterial disease has been detected and proven.
Physical inactivity now needs to be added to the list of established major
risk factors for CVD (Table 2).

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

Table 2: Factors that increase the risk of cardiovascular diseases

Living Habits Biochemical and Personal factors (that

physiological factors can not be modified)
(that can be modified)

Sedentary lifestyle Raised blood pressure Age (high)

Smoking Fitness level Sex (male)
Unhealthy diet Raised serum Early arterial disease
Excessive calorie cholesterol levels (high in close relative
intake LDL: HDL cholesterol (male under 55,
ratio) female under 65)
Heavy alcohol
consumption Raised serum
triglyceride levels
Diabetes
Obesity
Thrombogenic factors

1.2 Physical inactivity:

a recently-accepted risk factor
It has been suspected since the 1950s that physical inactivity
increases the risk of developing CHD, but it was not until the
beginning of 1990s that sufficient evidence had accumulated to
justify including physical inactivity among the major risk factors for
CHD.4 Physical inactivity is now also considered an established risk
factor for diabetes II, obesity and hypertension, one of the main
causes of cerebrovascular disease or stroke. For example, in 1999 the
National Stroke Association of the United States began
recommending physical activity as a measure for stroke prevention.5

1.3 Raising physical activity levels:

the greatest potential for reducing CVD in Europe
Physical inactivity is a strong risk factor for CVD. The risk-
increasing effect of being physically inactive as compared with being
physically active (relative risk) is around 2. This is of the same order
as the relative risk of cigarette smoking, high blood pressure and
raised blood-cholesterol levels.6,7

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EUROPEAN HEART NETWORK

Raising physical activity amongst the general population has been

described as ‘today’s best buy in public health’.8 This is because physical
activity has such a strong effect on CVD risk and because activity levels in
the European population are so low. Inadequate physical activity is more
common than any of the classic risk factors for CVD – smoking,
hypertension, raised blood cholesterol and overweight. The proportion of
CVD incidences that could theoretically be prevented if the population
belonged to the exposure group with the lowest risk – in this case, if
everyone were physically active – is known as the Population Attributable
Risk (PAR). For physical activity, PAR values in the region of 30–40% are
found. This compares with PAR values of 10–35% for smoking and around
3–10% for obesity and 10–20% for cholesterol.9 This means that,
theoretically, increasing physical activity levels has the potential to reduce
the number of incidences of CHD by up to 40%.10
The need for and value of physical activity is not limited to primary
prevention amongst those who do not yet have CVD. It is also important
for people who already have CVD in order to lower the risk of heart attack
and improve functional capacity and quality of life. Physical activity needs
to be part of cardiovascular rehabilitation and secondary prevention.11

1.4 Europe’s inactive population

Since the 1950s there has been a progressive elimination of physical
activity from normal daily living. For the majority of people, little physical
activity is involved in their work, domestic life or means of transport.
Increasingly, children are driven to school, commuting is rarely on foot or
by bicycle, and even a daily walk to the shops has been displaced by a
weekly drive to the out-of-town supermarket. Although there has been an
apparent boom in leisure-time activity (usually using exercise facilities
which you have to ‘go out’ to and pay for) this is restricted to certain ages
and socio-economic groups, and is far outweighed by the real decline in
the physical activity of daily life. There is evidence in the UK, for example,
that walking has increased as a leisure-time activity, but declined as a
means of transport.12 This reduction in physical activity has been
accompanied by an increase in obesity rates in many countries.13

1.5 The health burden of physical inactivity in Europe

Estimates of current levels of physical activity in EU countries suggest that
the majority of adults are physically active for less than 3 hours per week
(Figure 4). Sixty six percent do less than the recommended 30 minutes a
day (see Section 3).14 Precise comparisons between activity levels in
different countries are hampered by linguistic and cultural factors in

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

Figure 4: Percentage of EU subjects participating in various durations

of leisure time physical activities in a typical week14

% EU subjects

35
30 32
25
20 21
15
10 13
11
5 7 8 8

0
0 1 2 3 4 5 >5 hours per week

responding to interview questions, but there seems to be considerable

geographical variation (Figure 5, p.27). The widespread inactivity of
Europeans is even more worrying when the whole spectrum and scale of
the association between of physical inactivity and poor health is taken into
consideration, for example, cancer, diabetes, osteoporosis, arthritis,
hypertension and psychological problems (Annex 1, p.35). Regular
physical activity is one of the corner-stones of a healthy life and long-
lasting health and functional capacity. It promises to become a public
health necessity to counteract the health problems of the ageing
population of Europe.

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EUROPEAN HEART NETWORK

Section 2: The Evidence

2.1 Epidemiological evidence

Habitual physical activity decreases coronary heart disease morbidity and
mortality. This has been documented in numerous large prospective
population studies. No study has found a higher risk of CVD in the
physically active.

Pioneering studies
The first study of the effects of physical activity on CHD risk was published
in 1953 by Morris et al. in London.15 Morris found that bus drivers had a
40% higher incidence rate of CHD than bus conductors. The drivers and
conductors were comparable in most aspects of their lives except that the
bus conductors spent their day actively climbing the stairs between the
floors of the double-decker bus, whilst the drivers had a sedentary
occupation. Since the 1950s there has been a dramatic decline in the
number of occupations that involve physical labour, and differences in
physical activity levels are now largely due to differences in leisure-time
physical activity. The Harvard alumni study, which began in 1962,
pioneered research into the effects of leisure-time activity on CVD. Using a
detailed questionnaire to assess leisure activity it found that the relative
risk of CHD was increased by 84% in the sedentary group.16

Problems in estimating the relative risk of being sedentary

In most recent studies, the relative risk of being sedentary has been
estimated at around 2.6,7,17,18 This is widely considered to be an
underestimate attributed to two methodological problems specific to
studies of physical activity. First, physical activity is a complex behaviour
pattern in which the type, intensity, frequency and duration of the activity
have different physiological effects and, therefore, different protective
effects against CVD. Accurately assessing activity levels is complicated and
subjects are often misclassified at baseline in prospective studies. This leads
to a dilution of the real differences between active and sedentary groups
and an underestimation of the relative risk. The early studies of physical
activity suffered from this type of dilution.
Secondly, subjects change their behaviour during the long period of
follow-up (usually more than ten years) so that people classified as being

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

‘active’ at the start of a prospective study, may be less active (or vice versa)
during the subsequent years. This phenomenon is unique to studies
measuring physical activity exposure; smokers and non-smokers rarely
change exposure group during follow-up, but more than half of all subjects
change exposure level to physical activity during follow-up.

