Journal of Sports Sciences

ISSN: 0264-0414 (Print) 1466-447X (Online) Journal homepage: www.tandfonline.com/journals/rjsp20

The ABC of Physical Activity for Health: A

consensus statement from the British Association
of Sport and Exercise Sciences

Gary O'Donovan, Anthony J. Blazevich, Colin Boreham, Ashley R. Cooper,

Helen Crank, Ulf Ekelund, Kenneth R. Fox, Paul Gately, Billie Giles-Corti,
Jason M. R. Gill, Mark Hamer, Ian McDermott, Marie Murphy, Nanette
Mutrie, John J. Reilly, John M. Saxton & Emmanuel Stamatakis

To cite this article: Gary O'Donovan, Anthony J. Blazevich, Colin Boreham, Ashley R. Cooper,
Helen Crank, Ulf Ekelund, Kenneth R. Fox, Paul Gately, Billie Giles-Corti, Jason M. R. Gill,
Mark Hamer, Ian McDermott, Marie Murphy, Nanette Mutrie, John J. Reilly, John M. Saxton &
Emmanuel Stamatakis (2010) The ABC of Physical Activity for Health: A consensus statement
from the British Association of Sport and Exercise Sciences, Journal of Sports Sciences, 28:6,
573-591, DOI: 10.1080/02640411003671212

To link to this article: https://doi.org/10.1080/02640411003671212

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Journal of Sports Sciences, April 2010; 28(6): 573–591

The ABC of Physical Activity for Health: A consensus statement from

the British Association of Sport and Exercise Sciences

GARY O’DONOVAN1, ANTHONY J. BLAZEVICH2, COLIN BOREHAM3,

ASHLEY R. COOPER4, HELEN CRANK5, ULF EKELUND6, KENNETH R. FOX4,
PAUL GATELY7, BILLIE GILES-CORTI8, JASON M. R. GILL9, MARK HAMER10,
IAN MCDERMOTT11, MARIE MURPHY12, NANETTE MUTRIE13, JOHN J. REILLY9,
JOHN M. SAXTON5, & EMMANUEL STAMATAKIS10
1
University of Exeter, Exeter, UK, 2Edith Cowan University, Joondalup, WA, Australia, 3University College Dublin, Dublin,
Ireland, 4University of Bristol, Bristol, UK, 5Sheffield Hallam University, Sheffield, UK, 6MRC Epidemiology Unit,
Cambridge, UK, 7Leeds Metropolitan University, Leeds, UK, 8University of Western Australia, Crawley, WA, Australia,
9
University of Glasgow, Glasgow, UK, 10University College London, London, UK, 11Brunel University, London, UK,
12
University of Ulster, Newtownabbey, UK, and 13University of Strathclyde, Glasgow, UK

(Accepted 2 February 2010)

Absract
Our understanding of the relationship between physical activity and health is constantly evolving. Therefore, the British
Association of Sport and Exercise Sciences convened a panel of experts to review the literature and produce guidelines that
health professionals might use. In the ABC of Physical Activity for Health, A is for All healthy adults, B is for Beginners, and
C is for Conditioned individuals. All healthy adults aged 18–65 years should aim to take part in at least 150 min of moderate-
intensity aerobic activity each week, or at least 75 min of vigorous-intensity aerobic activity per week, or equivalent
combinations of moderate- and vigorous-intensity activities. Moderate-intensity activities are those in which heart rate and
breathing are raised, but it is possible to speak comfortably. Vigorous-intensity activities are those in which heart rate is
higher, breathing is heavier, and conversation is harder. Aerobic activities should be undertaken in bouts of at least 10 min
and, ideally, should be performed on five or more days a week. All healthy adults should also perform muscle-strengthening
activities on two or more days a week. Weight training, circuit classes, yoga, and other muscle-strengthening activities offer
additional health benefits and may help older adults to maintain physical independence. Beginners should work steadily
towards meeting the physical activity levels recommended for all healthy adults. Even small increases in activity will bring
some health benefits in the early stages and it is important to set achievable goals that provide success, build confidence, and
increase motivation. For example, a beginner might be asked to walk an extra 10 min every other day for several weeks to
slowly reach the recommended levels of activity for all healthy adults. It is also critical that beginners find activities they enjoy
and gain support in becoming more active from family and friends. Conditioned individuals who have met the physical
activity levels recommended for all healthy adults for at least 6 months may obtain additional health benefits by engaging in
300 min or more of moderate-intensity aerobic activity per week, or 150 min or more of vigorous-intensity aerobic activity
each week, or equivalent combinations of moderate- and vigorous-intensity aerobic activities. Adults who find it difficult to
maintain a normal weight and adults with increased risk of cardiovascular disease or type 2 diabetes may in particular benefit
from going beyond the levels of activity recommended for all healthy adults and gradually progressing towards meeting the
recommendations for conditioned individuals. Physical activity is beneficial to health with or without weight loss, but adults
who find it difficult to maintain a normal weight should probably be encouraged to reduce energy intake and minimize time
spent in sedentary behaviours to prevent further weight gain. Children and young people aged 5–16 years should accumulate
at least 60 min of moderate-to-vigorous-intensity aerobic activity per day, including vigorous-intensity aerobic activities that
improve bone density and muscle strength.

Keywords: Physical activity guidelines, chronic diseases, exercise

activity was associated with health: the coronary

1. Introduction
heart disease death rates of physically active bus
Simple comparisons of men in different occupations conductors and postmen were half those of physically
provided the first empirical evidence that physical inactive bus drivers and telephonists (Morris, Heady,

Correspondence: G. O’Donovan, School of Sport and Health Sciences, University of Exeter, St. Luke’s Campus, Heavitree Road, Exeter EX1 2LU, UK.
E-mail: [email protected]
ISSN 0264-0414 print/ISSN 1466-447X online Ó 2010 Taylor & Francis
DOI: 10.1080/02640411003671212
574 G. O’Donovan et al.

Raffle, Roberts, & Parks, 1953a, 1953b; Morris, 60 min of at least moderate-intensity physical activity
Kagan, Pattison, & Gardner, 1966). There is now a per day and adults should achieve at least 30 min of
wealth of sophisticated epidemiological evidence to moderate-intensity physical activity per day on five or
demonstrate that physical activity is associated with more days of the week. Second, the review might
reduced risk of coronary heart disease, obesity, type 2 help clarify the dose–response relationship between
diabetes, and other chronic diseases and conditions physical activity and health. Third, the review might
(Department of Health, 2004). It is estimated that identify various ways of meeting physical activity
ill-health attributable to physical inactivity costs the goals, in contrast to the ‘‘one size fits all’’ approach
National Health Service more than £1.06 billion in contemporaneous guidelines (Department of
per year and it is estimated that physical inactivity Health, 2004; Pate et al., 1995).
is directly responsible for more than 35,000 The methods used to produce the ABC of Physical
deaths each year in the UK (Allender, Foster, Activity for Health were modelled on those used to
Scarborough, & Rayner, 2007). produce the Chief Medical Officer’s report on
Physical activity guidelines have changed to reflect physical activity and health (Department of Health,
our evolving understanding of the relationship 2004). In phase 1, experts produced literature
between physical activity and health. In the 1970s reviews on physical activity and the prevention of
and 1980s, the available evidence suggested that overweight and obesity (Ekelund and Gately),
vigorous-intensity activity and the pursuit of cardio- physical activity and the prevention of type 2 diabetes
respiratory fitness were appropriate (the terms (Cooper and Gill), physical activity and the preven-
cardiorespiratory fitness and aerobic fitness can be tion of cardiovascular disease (Hamer and Murphy),
used interchangeably and both terms refer to the physical activity and the prevention of common
ability of the lungs, heart, blood, and vascular system cancers (Saxton and Crank), physical activity and
to transport oxygen and the ability of the tissues and psychological well-being (Fox and Mutrie), minimal
organs to extract and use oxygen) (American College and optimal levels of physical activity and physical
of Sports Medicine, 1978, 1990). In the 1990s, it fitness (Stamatakis and O’Donovan), physical activ-
became apparent that moderate-intensity aerobic ity and health in children and adolescents (Reilly and
activity also offered substantial health benefits (De- Boreham), and the prevention of musculoskeletal
partment of Health, 1995; Pate et al., 1995). In recent injury (Blazevich and McDermott). The reviewers
years, US guidelines have stated that physical activity were asked to consider the dose–response relation-
goals can be met through various doses of moderate- ship between physical activity and health and to
and/or vigorous-intensity aerobic activity (Haskell produce a series of evidence statements on the
et al., 2007; US Department of Health and Human minimal and optimal levels of physical activity in
Services, 2008). However, British physical activity men, women, and any sub-populations that might be
guidelines have not changed since 2004 (Department at increased risk of chronic diseases. The reviewers
of Health, 2004). The ABC of Physical Activity for specified the type (A–D) and strength (1–3) of
Health was written for an audience of health evidence in support of each evidence statement
professionals. Governments and other health-pro- using widely recognized definitions (National Cho-
moting agencies will provide physical activity guide- lesterol Education Program, 2002). The literature
lines that members of the public might read. For reviews were circulated and discussed during a
example, the British Heart Foundation is currently public meeting at Brunel University in April 2007
working with governments in England, Scotland, and delegates’ comments were recorded so that they
Wales, and Northern Ireland to produce updated might contribute to the consensus process. For
physical activity guidelines (www.bhfactive.org.uk). example, an expert on the built environment and
health (Giles-Corti) was recruited in light of dele-
gates’ comments. In phase 2, summary reviews were
2. The consensus process
circulated and members of the expert panel com-
It is recommended that a review should not be municated by email and conference call until each
commissioned if an existing review contains all the member approved the recommendations in this
evidence needed to inform policy makers and guide document. In phase 3, three independent experts
practitioners (Glanville & Sowden, 2001). The reviewed the document and it was revised in light of
present review was deemed necessary for three their comments.
interrelated reasons in September 2006. First, it
would provide the opportunity to incorporate studies
3. Recommendations: The ABC of Physical
published after the Chief Medical Officer’s report on
Activity for Health
physical activity and health (Department of Health,
2004), which reviewed the literature to early 2004 In the ABC of Physical Activity for Health, A is for
and concluded that children should achieve at least All healthy adults, B is for Beginners, and C is for
 The ABC of Physical Activity for Health 575