A sedentary lifestyle doubles the risk of CVD

Many recent studies have made a thorough assessment of physical activity
levels taking intensity, type and frequency of activity into account. Results
from these studies suggest that a sedentary lifestyle more than doubles the
risk of CVD19–22 and that the risk may be as high as five-fold.30 Meta-
analyses of the existing literature find a relative risk of just under 2,6,7,17 but,
allowing for the dilution effect due to changes in activity during follow-up,
a relative risk just over 2 is most likely to be found.
Few studies on physical activity and CVD have been carried out with
women as subjects. The incidence of CVD in women is less than half that
of men and therefore studies would need to include twice as many women
to achieve the same statistical power as studies on men. The few published
studies available suggest there is little difference in the relationship
between physical activity and CVD in men and women23–28 and that it is
safe to assume a similar reduction in CVD risk by increasing physical
activity.

The benefits of becoming more active

Perhaps even more important than the health advantage of being
physically active at a given time of life is the benefit of becoming more
active. Four comprehensive and thorough studies have found that taking
up a more physically active lifestyle in middle or older age was associated
with lower rates of death from CHD and all causes. Paffenbarger et al.29
found that when subjects started a moderately vigorous sports activity,
equivalent to brisk walking, the relationship was proportional – the greater
the increase in activity, the greater the decrease in CHD rate and vice versa.
Data from the Cooper Clinic30 which examined more than 10 000 men
twice in five years found that the age-adjusted relative risk of death was
more than 2 in men who became active compared with those who
remained sedentary. Similar results were obtained in men in the British
heart study31 and in women from Gothenbourg. 24 These findings are
important because they show that it is possible to reduce the risk of CHD
by making lifestyle changes even relatively late in life – in middle or older
age. The decrease in risk was of the same order as cessation of smoking.
They also help establish a causal relationship between inactivity and CVD.

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Becoming more active has been shown to help the prevention and
treatment of a whole range of health conditions and diseases. Some
examples are given in Annex 2 (p.38).

2.2 How physical inactivity influences CVD risk:

biological mechanisms
Physical inactivity is an independent risk factor for CVD. There are
substantial plausible biological data supporting a causal relationship. The
biological mechanism for the beneficial effects of physical activity may
work directly on the cardiovascular system by decreasing the workload of
the heart (lowering peripheral resistance and increasing blood volume) or
by improving the ability of the heart to work. It may also work indirectly
through metabolic changes, particularly in insulin sensitivity, that affect
other major risk factors such as blood pressure, HDL/LDL cholesterol
ratios, fibrinolysis and sympathetic nervous activity.32 In turn this reduces
the risk of a number of diseases related to increased CVD risk, namely
diabetes II, hypertension and obesity. These changes tend to occur over
the weeks or months after beginning regular exercise. Some of the most
significant changes are described below.

Lower heart rate

Physical activity has a training effect on the heart which lowers the heart
rate both at rest and during a given submaximal dynamic workload. This is
because physical activity increases total blood volume so that the heart fills
better and lowers the resistance of peripheral blood vessels to blood flow
(peripheral resistance). The lower the peripheral resistance, the easier it is
for the heart to pump blood around the body, so that for a given workload
the heart of a physically active person will have less work to do than the
heart of an unfit person. This is particularly important for patients with
CHD and angina pectoris.

Raised insulin sensitivity

The level of the hormone insulin circulating in the bloodstream has a
profound effect on sugar and lipid metabolism and on blood pressure.
‘Insulin sensitivity’ refers to the body’s ability to respond to insulin.
‘Insulin insensitivity’ means that the body requires higher levels of insulin
to achieve a response. Physical activity may increase insulin sensitivity by
25% so that circulating concentrations of insulin and adrenaline are much
lower in a physically active person.33 This could be because physical activity

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

causes more insulin receptors to be formed on the membrane of a trained

muscle cell, or because it makes the transportation of sugar within the cell
more efficient. Insulin insensitivity causes Diabetes II, therefore physical
activity reduces the risk of diabetes and physical training can be a
component in the treatment of diabetic patients.34

Lower blood pressure

Blood pressure is influenced by cells in the brain (in the hypothalamus)
that are sensitive to circulating insulin. The cells are activated by high levels
of insulin, and high insulin levels are translated into an increase in blood
pressure. Analyses of published studies show that over a training period of
a few months, blood pressure can be lowered by an average of 13/8
(systolic/diastolic) mmHg in people with elevated blood pressure, but that
there is a large variation in individual response.35

Raised HDL/ total blood cholesterol ratio

The reduction in insulin levels achieved by physical activity has a
favourable influence on blood lipids by increasing levels of beneficial high-
density lipoprotein (HDL cholesterol) and decreasing levels of deleterious
low-density lipoprotein (LDL cholesterol). The nature of the changes
differs between men and women, but in both sexes physical activity raises
the HDL to LDL or total cholesterol ratio by between 5% and 15%, thereby
reducing risk of CVD.11,36,37

Help in weight control

Obesity and overweight are important risk factors for CVD. Physical
activity can help control weight in several ways. Doing more exercise
increases energy expenditure and in the longer term may raise total muscle
mass so that even resting energy expenditure may increase. But, more
importantly, physical activity alters fat metabolism so that a higher
percentage of fat is used as a fuel source. This means that weight loss
strategies that combine diet and physical activity are much more successful
than either when used independently. Furthermore, the person losing
weight benefits from changes in other risk factors affected by the physical
activity (as described above) as well as from the weight loss.11,13,18

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2.3 Summary
Evidence that regular physical activity has a protective effect against CHD
is now overwhelming.18,38 Corresponding evidence related to
cerebrovascular disease (stroke)39–41 and, to a lesser extent, peripheral
arterial disease, is substantial. The preventative effect is evident in both
primary and secondary prevention (rehabilitation)11 of CVD and it is seen
in men and women of all ages. The reduction in risk attributed to
moderate physical activity is of the same order as that of the other major
behavioural risk factors and increases with the amount and intensity of the
activity. There is growing consensus that a sedentary lifestyle more than
doubles risk of CVD, but relative risks as great as 5 have been found when
the activity is intense. Taking up physical activity even relatively late in life
still has a protective effect.

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Section 3:
Recommendations for individuals –
How much, how often, how hard and
how long?