Conditioned individuals. This emphasis on appro-

3.1. All healthy adults
priate levels for all adults as well as subgroups is
novel and important because wide ranges of physical All healthy adults aged 18–65 years should aim to
activity experience exist in the general population. All take part in at least 150 min of moderate-intensity
healthy adults are healthy men and women aged 18– aerobic activity each week, or at least 75 min of
65 years and those in the same age range with vigorous-intensity aerobic activity each week, or
conditions not associated with inactivity (such as equivalent combinations of moderate- and vigor-
hearing impairment). Physical activity guidelines for ous-intensity aerobic activities. Moderate-intensity
older adults are described in detail elsewhere activities are those in which heart rate and breath-
(Nelson et al., 2007). Beginners are healthy adults ing are raised, but it is possible to speak
who do not take part in the recommended levels of comfortably. Vigorous-intensity activities are those
activity, including those who take part in little or no in which heart rate is higher, breathing is heavier,
activity, those who are somewhat active, and those and conversation is harder. Aerobic activities
who are resuming an active lifestyle after a period of should be undertaken in bouts of at least 10 min
inactivity. Conditioned individuals are those who have and, ideally, should be performed on five or more
met the physical activity levels recommended for ‘all days of the week. All healthy adults should also
healthy adults’ for at least 6 months. The key perform muscle-strengthening activities such as
recommendations are summarized in Box 1 and weight training, circuit classes or yoga. Resistance
described in this section; the evidence behind the exercise is an important complement to aerobic
ABC of Physical Activity for Health is summarized in exercise and the recommended level is equivalent
Section 4; physical activity in children and adoles- to 8–10 sets (exercises) of 8–12 repetitions on two
cents, adults struggling to maintain normal weight, or more days each week. The major muscle groups
and adults at increased risk of chronic diseases is should be targeted and a weight or resistance
discussed in Section 5; screening and injury preven- should be chosen that brings about local muscular
tion are discussed in Section 6; an explanation of fatigue at the end of each set. All adults should
how beginners might become more active is given in take every opportunity to be active and should
Section 7; and the role of the built environment is minimize sedentary time because all movement
discussed in Section 8. contributes towards daily energy expenditure.

Box 1. Key recommendations in the ABC of Physical Activity for Health.

. Children and adolescents aged 5–16 years should accumulate at least 60 min of moderate-to-
vigorous intensity activity per day, including vigorous-intensity aerobic activities that improve bone
density and muscle strength.
. All healthy adults should take part in at least 150 min of moderate-intensity aerobic activity each
week, or at least 75 min of vigorous-intensity aerobic activity each week, or equivalent combinations
of moderate- and vigorous-intensity aerobic activities. Weight training, circuit classes, and other
resistance exercises are a complement to aerobic exercise, and it is recommended that all healthy
adults perform 8–10 different exercises on two or more non-consecutive days each week. A resistance
(weight) should be selected that brings about local muscular fatigue after 8–12 repetitions of each
exercise.
. Beginners should steadily work towards meeting the physical activity levels recommended for all
healthy adults.
. Conditioned individuals who have met the physical activity levels recommended for all healthy
adults for at least 6 months may obtain additional health benefits by engaging in 300 min or more of
moderate-intensity aerobic activity each week, or 150 min or more of vigorous-intensity aerobic
activity each week, or equivalent combinations of moderate- and vigorous-intensity aerobic activities.
. Adults with increased risk of cardiovascular disease or type 2 diabetes may benefit in particular
from going beyond the levels of activity recommended for all healthy adults and gradually progressing
towards meeting the recommendations for conditioned individuals.
. Adults who find it difficult to maintain a normal weight may also need to meet the physical
activity recommendations for conditioned individuals, reduce energy intake, and minimize sedentary
time to reduce the risk of overweight and obesity.
576 G. O’Donovan et al.

Activity for Health, including evidence from cross-

3.2. Beginners
sectional studies, experimental studies, and cohort
Beginners should work steadily towards meeting the studies. In a cross-sectional study, risk factors for
physical activity levels recommended for ‘all healthy disease are compared in habitual exercisers and their
adults’. In the early stages, even small increases in sedentary counterparts at one particular time. In an
activity will bring some health benefits. For example, a experimental study, risk factors for disease are
beginner might walk an extra 10 min every other day measured before and after an exercise intervention
for several weeks before slowly increasing the amount while controlling for potential confounders such as
of walking to reach the recommended levels of activity weight loss or a change in diet. In a cohort study, a
for all healthy adults. Priority should be given to large number of healthy people are observed over a
supporting changes in activity patterns rather than the long period and the incidence of disease or death is
extent to which recommended levels have been met. It compared in groups of different physical activity
is important that beginners set achievable goals that levels.
provide success, build confidence. and increase
motivation. Finding activities that can be enjoyed
4.1. Doses of activity
and gaining support from friends and family to
become more active are both critical for the beginner The doses of activity are the recommended types and
as they progress towards reaching the physical activity amounts of activity. Aerobic activity is the cornerstone
levels recommended for all healthy adults. of most guidelines and physical activity goals are
usually expressed as minutes per day (Pate et al.,
1995), calories per week (US Department of Health
3.3. Conditioned individuals
and Human Services, 1996) or minutes per week (US
Conditioned individuals who have met the physical Department of Health and Human Services, 2008).
activity levels recommended for ‘all healthy adults’ for The available evidence suggests that ‘‘any activity is
at least six months may obtain additional health better than none’’ (US Department of Health and
benefits by engaging in 300 min or more of moder- Human Services, 1996), but the doses recommended
ate-intensity aerobic activity per week, or 150 min or in the ABC of Physical Activity for Health are
more of vigorous-intensity aerobic activity per week, associated with substantial health benefits.
or equivalent combinations of moderate- and vigor- Depending on body weight, 150 min of moderate-
ous-intensity aerobic activities. Heavy resistance intensity aerobic activity per week or 75 min of
training once or twice per week may increase muscular vigorous-intensity aerobic activity per week expends
strength, but exceeding the recommended level of around 800–1200 kcal (3349–5023 kJ). Cross-
resistance training may not offer other benefits. sectional studies and exercise interventions suggest
Indeed, a large volume of resistance training may lead that these doses of activity are associated with
to overreaching and overtraining if the balance favourable changes in blood pressure (Cornelissen
between training and recovery is inappropriate [over- & Fagard, 2005b; Murphy, Nevill, Murtagh, &
reaching refers to a decrease in performance that may Holder, 2007), lipid and lipoprotein profiles
last several days to several weeks and overtraining (Durstine et al., 2001; Kodama et al., 2007; Shaw,
refers to a decrease in performance that may last Gennat, O’Rourke, & Del Mar, 2006), markers of
several weeks to several months and may be accom- inflammation (Hamer, 2007), insulin sensitivity
panied by greater fatigue, performance decline, and (Cornelissen & Fagard, 2005b), and other risk
mood disturbance (Halson & Jeukendrup, 2004)]. factors for chronic diseases (Autenrieth et al., 2009;
El-Sayed, El-Sayed Ali, & Ahmadizad, 2004).
Evidence is also emerging that 150 min of moder-
4. The evidence behind the recommendations
ate-intensity exercise per week may improve physical
Causal relationships between physical activity and and mental quality of life (Martin, Church, Thomp-
cardiovascular disease, type 2 diabetes, colon cancer, son, Earnest, & Blair, 2009) and cognitive function
and all-cause mortality have been recognized for some in those aged 45–50 years and older (Lautenschlager
time (Allender et al., 2007; Paffenbarger, 1988; US et al., 2008). Prospective cohort studies suggest that
Department of Health and Human Services, 1996). the recommended doses of activity are associated
More recently, the pertinent issue has been the dose– with 20–30% reductions in the risks of cardiovas-
response relationship between physical activity and cular disease (Hamer & Chida, 2008), type 2 dia-
health (Blair, Cheng, & Holder, 2001a): What is the betes (Gill & Cooper, 2008), depression (Camacho,
minimum dose of activity associated with health and Roberts, Lazarus, Kaplan, & Cohen, 1991; Farmer
well-being? What doses of activity offer greater health et al., 1988), cognitive impairment in older adults
benefits? This section provides evidence for the doses (Laurin, Verreault, Lindsay, MacPherson, & Rock-
of activity recommended in the ABC of Physical wood, 2001; Rovio et al., 2005; Scarmeas et al.,
 The ABC of Physical Activity for Health 577

2009), post-menopausal breast cancer (Monninkhof studies and are associated with 40–50% reductions
et al., 2007), and all-cause mortality (Blair et al., in the risks of chronic diseases and premature death
2001a). Higher doses of activity may be necessary to (Blair et al., 2001a; G. Hu et al., 2004, 2005). For
reduce the risks of other common cancers, such example, a recent study of more than 250,000
as colon cancer (Samad, Taylor, Marshall, & middle-aged men and women found that cardiovas-
Chapman, 2005) and, possibly, high-grade or cular disease risk and all-cause mortality risk were
advanced prostate cancer (the diagnosis of prostate reduced by around 40% in those who met ‘‘conven-
cancer stages is described online: www.prostate- tional’’ recommendations (at least 30 min of mod-
cancer.org.uk) (Giovannucci, Liu, Leitzmann, erate-intensity activity on most days of the week), by
Stampfer, & Willett, 2005; Nilsen, Romundstad, & around 40% in those who met ‘‘traditional’’ recom-
Vatten, 2006; Patel et al., 2005). mendations (at least 20 min of vigorous-intensity
The reductions in morbidity and mortality asso- activity three times per week), and by around 50% in
ciated with physical activity might sound modest, but those whose activity was equivalent to meeting both
they are the most conservative of estimates obtained recommendations (Leitzmann et al., 2007). The
by statistically isolating physical activity from poten- continuous nature of the dose–response relationship
tial confounders, such as age, smoking habit, is such that exceeding the levels of activity recom-
cholesterol profile, and blood pressure. Statistical mended for ‘‘conditioned individuals’’ is likely to
adjustments are appropriate, but it is possible that provide additional health benefits (Table I), although
conservative models underestimate the relationships there is probably a ‘‘law of diminishing returns’’ with
between physical activity and health. For example, greater levels of activity offering fewer additional
it could be argued that cholesterol profile and benefits (Department of Health, 2004).
blood pressure are mediators on the causal pathway
between physical activity and health, rather 4.1.1. Frequency of activity. The available evidence
than confounding variables (Mora, Cook, Buring, suggests many ways an adult can meet the physical
Ridker, & Lee, 2007). It is also possible that the activity goals of 150 min of moderate-intensity aero-
relationship between physical activity (exposure) and bic activity or 75 min of vigorous-intensity aerobic
health (outcome) has been underestimated because it activity per week (Haskell et al., 2007; US Depart-
has been difficult to measure accurately people’s ment of Health and Human Services, 2008). Studies
exposure to physical activity (Lee & Paffenbarger, of ‘‘weekend warriors’’ have shown that taking part in
1996). The relationship may become clearer and one or two bouts of vigorous-intensity exercise per
stronger with the use of accelerometry and other week can reduce the risk of chronic diseases and
accurate measures of physical activity. premature death (Lee, Sesso, Oguma, & Paffenbar-
Prospective cohort studies also suggest that there ger, 2004; Okada et al., 2000; Wisloff et al., 2006).
is a dose–response relationship between physical This approach may suit some people, but there are at
activity and health, which strengthens the argument least two reasons to believe it may be advantageous to
for causality (Table I). The doses of activity be active more often. First, sedentary behaviour may
recommended for ‘‘conditioned individuals’’ are increase the risk of obesity (Stamatakis, Hirani, &
similar to the highest doses investigated in many Rennie, 2009), depression (van Gool et al., 2003),