A striking finding of all the epidemiological and training studies of physical

activity and CVD risk is that any level of physical activity exceeding total
inactivity provides benefits in relation to CVD risk.42 A consensus is now
emerging that low- to moderate-intensity physical activity may reduce the
risk of CVD without having any notable influence on fitness. The public
health message is that adopting a lifestyle that exceeds complete
sedentariness will produce health benefits. At very low levels, these benefits
may not be due to improvements in cardiovascular health but reduce CVD
risk indirectly through, for example, better control of body weight and
better management of psycho-social stress.18,39

3.1 Daily, moderate and accumulated

The activity-health continuum:

moderate is good, more is even better
The benefit of physical activity extends across the full range of activity
levels, but the relationship is not linear: people with the lowest levels of
activity have the most to gain from a given increase in activity. At the top
end of the activity spectrum, doing even more is likely to produce a
proportionately smaller reduction in risk. Most studies have found the
greatest difference in CHD incidence rates between the completely
sedentary and those being moderately active.18,39
Given the continuous nature of the activity–health relationship, making
recommendations for minimum amounts of physical activity is largely
arbitrary. Even though the question ‘How much exercise is enough?’ is
frequently asked – there is no straightforward answer. The more a person
does, the lower their risk, whatever their existing level of activity. However,
quantified recommendations can provide useful benchmarks to motivate
individuals and to develop targets for national programmes. Current
consensus recommends an accumulation of 30 minutes of moderate-
intensity physical activity per day.43

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Frequency is more important than intensity:

daily and moderate
The consensus among scientists in the 1990s is to promote daily physical
activity at moderate intensity, such as walking, cycling, using the stairs etc.
This view is based on numerous studies which show that many functions
related to cardiovascular health can be improved by a bout of physical
activity.42 In order to maintain these benefits the activity has to be repeated
frequently, i.e. daily: one long walk during the weekend does not confer all
the health benefits that are gained by shorter daily walks.
Today it is generally accepted that moderate intensity activity, demanding
only 50% of VO2 max and 60% of maximum heart rate, may confer
important health benefits, particularly in relation to CVD risk, without a
significant improvement in cardio-respiratory fitness. This represents a
substantial shift from recommendations in the 1980s which were designed
to increase cardio-respiratory fitness. They called for continuous bursts of
intense activity so that participants felt sweaty and out of breath, for
example, 20 minutes exercise three times a week at more than 60% VO2
max and at up to 90% of maximum heart rate.44,45 (See Annex 3, p.40, for
an explanation of the differences between physical activity and cardio-
respiratory fitness). Some studies found that only vigorous exercise,
demanding a relatively high oxygen uptake, provided protection against
CHD.46,47 It is now considered that the failure to find benefits accruing
from lower-intensity exercise may have been due to poor methodological
assessment.
This change in physical activity recommendations has significant policy
implications. Exercise to increase cardio-respiratory fitness has to be
vigorous and tends to be achieved through dedicated sports or exercise
activities. Moderate-intensity exercise can be achieved through the
activities of daily life in an environment that favours activity.

Moderate-intensity exercise:
intensity depends on the existing level of fitness
From a physiological perspective, the intensity of a particular activity will
depend on the fitness level of the person undertaking it.46,48 A ‘moderate-
intensity’ brisk walk for an older or unfit person will be at a much slower
pace than for a younger or fitter person. It seems plausible that, regardless
of age, for very unfit individuals even activities carried out below the
intensity threshold of brisk walking will not only enhance health but will
also exhibit a significant training effect on cardio-respiratory fitness.49,50
Moreover, regardless of intensity, any physical activity performed regularly

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

in old age may help preserve functional capacity, which is crucial for
individual autonomy and quality of life.
Common examples of moderate-intensity activities for the moderately fit
include brisk walking at 5–6km/h, cycling at approximately 16 km/h,
walking up stairs, or heavy forms of gardening and housework.

Accumulated activity:
also effective
A further and recent development in the health recommendations is that
activity accumulated in short bouts is just as valuable as continuous
periods of activity.49,51,52 It is no longer necessary to specify a minimum of
20 minutes of continuous activity. Even short-duration activities during
the day, such as climbing stairs, mowing a small lawn or walking up a hilly
street, have a health enhancing effect when added together.18

Lifelong activity:
habitual, current and continuing
Whilst a history of physical activity may have some health benefit, it does
not provide lasting protection against CVD. Activity needs to be current
and continuing.

3.2 EHN Recommendation:

Every European adult should accumulate 30 minutes of

moderate-intensity physical activity most and preferably
every day of the week.
(This is in accordance with recommendations from the US
Department of Health and Human Services.)53

An example of moderate-intensity physical activity is brisk walking that

leaves the participant slightly out of breath, but still able to talk.54 The 30
minutes can be accumulated in several bouts throughout the day, carried
out as a part of active daily life.
People who are currently sedentary or minimally active should gradually
build up to the daily goal of 30 minutes of moderate activity by adding a

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few minutes each day. This will reduce the cardiac and musculo-skeletal
risks associated with suddenly increasing the amount or intensity of
exercise.
Those who currently meet these standards may derive additional health
and fitness benefits by becoming more physically active or including more
vigorous activity.

Young people:
an early start has a long-lasting effect
Recent expert recommendations state that
– all young people (aged 5–18) should participate in physical activity of at
least moderate intensity for one hour a day55
– young people who currently engage in little activity should participate
in physical activity of at least moderate intensity for at least half an hour
a day.
These recommendations are based on current scientific evidence and
expert opinion, although it is acknowledged that neither the minimal nor
the optimal amount of physical activity for young people can be precisely
defined at this time. Experts felt that a higher level of physical activity may
be necessary for younger people to support optimal growth and
development as well as for prevention of cardiovascular diseases in later
life. It should also foster the adoption of an active lifestyle – there is
evidence that active children are more likely than inactive children to
become active adults.56

3.3 Adverse effects:

they can be avoided
The potential risks of physical activity are far outweighed by its benefits.57
The type of increase in physical activity in daily life which EHN
recommends should cause little health risk if increased gradually. Concerns
about exercise relate mainly to intense, vigorous cardio-respiratory activity
and even these have often been over-emphasised. However, people
planning to take up more intense types of activity or formal exercise do
need to consider the risks.
The most common risk in exercising is injury to muscles and joints, and
this is more likely if people who have previously been inactive begin
exercising too hard or for too long. Graduated activity that allows muscles,
tendons and cartilage to adapt rarely causes problems.

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

The overall risk of CVD is reduced by physical activity, but risk may be
increased during the actual activity. The most severe risks are myocardial
infarction and sudden death during heavy physical activity.58–60 This is
particularly true for untrained subjects who start intense physical activity.
Under 30 years of age, those at risk are people with congenital heart
disease. Amongst the over 40s, people with underlying coronary artery
disease are at risk. This may be completely symptomless or, in many cases,
can be preceded by warning signs such as chest pain, breathlessness or
fainting. Programmes designed to promote physical activity should include
screening for high-risk individuals, who should be referred to their
physician prior to participation. (For a self-administered screening
questionnaire see Annex 4, p.41.)