Table I. Evidence for a causal relationship between physical activity and reduced risk of chronic diseases, according to Hill’s (1965) criteria
for causality.

Criteria

Strength of Temporal Biological Experimental Dose–

Disease or condition association* Consistency sequence plausibility evidence response

Cardiovascular disease üüü üüü üüü üüü üüü üüü

Type 2 diabetes üüü üüü üüü üüü üüü üüü
Overweight and obesity üüü üü ü üüü ü ü
Post-menopausal breast cancer üü üü üü ü ü
Colon cancer ü üü üü ü ü
Psychological well-being ü ü ü ü
Clinical depression üü ü ü ü
Cognitive impairment ü üü ü
Prostate cancer# ü ü ü
Anxiety disorders

ü ¼ moderate evidence. üü ¼ strong evidence. üüü ¼ very strong evidence. *‘Very strong’ strength of association refers to a two-fold
increase in risk associated with inactivity after adjustment for confounding variables. #Evidence refers to the incidence of advanced prostate
cancer observed in large cohort studies.
578 G. O’Donovan et al.

and all-cause mortality (Katzmarzyk, Church, Craig, weight gain (Brown, Williams, Ford, Ball, & Dobson,
& Bouchard, 2009). Second, single bouts of aerobic 2005) and television watching was associated with
activity can lower blood pressure, increase insulin increased risk of type 2 diabetes (Hu et al., 2001)
sensitivity, and improve lipid and lipoprotein profiles independent of leisure-time physical activity.
for up to 24–48 h (Gill & Hardman, 2003; Perseghin
et al., 1996; Thompson et al., 2001; Wojtaszewski & 4.1.3. Intensity of activity. Physical activity is
Richter, 2006). usually expressed in absolute terms in prospective
cohort studies: moderate-intensity is typically char-
4.1.2. Duration of bouts. The Chief Medical Officer’s acterized as 3–6 METs and vigorous-intensity is
report on physical activity and health tentatively typically characterised as 46 METs (where one
concluded that physical activity goals could be met MET is equivalent to the energy expended at rest).
in 10-min bouts (Department of Health, 2004). More There is compelling evidence of a dose–response
recent research supports this conclusion (Altena, relationship between physical activity intensity and
Michaelson, Ball, Guilford, & Thomas, 2006; Altena, cardiovascular disease: activities 46 METs are
Michaelson, Ball, & Thomas, 2004; Murphy, Blair, & associated with lower risk of cardiovascular disease
Murtagh, 2009; Strath, Holleman, Ronis, Swartz, & than activities of 3–6 METs, especially in men
Richardson, 2008). In a recent study of 3250 (Figure 1). Experimental studies and cohort studies
adults, for example, body mass index (BMI) was also suggest that there is a dose–response relation-
1.2 kg  m72 lower and waist girth was 2.7 cm smaller ship between physical activity and other chronic
in those who accumulated 30 min of moderate-to- diseases and conditions (Table I). ‘‘Moderate-
vigorous-intensity physical activity per day in bouts of intensity’’ and ‘‘vigorous-intensity’’ activities can be
10 min or longer than all other individuals (Strath readily identified outside the laboratory using the 6–
et al., 2008). Although more research is required, there 20 ratings of perceived exertion (RPE) scale (Borg,
is some evidence that bouts of less than 10 min may 1998) or the ‘‘talk test’’ (Persinger, Foster, Gibson,
also be beneficial to health (Miyashita, Burns, & Fater, & Porcari, 2004). In men and women of all
Stensel, 2008; Strath et al., 2008). There is also ages, an RPE of 12–13 represents moderate intensity
growing evidence that it is beneficial to avoid sitting and one of 14–16 vigorous intensity (Demello,
and other sedentary behaviours (Hamilton, Hamilton, Cureton, Boineau, & Singh, 1987; Mahon, Duncan,
& Zderic, 2007; Levine, 2007). For example, physical Howe, & Del Corral, 1997; Prusaczyk, Cureton,
activity (self-reported walking, sports, and exercise) Graham, & Ray, 1992). An individual’s level of
and sedentary behaviour (television and other screen- fitness influences his or her perception of effort and
based entertainment) were independently related to Tables II–VII give examples of activities that may be
obesity (BMI and waist girth) in the 2003 Scottish perceived as ‘‘moderate’’ or ‘‘hard’’ (hard is equiva-
Health Survey (Stamatakis et al., 2009); and, in recent lent to vigorous) in men aged 20–79 years of different
prospective studies, sitting time was associated with fitness levels. VIII–XII give examples of activities