3.4 Implications:
we can do better
The new recommendations, advocating daily, moderate and accumulated
activity, offer scope for new patterns of exercise and promotion of physical
activity. Thirty minutes of activity means being active for just 2% of the
day. Data on activity patterns in the EU (Figure 4, p.15) indicate that the
majority of Europeans – 66% – do not meet the EHN recommendation of
30 minutes activity on most days. More than a third of the adult
population engages in virtually no physical activity.14

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Section 4:
Policy recommendations –
The challenge and the potential for
change

Substantial increases in regular physical activity among people of all ages

throughout the European Union are called for to improve both
cardiovascular and general health. New findings that show that the
detrimental effect of physical inactivity has previously been
underestimated, and that even small increases in activity are beneficial.
This has significant policy implications: physical activity needs to be
promoted as part of normal daily life rather than an intermittent activity in
a track-suit or at a sports centre. Policies need to foster greater
opportunities for, and willingness of, people to engage in physical activity
as part of day-to-day living, such as walking to the shops or climbing the
stairs. This strategy offers the best hope that at least the minimum
requirements of regular health-enhancing physical activity can be attained
by the largest possible proportion of the population in the most
economical and ecological way and in a manner which does not
discriminate between socio-economic groups.
Making the daily lives of Europeans more physically active will take a
concerted strategy on the part of many players. The EU, governments,
national agencies, communities and individuals all have a part to play. The
first step is to publicise the new recommendations and findings on the
value and potential of physical activity for health. This includes alerting
policy and decision makers, health care professionals, school
administrators and teachers, land use and transport planners and media
professionals to the daily, moderate and accumulated message. The second
step is to put strategies for action in place. Evidence suggests that success is
only achievable through multi-level strategies that utilise all levels of
influence on health, from the individual through to community action and
legislative policy change.61,62 This section sets out recommendations for
action by the EU and outlines a number of broad policy interventions at
the national level that can have an effect on levels of participation in
physical activity.

4.1 Recommendations for action at European Union level

Subsidiarity is one of the key principles underpinning the functions of the
EU. However, without violating the principles of subsidiarity, some

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actions and initiatives carried out at a European level have more prestige
and credibility than national- and local-level initiatives. People tend to pay
more attention to actions that have the backing of the whole European
community.
The EU has already recognised the importance of physical activity in
promoting health. In 1995–6, three projects aimed at promoting physical
activity received financial support from the European Community’s
Action Programme on Health Promotion, Information, Education and
Training. These projects include a pan-EU survey on consumer attitudes
to physical activity, body-weight and health; a project aimed at developing
a European strategy, network and action programme for promoting
health-enhancing physical activity; and a programme, Slì na Slàinte (Path
to Health), designed to stimulate people who lead sedentary lifestyles to
take up regular physical activity, especially walking, and to create pathways
so that people can walk in enjoyable surroundings.
Despite the European Union’s acknowledgement of physical activity as an
important health determinant, only three EU Member States currently
have a nation-wide government-endorsed programme to promote a
physically active lifestyle – Finland, the Netherlands and the UK. Given the
lack of sufficient health-enhancing activity in all European countries and
the huge variation in national physical activity patterns (Figure 5) there is
plenty of scope for the EU to continue and increase its supportive role in
the promotion of physical activity as a health-enhancing measure.

Fig.5: Percentage of subjects in EU States that do not meet the current

physical activity recommendation (of at least 30 minutes per day)14

Sweden 32
Finland 33
Ireland 35
Austria 38
Netherlands 43
Denmark 46
Luxembourg 47
UK 48
Germany 56
Greece 62
France 63
Spain 65
Italy 66
Belgium 67
Portugal 83
EU average 57

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Recommendations:
EU policy: Develop an EU policy on health-enhancing physical
activity and a broad strategy for implementation in a range of sectors.
This should be linked to other policies that affect opportunities for
physical activity such as economy and finance, employment,
transport, environment, regional policies, education and tourism.
Pan-European Initiatives: Support Pan-European initiatives aimed
at facilitating the uptake of regular physical activity and increasing
awareness of the health benefits of physical activity. These should
stress that most health benefits are gained by moving from a sedentary
lifestyle to one with a moderate level of daily physical activity.
Regular Surveys: Monitor EU citizens’ participation in physical
activity through regular surveys.
Research on special groups: Conduct Pan-European research on
physical activity patterns and effective intervention among children,
women and the elderly and among the lower socio-economic groups.
Information Exchange: Encourage information exchange on
effectiveness of interventions in the area of physical activity among
relevant Pan-European networks in such areas as health, education
and training, environment and transport.

4.2 Recommendations for action at a national level

1 Information

Raise awareness among key professionals

of the importance of physical inactivity as a risk factor for CVD.

Justification: Physical activity is often left out of the discussion and

practical implementation of cardiovascular disease prevention policies,
strategies and measures. This may be for several reasons:
Poor dissemination: Information explaining that physical inactivity is a
strong and significant risk factor may not yet have reached, been accepted
or been adopted by organisations and health professionals working in the
field. Unfortunately dissemination of information on physical activity

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

lacks the investment and support that tends to accompany information

related to preventive measures using drugs or other means linked to
commercial interests.
Outdated information: It may be mistakenly believed that participation in
vigorous sport is required for risk reduction, and that this type of activity
might be inappropriate for the people who need to make changes.
Outside the health domain: Physical activity depends on facilities and
environments over which health professionals feel they have little control.
This may deter them from prescribing increases in physical activity.
Too few EU countries have national policies in place that outline their
approach to promoting physical activity, and strategies that set out the
main objectives, the key players involved and the relevant actions to be
undertaken. Whether at national, regional or local level, agreeing a strategy
is important as it provides clear direction for all concerned and provides
benchmarks against which progress can be measured

2 A new message

Raise public awareness

of the modern health message that even low levels of physical activity
are beneficial, and that these can easily be achieved through activities
as part of daily life.

Justification: Many people think of physical activity as something that is

hard work and sweaty. This image can be an important barrier. The pan-
EU survey found that on average 25% of Europeans cited the sporty image
of physical activity as a major deterrent, this varied from 12% in Finland to
33% in Belgium and Germany and was generally more often voiced by
women than by men.14
Education campaigns can help to promote the image of physical activity,
and make it seem more appropriate. Campaigns may comprise mass media
communication, leaflets, posters, educational seminars, lectures, or
counselling by professionals. The core function of these activities should
be that they provide some key information about healthy physical activity.
They may stress a number of aspects, including:
– The health benefits of short- and long-term physical activity.
– The amount of physical activity needed to benefit health.

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– How to overcome personal barriers to physical activity.

– Skills development (such as posture training, cycle proficiency).
– The experience of fun, joy and companionship while being physically
active.

3. Environment and Transport

Encourage infrastructural and policy changes

that increase the opportunities for physical activity as part of daily
living and transportation.