Figure 1. Intensity of physical activity and risk of cardiovascular disease in men and women. In each of these prospective cohort studies, the
reference group is sedentary or inactive, and vigorous activity required 6 METs. The most conservative multivariate relative risk is cited.
HA is the 15-year Harvard Alumni Health Study of 13,485 men (Lee & Paffenbarger, 2000); HP is the 12-year Health Professionals’ Follow-
Up Study of 44,452 men (Tanasescu, Leitzmann, Rimm, & Hu, 2003); HUNT is the 16-year Hunt Study, Norway, of 27,143 men and
28,929 women (Wisloff et al., 2006); JACC is the 10-year Japanese Collaborative Cohort Study of 31,023 men and 42,242 women (Noda
et al., 2005); FT is the 17-year Finnish Twin Cohort of 7925 men (Kujala, Kaprio, Sarna, & Koskenvuo, 1998); NHS is the 8-year Nurses’
Health Study of 70,102 women (Hu et al., 1999); WHIOS is the 3-year Women’s Health Initiative Observational Study of 73,743 post-
menopausal women (Manson et al., 2002); and WHS is the 5-year Women’s Health Study of 39,372 women (Lee, Rexrode, Cook,
Manson, & Buring, 2001).
 The ABC of Physical Activity for Health 579

Table II. Perception of effort for various physical activities in men aged 20–29 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Above Well above

Activity (MET costs) average (10.1) Below average (11.5) Average (12.5) average (13.8) average (15.4)

Vacuuming or mopping (3.5) Light Light Light Light Light

Brisk walking (3.8) Light Light Light Light Light
Cycling at <10 mph (4) Moderate Light Light Light Light
Mowing lawn with power mower (4.5) Moderate Light Light Light Light
Tennis, doubles (6) Moderate Moderate Moderate Moderate Light
Badminton, competitive (7) Hard Hard Moderate Moderate Moderate
Circuit training or jogging at 5 mph (8) Hard Hard Hard Moderate Moderate
Cycling at 14.0–15.9 mph (10) Maximal Very hard Hard Hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Maximal Very hard

*Fitness levels from 2606 men, courtesy of The Cooper Institute, Dallas, TX: well below average is 10th percentile, below average is 30th
percentile, average is 50th percentile, above average is 70th percentile, and well above average is 90th percentile. METs are metabolic
equivalents, where one MET is equivalent to the energy expended at rest. MET costs from Ainsworth and colleagues’ (1993, 2000)
compendia. Perceived effort estimated by equating RPE scores with exercise intensity: ‘‘very light’’ on the 6–20 RPE scale is equivalent to
<20% of aerobic capacity, ‘‘light’’ is 20–39%, ‘‘moderate’’ is 40–59%, ‘‘hard’’ is 60–84%, ‘‘very hard’’ is (85%, and maximal is around
100% of aerobic capacity (American College of Sports Medicine, 1998). For example, brisk walking (a 3.8-MET activity) is perceived as
‘‘moderate’’ in an individual with a 9.2-MET capacity (3.8/9.2 ¼ 41% of aerobic capacity). ‘‘Hard’’ is equivalent to ‘‘vigorous’’.
‘‘Impossible’’ indicates that the activity is more demanding than the individual’s aerobic capacity and is therefore unsustainable.

Table III. Perception of effort for various physical activities in men aged 30–39 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Above Well above

Activity (MET costs) average (9.6) Below average (11.0) Average (12.1) average (13.4) average (15)

Vacuuming or mopping (3.5) Light Light Light Light Light

Brisk walking (3.8) Moderate Light Light Light Light
Cycling at <10 mph (4) Moderate Light Light Light Light
Mowing lawn with power mower (4.5) Moderate Moderate Light Light Light
Tennis, doubles (6) Hard Moderate Moderate Moderate Moderate
Badminton, competitive (7) Hard Hard Moderate Moderate Moderate
Circuit training or jogging at 5 mph (8) Hard Hard Hard Hard Moderate
Cycling at 14.0–15.9 mph (10) Impossible Very hard Hard Hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Very hard

*Fitness levels from 13,158 men, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.

Table IV. Perception of effort for various physical activities in men aged 40–49 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Well above

Activity (MET costs) average (9.1) Below average (10.5) Average (11.5) Above average (12.6) average (14.6)

Vacuuming or mopping (3.5) Light Light Light Light Light

Brisk walking (3.8) Moderate Light Light Light Light
Cycling at <10 mph (4) Moderate Light Light Light Light
Mowing lawn with power mower (4.5) Moderate Moderate Light Light Light
Tennis, doubles (6) Hard Moderate Moderate Moderate Moderate
Badminton, competitive (7) Hard Hard Hard Moderate Moderate
Circuit training or jogging at 5 mph (8) Very hard Hard Hard Hard Moderate
Cycling at 14.0–15.9 mph (10) Impossible Very hard Very hard Hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Very hard

*Fitness levels from 16,534 men, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.
580 G. O’Donovan et al.

Table V. Perception of effort for various physical activities in men aged 50–59 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Below Above Well above

Activity (MET costs) average (8.1) average (9.5) Average (10.5) average (11.7) average (13.4)

Vacuuming or mopping (3.5) Moderate Light Light Light Light

Brisk walking (3.8) Moderate Moderate Light Light Light
Cycling at <10 mph (4) Moderate Moderate Light Light Light
Mowing lawn with power mower (4.5) Moderate Moderate Moderate Light Light
Tennis, doubles (6) Hard Hard Moderate Moderate Moderate
Badminton, competitive (7) Very hard Hard Hard Hard Moderate
Circuit training or jogging at 5 mph (8) Maximal Hard Hard Hard Moderate-to-hard
Cycling at 14.0-15.9 mph (10) Impossible Impossible Very hard Very hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Maximal

*Fitness levels from 9102 men, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.

Table VI. Perception of effort for various physical activities in men aged 60–69 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Well above

Activity (MET costs) average (6.9) Below average (8.4) Average (9.4) Above average (10.5) average (12.3)

Vacuuming or mopping (3.5) Moderate Moderate Light Light Light

Brisk walking (3.8) Moderate Moderate Moderate Light Light
Cycling at <10 mph (4) Moderate Moderate Moderate Light Light
Mowing lawn with power mower (4.5) Hard Moderate Moderate Moderate Light
Tennis, doubles (6) Very hard Hard Hard Moderate Moderate
Badminton, competitive (7) Impossible Hard Hard Hard Moderate
Circuit training or jogging at 5 mph (8) Impossible Very hard Very hard Hard Hard
Cycling at 14.0–15.9 mph (10) Impossible Impossible Impossible Very hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Impossible

*Fitness levels from 2682 men, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.

Table VII. Perception of effort for various physical activities in men aged 70–79 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Well above

Activity (MET costs) average (5.9) Below average (7.4) Average (8.4) Above average (9.4) average (11.3)

Vacuuming or mopping (3.5) Moderate Moderate Moderate Light Light

Brisk walking (3.8) Hard Moderate Moderate Moderate Light
Cycling at <10 mph (4) Hard Moderate Moderate Moderate Light
Mowing lawn with power mower (4.5) Hard Hard Moderate Moderate Moderate
Tennis, doubles (6) Maximal Hard Hard Hard Moderate
Badminton, competitive (7) Impossible Maximal Hard Hard Hard
Circuit training or jogging at 5 mph (8) Impossible Impossible Maximal Very hard Hard
Cycling at 14.0–15.9 mph (10) Impossible Impossible Impossible Impossible Very hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Impossible

*Fitness levels from 467 men, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.
 The ABC of Physical Activity for Health 581

Table VIII. Perception of effort for various physical activities in women aged 20–29 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Above Well above

Activity (MET costs) average (8.0) Below average (9.5) Average (10.8) average (12.1) average (14.3)

Vacuuming or mopping (3.5) Moderate Light Light Light Light

Brisk walking (3.8) Moderate Moderate Light Light Light
Cycling at <10 mph (4) Moderate Moderate Light Light Light
Mowing lawn with power mower (4.5) Moderate Moderate Moderate Light Light
Tennis, doubles (6) Hard Hard Moderate Moderate Moderate
Badminton, competitive (7) Very hard Hard Hard Moderate Moderate
Circuit training or jogging at 5 mph (8) Maximal Hard Hard Hard Moderate
Cycling at 14.0–15.9 mph (10) Impossible Impossible Very hard Hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Very hard

*Fitness levels from 1350 women, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.

Table IX. Perception of effort for various physical activities in women aged 30–39 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Well above

Activity (MET costs) average (7.3) Below average (9.0) Average (10.0) Above average (11.3) average (13.3)

Vacuuming or mopping (3.5) Moderate Light Light Light Light

Brisk walking (3.8) Moderate Moderate Light Light Light
Cycling at <10 mph (4) Moderate Moderate Moderate Light Light
Mowing lawn with power mower (4.5) Hard Moderate Moderate Moderate Light
Tennis, doubles (6) Hard Hard Hard Moderate Moderate
Badminton, competitive (7) Very hard Hard Hard Hard Moderate
Circuit training or jogging at 5 mph (8) Impossible Very hard Hard Hard Hard
Cycling at 14.0–15.9 mph (10) Impossible Impossible Maximal Very hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Maximal

*Fitness levels from 4394 women, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.