Justification: There is growing appreciation of the impact of the

environment on how we live our lives and how physically active we are.
Making changes to the environment to support physically active lifestyles
aims to increase the supply of appropriate environments, where physical
activity can take place, rather than attempting to further increase the
demand for physical activity – as has been the case with most other
promotional campaigns. Such environmental changes can be quite diverse
as such a wide range of different types of physical activity are beneficial for
health. For example, programmes can focus on green spaces or urban areas
for walking and cycling as well as more traditional sports or exercise
facilities.
Examples of environmental changes to promote physical activity:
– Developing an integrated transport strategy that emphasises walking
and cycling.
– Ensuring streets are safe and well-lit to encourage walking.
– Marking-out safe routes for walking and cycling, particularly around
schools.
– Providing and promoting the use of local parks and green spaces.
– Producing maps and guides of good places to walk or cycle.
– Improving bicycle parking facilities near public amenities, work-sites
and residential housing so that they are secure and easy-to-use.
– Improving access to sports and leisure facilities for all sections of the
community by providing, for example, free creches, discounted access
for the unemployed, over 50s sessions and late-night sessions.

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 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

– Staging ‘taster days’ for the non-exerciser at gyms and exercise facilities.
– Ensuring stairs are prominent in new buildings.
– Encouraging the use of stairs in shops and offices through sign systems.
– Encouraging town planners to provide facilities that can be walked to
and around, such as local markets, town squares, pedestrianised areas.

4. Facilities

Increase opportunities and facilities

for appropriate sport and active recreation for individuals and
families.

Justification: people are more likely participate in sport and recreation if

suitable facilities are available locally. Increasing the supply of such
facilities should be seen as equally important to stimulating demand
through marketing and promotional campaigns.
Appropriate facilities should not only be seen as traditional sports halls or
gyms, but also playing-fields, parks, footpaths, inner-city basketball hoops
and open spaces. These need to be carefully designed and promoted so
that they appeal to people from a wide range of backgrounds who do not
normally take part in sport.

5. The workplace

Promote physical activity through the workplace

and encourage commuting to work on foot or by bicycle.

Justification: The workplace has enormous potential as a setting for the

promotion of physical activity. Most adults spend half their waking hours
at the workplace, and the journey to and from work makes up a large part
of the total distance travelled each day. Converting to walking or cycling
for all or part of the daily commuting journey can be sufficient to confer
substantial health benefits.

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Examples of workplace interventions to promote physical activity

– Encouraging employers to produce ‘green commuter plans’ that put in
place measures to make it easier for employees to walk or cycle to work.
– Providing access to cycles in the workplace and competitive mileage
allowance rates for cycling as part of the working day.
– Encouraging employees to use the stairs in the workplace.
– Providing fitness-testing programmes and exercise facilities.
– Hosting workplace sports and activity days.
– Providing a free or subsidised company sports/health club.
– Encouraging managers and role models to set an active example.

6. Education and Physical Activity Skills

Develop school and teacher-training programmes

that emphasise enjoyable non-competitive physical activity, and foster
the acquisition of essential skills and a lifelong physical activity habit.

Justification: Promotion of physical activity needs to target an early age-

group, to sow the seeds for lifetime participation. Strategies should be put
in place to ensure that young people have access to programmes, facilities
and environments that encourage enjoyable experiences of activity.
Physical activity education should focus on equipping children with the
skills for a diverse range of physical activities rather than on a narrow range
of traditional competitive sports.
Research suggests a number of recommended strategies:
– Appropriately designed, delivered and supported physical education
curricula.
– Involving the whole family.
– Providing suitable and accessible environments.
– Involving young people in decision-making and programme design.
– Active participation of teachers and other staff as role models.

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7. Older people and those at high risk

Promote appropriate physical activity

and provide opportunities for older people and for people with a high
risk of complications in exercise, e.g. individuals with CVD, which
give opportunities for the development of social networks and
enhance quality of life and independence.

Justification: In most countries, older people tend to be less physically

active, despite the enormous health benefits to be gained from activity in
later life. In the pan-European activity survey, 28% of Europeans over the
age of 55 said that they thought they were too old for active sports and
leisure.14 Demographic patterns point towards a rapidly ageing population.
This makes older people a key target group for intervention.
Living an active lifestyle into older age can help offset many aspects of
ageing that are often regarded as inevitable. It helps to delay the decline in
some physical functions, avoid falls and accidents and to preserve
independent living. Activities that enhance strength, flexibility and co-
ordination are particularly important.

8. Community involvement

Encourage whole-community approaches

to the promotion of physical activity to all sectors of the population.

Justification: Community action can be a particularly powerful tool to

improve conditions and provide motivation for physical activity. Many
community-level cardiovascular prevention programmes have
demonstrated the strong effect that communities can play in a multi-level
health promotion programme, even though physical activity tended not to
be a major factor within these projects. Although national strategy/policy
is important, it will be within local communities that real change occurs, as
the impact of other changes – to the environment, to education, or to legal
or regulatory frameworks – is translated into action.

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The promotion of physically active lifestyles lends itself particularly well to

working in alliances – it may even be the best example of a subject that can
be tackled in so many different ways by so many different agencies. An
effective community alliance would bring to work together a range of key
players including community leaders, active volunteers, and professionals
from health, education, transport, and the environment sectors. A crucial
element of such a community-based approach is community consultation:
ensuring that the views, experiences and ideas of all sections of the
community are taken into account in planning and implementation.

9. Disabled people

Develop clear well-structured physical activity programmes

for disabled people.

Justification: Disabled people (whether physically or mentally disabled)

suffer from unequal access to facilities and opportunities to be active. Yet
physical activity can play an important role in prevention and treatment of
many conditions, as well as offering valuable opportunities for enjoyment
and social contact.

10. Equal access

Reduce the inequality in provision

that affects black and minority ethnic groups, the long term
unemployed, and people from lower socio-economic groups.

Justification: In many countries there is a gradient in participation in

physical activity according to social class, education and ethnic group.
This may contribute to the large inequalities in coronary heart disease.
Appropriate programmes need to be specifically targeted at lower socio-
economic groups to reduce these inequalities.

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4.3 Conclusion:
everything to gain
All of EHN’s recommendations on physical activity – to individuals to do
more, and to the EU, national governments and organisations to create
environments which facilitate active living and changes in attitudes
towards being more physically active – offer great potential for benefits
over and above their impact on CVD. For the individual, being more
active will confer a whole range of health benefits. At national and EU
level, making daily lives more physically active is fully concordant with
policies to promote a greener and more ecologically aware society and
environment. Raising physical activity levels in Europe needs to be seen as
less of a challenge, and more of an opportunity – an opportunity that
needs to be seized promptly, before we all pay the price for our
predominantly sedentary lifestyles.

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Annex 1
The health benefits of regular physical activity or,
conversely, the health costs of inactivity
(adapted from Haskell 1998)63

The following table is based on a total physical fitness program that

includes physical activity designed to improve both aerobic and musculo-
skeletal fitness.
«««« Strong consensus, with little or no conflicting data.
««« Most data are supportive, but more research is needed for
clarification.
««« Some data are supportive, but much more research is needed.

Physical activity benefit Surety rating

Fitness of body
Improved heart and lung fitness ««««
Improved muscular strength/size ««««

Cardiovascular disease
Coronary heart disease prevention ««««
Prevention of atherosclerosis ««
Treatment of heart disease «««
Prevention of stroke ««

Cancer
Prevention of colon cancer ««««
Prevention of breast cancer ««
Prevention of uterine cancer ««
Prevention of prostate cancer ««

Diabetes
Prevention of NIDDM ««««
Treatment of NIDDM «««
Improvement in diabetic life quality «««

Osteoporosis
Helps build up bone density ««««
Prevention of osteoporosis «««
Treatment of osteoporosis ««

Arthritis
Improvement in life quality/fitness ««««

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Physical activity benefit Surety rating

Low back pain

Prevention of low back pain ««
Treatment of low back pain ««

Asthma
Improvement in life quality «««

Infection and immunity

Prevention of the common cold ««
Improvement in overall immunity ««

Blood cholesterol/lipoproteins
Lower triglycerides «««
Raised HDL-cholesterol «««

High blood pressure

Prevention of high blood pressure ««««
Treatment of high blood pressure ««««

Weight management
Prevention of weight gain ««««
Treatment of obesity ««
Maintenance of weight loss «««

Psychological well-being
Elevation of mood ««««
Buffering of effects of mental stress «««
Alleviation/prevention of depression ««««
Anxiety reduction ««««
Improvement in self-esteem ««««

Cigarette smoking
Improvement in successful cessation ««

Nutrition and diet quality

Improvement in diet quality ««
Increase in total energy intake «««

Sleep
Improvement in sleep quality «««

Children and young people

Prevention of obesity «««
Control of disease risk factors «««
Reduction of unhealthy habits ««
Improved odds of adult activity ««

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Physical activity benefit Surety rating

Special issues for women

Improved total body fitness ««««
Improved fitness while pregnant ««««
Improved childbirth ««
Improved health of fœtus ««
Improved health during menopause «««

The elderly and the aging process

Improvement in physical fitness ««««
Countering of loss in heart/lung fitness ««
Countering of loss of muscle «««
Countering of gain in fat «««
Improvement in life expectancy ««««
Improvement in life quality ««««

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 Annex 2

[40]
Examples of the strength of association (indicating partially size of effect) between moderate
physical activity and various health outcomes

Table based on studies cited in the US Surgeon General’s Report (1996),18 and in Vuori (1998).64
EUROPEAN HEART NETWORK

Health Outcome Association with physical activity (PA) and size of effect References
Aerobic capacity (AC) PA decreases the rate of decrease of AC by up to 50 % and delays its Shephard 1993,
decline to a level threatening independent living by 10–20 years Rogers 1994

Functional limitations Risk of developing FLs in the elderly in 3–5 years 2–4 times greater in Simonsick et al. 1993,
(FL) sedentary than active Schroll et al. 1997,
Laukkanen et al. 1998
All-cause mortality Risk of death
– 19 % lower/one more mile walked/day in 12 years in 61–81-year-old Hakim et al. 1998
men
– decreased to about half in 12–14 years in 40–59-year-old men by Wannamethee et al. 1998
increasing PA from sedentary to light-moderate level Lissner et al. 1996
– increased by a factor of 2 in 6 years in 38–60-year-old women who Kujala et al. 1998
became sedentary Kushi et al. 1997
– about twice as high in 18 years in 25–64-year-old sedentary Erikssen et al. 1998
compared to active same-sex twins
– 25–40 % higher in sedentary post-menopausal women in 7 years
– increase of fitness decreased risk of death by 30–50 % in 13 years in
40–60-year-old men
 Health Outcome Association with physical activity and size of effect References

Coronary artery disease Risk in sedentary about twice as high as in active Wannamethee et al. 1998

Stroke Approximately as above Lee et al. 1998, Sacco et al.

1998

Hypertension Risk of developing hypertension in sedentary about 30 % higher than in Fagard and Tipton 1994,
active; PA decreases normal systolic/diastolic (~3 mmHg), elevated (6/7 Halbert et al. 1997, Cook et
mmHg) and hypertensive (10/8 mmHg) pressure al. 1995
PA decreases systolic/diastolic pressure 3.6/3.1 mmHg à large
reduction of hypertension, coronary heart disease and stroke predicted
at population level (2 mmHg decrease in diastolic pressure à 17 %
decrease in the prevalence of hypertension, 6 % decrease in coronary
heart disease and 15 % reduction in the incidence of stroke and
transient ischaemic attacks

Non-insulin dependent Risk in active 20–60 % lower than in sedentary, dose-dependent, Lynch et al. 1996
diabetes greatest reduction in high-risk subjects Pan et al. 1997
Risk decreased by 46 % during 6 years of exercise intervention

Colon cancer Most but not all (Lee et al. 1997) recent studies support the earlier Giovannucci et al. 1995,
findings suggesting decreased risk (40–50 %) in active subjects Longnecker et al. 1995,
Thune and Lund 1996,
Martinez et al. 1997,
Slattery et al. 1997

Overweight Prevalence of obesity and risk of becoming obese about one half in Haapanen et al. 1997
active as compared to sedentary subjects

Osteoporotic fractures Risk of hip and vertebral fractures 30–50 % smaller in physically active Joakimsen et al. 1997, Gregg
as compared to sedentary subjects et al. 1998
PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

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Annex 3
Physical activity and physical fitness:
explaining the differences
It is not known whether physical activity itself protects against CHD or
whether it is the effect of physical activity on fitness, or a combination of
both, that is beneficial. Physical activity is a behaviour pattern whereas
fitness is a trait that is determined by physical activity, age, sex and
genetics. One indicator of cardio-respiratory fitness is the maximum
volume of oxygen that a person can uptake when exercising hard – VO2
max, adjusted for body weight. Genetics accounts for only 25% of the
variability in VO2 max.65 A much greater proportion of the variability is
due to differences in the amount of high intensity physical activity a
person has undertaken. Someone who has trained hard is likely to be
‘fitter’ in cardio-respiratory terms and have a greater VO2 max. Amongst
the active ‘exercising population’, genetics is probably the most important
determinant of differences in fitness, but amongst the less active
population, disease and inactivity have a larger influence.

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Annex 4
Physical activity readiness questionnaire

Questionnaire to screen for high-risk individuals – to be completed by the

person prior to taking up a programme of vigorous physical exercise.

1 Has a doctor ever said that you have a heart condition

and/or recommended that you should only exercise
under medical supervision? yes q no q

2 Do you ever experience chest pain brought on by

physical activity? yes q no q

3 Have you developed chest pain in the past month? yes q no q

4 Have you ever lost consciousness or

fallen over as a result of dizziness? yes q no q
– in the past 10 years? yes q no q
– as an adult? yes q no q

5 Do you have a bone or joint problem that could be

aggravated by the proposed physical activity? yes q no q

6 Has a doctor ever recommended medication for

your blood pressure or a heart condition? yes q no q

7 Are you aware, through your own experience or a

doctor’s advice, of any other physical reason that
would prohibit you from exercising without
medical supervision? yes q no q

If you answered ‘yes’ to any of these questions,

call your personal physician or health-care provider
before increasing your level of physical activity.

(Adapted from Shephard et al.66 and Thomas et al.67)

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References
1
European Commission. The state of health in the European Community:
report from the Commission. Luxembourg, European Commission 1996.
2
World Health Report 1998. Life in the 21st century. A Vision for all. WHO,
Geneva 1998.
3
Sans S, Kesteloot H, Kromhout D. The burden of cardiovascular diseases
mortality in Europe. Task Force of the European Society of Cardiology on
Cardiovascular Mortality and Morbidity Statistics in Europe. Eur Heart J
1997;18:1231-1248.
4
Fletcher GF, Blair SN, Blumenthal J, Caspersen C, Chaitman B, Epstein S,
Falls H, Froelicher ES, Froelicher VF, Pina IL. Statement on exercise:
benefits and recommendations for physical activity programs for all
Americans: a statement for health professionals by the Committee on
Exercise and Cardiac Rehabilitation of the council on Clinical Cardiology,
American Heart Association. Circulation 1992;86:340-344.
5
Gorelick PB, Sacco RL, Smith DB, Alberts M, Mustone-Alexander L,
Rader D, Ross JL, Raps E, Ozer MN, Brass LM, Malone ME, Goldberg S,
Booss J, Hanley DF, Toole JF, Greengold NL, Rhew DC. Prevention of a
first stroke: a review of guidelines and a multidisciplinary consensus
statement from the National Stroke Association. JAMA 1999 Mar 24-
31;281(12):1112-20.
6
Powell KE, Thompson PD, Caspersen CJ, Kendrick CS. Physical activity
and the incidence of coronary heart disease. Ann Rev Public Health
1987;8:253-287.
7
Berlin JA, Colditz GA. A meta-analysis of physical activity in the
prevention of coronary heart disease. Am J Epid 1990;132:612-628.
8
Morris JN. Exercise in the prevention of coronary heart disease:today’s
best buy in public health. Medicine and Science in Sports and
Exercise.1994;26:807-814.
9
(The sum of all calculated PAR values may exceed 100%, because the risk
factors are related to each other.)
10
Haapanen-Niemi N, Vuori I, Pasanen M. Public health burden of
coronary heart disease risk factors among middle-aged and elderly men.
Preventive Medicine 1999;28:343-348.
11
Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation
1999;99:963-972.
12
British Medical Association. Road transport and health. The Chameleon
Press, London, 1997.
13
World Health Organisation. Obesity: preventing and managing the
global epidemic. Geneva, WHO,1998.

[44]
 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

14
A pan-EU survey on consumer attitudes to physical activity, body weight
and health. Brussels, Euopean Commission, 1999.
15
Morris JN, Heady JA, Raffle PAB, Roberts CG, Parks JW. Coronary
heart-disease and physical activity of work. Lancet 1953;1053-1057.
16
Paffenbarger, R. S. and Hyde, R. T. Physical activity and longivity of
college alumni. New Engl.J.Med. 1986;315: 399-401.
17
Eaton CB. Relation of physical activity and cardiovascular fitness to
coronary heart disease. Part 1.: A meta-analysis of the independent relation
of physical activity and coronary heart disease. Am J Board Fam Pract
1992;5:31-42.
18
US Department of Health and Human Services. Physical Activity and
Health: A Report of the Surgeon General. Atlanta, GA: US Department of
Health and Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health Promotion,
1996.
19
Manson JE, Hu FB, rich-Edwards JW, Colditz GA, Stampfer MJ, Willett
WC, Speizer FE, Hennekens CH. A prospective study of walking as
compared with vigorous exercise in the prevention of coronary heart
disease in women. N Eng J Med 1999:341:650-658
20
Morris JN, Clayton DG, Everitt MG, Burgess EH. Exercise in leisure
time: coronary attack and death rates. Br Heart J 1990;63:325-334.
21
Lakka TA, Venäläinen J, Rauramaa R, Salonen R, Tuomilehto J, Salonen
JT. Relation of leisure-time physical activity and cardio-respiratory fitness
to the risk of acute myocardial infarction in men. N Engl J Med
1994;330:1549-1554.
22
Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. Characteristics of
leisure-time physical activity associated with decreased risk of premature
all-cause and cardiovascular disease mortality in middle-aged men. Am J
Epid 1996,143:870-880.
23
Kananel WB, Kannel C, Paffenbarger RS, Cupples LA. Heart rate and
cardiovascular mortality: The Framingham Study. Am.Heart J.
1987;113:1489-1494.
24
Lissner, L., Bengtsson, C., Björkelund, C., and Wedel, H. Physical activity
levels and changes in relation to longivity. A prospective study of Swedish
women. Am.J.Epidemiol.1996;143: 54-62.
25
Lemaitre RN, Heckbert SR, Psaty BM, Siscovick DS. Leisure-time
physical activity and the risk of nonfatal myocardial infarction in
postmenopausal women. Arch Intern Med 1995;155:2302-2308.
26
Folsom AR, Arnett DK, Hutchinson RG, Liao F, Clegg LX, Cooper LS.
Physical activity and incidence of coronary heart disease in middle-aged
women and men. Med Sci Sports Exerc 1997;29(7):901-909.

[45]
EUROPEAN HEART NETWORK

27
Kushi LH, Fee RM, Folsom AR, Mink PJ, Anderson KE, Sellers TA.
Physical activity and mortality in postmenopausal women. JAMA
1997;277:1287-1292.
28
Manson JE, Hu FB, Rich-Edwards JW, Colditz GA, Stampfer MJ, Willett
WC, Spiezer FE, Hennekens CH. A prospective study of walking as
compared with vigorous exercise in the prevention of coronary heart
disease in women. N Engl J Med 1999;341:650-658.
29
Paffenbarger RS, Kampert JB, Lee I-M, Hyde RT, Leung RW, Wing AL.
Changes in physical activity and other lifeway patterns influencing
longevity. Med.Sci.Sports Exerc. 1994;26:857-865.
30
Blair SN. 1993 C.H. Mccloy research lecture: Physical activity, physical
fitness, and health. Res.Q.Exerc.Sport. 1993;64:365-376.
31
Wannamethee, G., Shaper, A. G., and Walker, M. Changes in physical
activity, mortality, and incidence of coronary heart disease in older men.
Lancet 1998;351:1603-1608.
32
Haskell WL. Physical activity, lifestyle, and cardiovascular health. In:
Leon AS (ed.) Physical activity and cardiovascular health. A national
concensus. Human Kinetics, Champaign IL, 1997.
33
DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome
responsible for NIDDM, obesity, hyperten sion, dyslipidemia, and
atherosclerotic cardiovascular disease. Diabetes Care 1991;14:173-194.
34
Cautier, J. F., Scheen, A., and Lefèbvre, P. J. Exercise in the management
of non-insulin-dependent (type 2) diabetes mellitus. Int.J.Obesity.
1995;19(suppl 4),58-61.
35
Petrella RJ. How effective is exercise training for the treatment of
hypertension? Clin J Sports Med 1998;8(3):224-231.
36
Stefanick ML. Physical activity and lipid metabolism. In: Leon AS (ed.)
Physical activity and cardiovascular health. A national concensus. Human
Kinetics, Champaign IL, 1997.
37
Stefanick ML, M;ackey S, Sheehan M, Ellsworth N, Haskell WL, Wood
PD. Effects of diet and exercise in men and postmenopausal women with
low levels of HDL cholestrol and high levels of LDL cholesterol. N Engl J
Med 1998;339:12-20.
38
Sacco RL, Gan R, Boden-Albala B, Lin I-F, Kargman DE, Hauser WA,
Shea S, Paik MC. Leisure-time physical activity and ischemic stroke risk.
The Northern Manhattan Stroke Study. Stroke 1998;29:380-387.
39
Leon AS (Ed). Physical activity and cardiovascular health: A National
Consensus. (US) Human Kinetics, Champaign IL, 1997.
40
Gillum RF, Mussolino ME, Ingram DD. Physical activity and stroke
incidence in women and men. The NHANES I Epidemiologic Follow-up
Study. Am J Epidemiol 1996;143:860-869.

[46]
 PHYSICAL ACTIVITY AND CARDIOVASCULAR DISEASE PREVENTION IN THE EU

41
Lee I-M, Paffenbarger RS. Physical activity and stroke incidence. The
Harvard Alumni Health Study. Stroke 1998;29:2049-2054.
42
Haskell WL. Health consequences of physical activity: Understanding
and challenges regarding dose-response. Med Sci Sports Exerc 1994,
26:649-66.
43
Pate RR, Pratt M, Blair SN et al., Physical activity and public health.
JAMA. 1995;273:402-407.
44
American College of Sports Medicine. Guidelines for graded exercise
testing and exercise prescription. 3rd Ed. Phiadelphia, Lea & Fabiger, 1985.
45
Hollmann W, Rost R, Dufaux B et al. Pravention und rehabilitation von
herz kreislaufkrankheiten durch korperliches training. Stutgart,
Hippokrates,1983.
46
Leon AS. Contributions of regular moderate-intensity physical activity to
reduced risk of coronary heart disease. In: Leon AS (ed.) Physical activity
and cardiovascular health. A national concensus. Human Kinetics,
Champaign IL, 1997.
47
Shaper AG, Wannamethee G. Physical activity and ischaemic heart
disease in middle-aged British men. Br.Heart J. 1991;66:384-394.
48
Morris JN, Clayton DG, Everitt MG, Semmence AM, Burgess EH.
Exercise in leisure time: coronary attack and death rates. Br.Heart J.
1990;63:325-334.
49
Dunn AL, Bess HM, Kampert JB et al. Comparison of lifestyle and
structured interventions to increase physical activity and cardio-
respiratory fitness. JAMA 1999;281:327-334.
50
King AC, Haskell WL, Young Dr et al. Long term effects of varying
intensities and formats of physical activity on participation rates, fitness
and lipoproteins in men and women aged 50 to 65. Circulation
1995;91:2596 -2 604
51
Murphy MH, Hardman AE. Training effects of short and long bouts of
brisk walking in sedentary women. Med Sci Sports Exerc 1998;30:152-157.
52
Pratt M. Benefits of lifestyle activity vs structured exercise. JAMA
1999;281:375-376.
53
US Dept of Health and Human Services – ibid.
54
Morris JN, Hardman AE. Walking to health. Sports Medicine
1997;23:306-332.
55
Health Education Authority. Young and active? Policy framework for
young people and health enhancing physical activity. London, HEA,1998.
56
National Forum for CHD Prevention. Physical acitivity: An agenda for
action. London, National Forum for CHD Prevention, 1995.
57
Kohl HW 3rd; Powell KE. Physical activity, physical fitness, and sudden
cardiac death. Epidemiol Rev 1992; 14: 37-58

[47]
EUROPEAN HEART NETWORK

58
Willich SN; Lewis M; Löwel H; Arntz HR; Schubert F; Schröder R.
Physical exertion as a trigger of acute myocardial infarction. N Engl J Med
1993; 329: 1684-90
59
Mittelman MA; Maclure M; Tofler GH; Sherwood JB; Goldberg RJ;
Muller JE. Triggering of acute myocardial infarction by heavy physical
exertion. Protection against triggering by regular exertion. N Engl J Med
1993; 329: 1677-83
60
Vuori IM. Sudden death and exercise: effects of age and type of activity.
Sports Science Review 1995;4(2):46-84.
61
Sallis JF, Bauman A, Pratt M. Environmental and policy interventions to
promote physical activity. An J Prev Med 1998;15(4):379-397.
62
U.S. Department of Health and Human Services: Promoting Physical
Activity: A guide for Community Action. Humn Kinetics, Champaign IL,
Kinetics 1999.
63
Haskell WL. The benefits of regular exercise. In Nieman DC. The
exercise-health connection. Human Kinetics, Champaign IL 1998:301-309.
64
Vuori I. Does physical activity enhance health? Patient Education and
Ccounseling 1998;33:S95-S103.
65
Bouchard C, Dionne FT, Simoneau J-A, Boulay MR. Genetics of aerobic
and anaerobic performances. Exerc. Sport Sci. Rev. 1992;20:27-58.
66
Shephard R J; Thomas S, Weller I. The Canadian home fitness test: 1991
update. Sports Med. 1991; 11: 358-66.
67
Thomas S; Reading J; Shephard RJ. Revision of the Physical Activity
Readiness. Questionnaire (PAR-Q). Can. J. Sports Sci. 1992, 17: 338-45.

[48]