Table X. Perception of effort for various physical activities in women aged 40–49 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Above Well above

Activity (MET costs) average (6.7) Below average (8.1) Average (9.3) average (10.5) average (12.5)

Vacuuming or mopping (3.5) Moderate Moderate Light Light Light

Brisk walking (3.8) Moderate Moderate Moderate Light Light
Cycling at <10 mph (4) Hard Moderate Moderate Light Light
Mowing lawn with power mower (4.5) Hard Moderate Moderate Moderate Light
Tennis, doubles (6) Very hard Hard Hard Moderate Moderate
Badminton, competitive (7) Impossible Very hard Hard Hard Moderate
Circuit training or jogging at 5 mph (8) Impossible Impossible Very hard Hard Hard
Cycling at 14.0–15.9 mph (10) Impossible Impossible Impossible Very hard Hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Impossible

*Fitness levels from 4834 women, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.
582 G. O’Donovan et al.

Table XI. Perception of effort for various physical activities in women aged 50–59 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Well above

Activity (MET costs) average (6.0) Below average (7.3) Average (8.3) Above average (9.2) average (11.0)

Vacuuming or mopping (3.5) Moderate Moderate Moderate Light Light

Brisk walking (3.8) Hard Moderate Moderate Moderate Light
Cycling at <10 mph (4) Hard Moderate Moderate Moderate Light
Mowing lawn with power mower (4.5) Hard Hard Moderate Moderate Moderate
Tennis, doubles (6) Maximal Hard Hard Hard Moderate
Badminton, competitive (7) Impossible Maximal Hard Hard Hard
Circuit training or jogging at 5 mph (8) Impossible Impossible Maximal Very hard Hard
Cycling at 14.0–15.9 mph (10) Impossible Impossible Impossible Impossible Very hard
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Impossible

*Fitness levels from 3103 women, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.

Table XII. Perception of effort for various physical activities in women aged 60–69 years of different aerobic fitness levels.

Aerobic fitness levels (METs)*

Well below Well above

Activity (MET costs) average (5.3) Below average (6.4) Average (7.3) Above average (8.3) average (9.8)

Vacuuming or mopping (3.5) Hard Moderate Moderate Moderate Light

Brisk walking (3.8) Hard Moderate Moderate Moderate Light
Cycling at <10 mph (4) Hard Hard Moderate Moderate Moderate
Mowing lawn with power mower (4.5) Very hard Hard Hard Moderate Moderate
Tennis, doubles (6) Impossible Very hard Hard Hard Hard
Badminton, competitive (7) Impossible Impossible Maximal Hard Hard
Circuit training or jogging at 5 mph (8) Impossible Impossible Impossible Maximal Hard
Cycling at 14.0–15.9 mph (10) Impossible Impossible Impossible Impossible Maximal
Running at 8 mph (13.5) Impossible Impossible Impossible Impossible Impossible

*Fitness levels from 1088 women, courtesy of The Cooper Institute, Dallas, TX. See footnote to Table II.

that may be perceived as ‘‘moderate’’ or ‘‘hard’’ in strengthening activity should not replace aerobic
women aged 20–69 years of different fitness levels activity and the dose recommended for ‘‘all healthy
(examples for older women are not provided because adults’’ (around 30 min per week) is probably
fitness norms are not available). The talk test is a sufficient for health (Tanasescu et al., 2002).
simple and effective tool and we define moderate- Resistance training may be particularly beneficial in
intensity activities as those in which heart rate and older adults because it may reduce the loss of muscle
breathing are raised, but it is possible to speak mass and strength and concomitant loss of indepen-
comfortably; while vigorous-intensity activities are dence that may occur with age (Doherty, 2003).
those in which heart rate is higher, breathing is Resistance training and balance training are particularly
heavier, and conversation is harder. beneficial in older adults at risk of falls. In recent US
guidelines for men and women aged 65 years and
those aged 50–64 years with clinically significant
4.2. Muscle strengthening activity
chronic conditions and/or functional limitations, the
Muscle-strengthening activity or ‘‘resistance train- recommended doses of aerobic activity and muscle
ing’’ was not explicitly recommended in the Chief strengthening activity were similar to those described
Medical Officer’s report on physical activity and here for ‘‘all healthy adults’’ and it is recommended that
health (Department of Health, 2004). However, community-dwelling older adults at risk of falls should
there is now sufficient evidence to recommend perform exercises that maintain or improve balance
regular resistance training for all healthy adults (Nelson et al., 2007). The available evidence suggests
because it can lower blood pressure (Cornelissen & that general exercise, Tai Chi or a programme of muscle
Fagard, 2005a), improve glucose metabolism strengthening and balance training may reduce falls
(Wojtaszewski, Pilegaard, & Dela, 2008) and reduce (Gillespie et al., 2009). More research is required to
cardiovascular disease risk (Tanasescu et al., 2002). determine the optimal dose of exercise, but the
The available evidence suggests that muscle- combination of resistance training and aerobic exercise
 The ABC of Physical Activity for Health 583

was more effective in reducing insulin resistance and Table XIII. Classification of overweight and obesity by body mass
functional limitation than either modality alone in a index (BMI), waist circumference, and associated disease risks in
Caucasians.
recent 6-month study of 136 obese adults aged 60–80
years (functional limitation was assessed using seated Disease risk relative to normal
arm curls, chair stands, a stepping-in-place test, and a weight and waist
record of the time taken to get out of a chair, walk 2.4 m circumference*
and return to the seated position in the chair) (Davidson Waist circumference
et al., 2009).
BMI Men  102 cm Men 4 102 cm
Classification (kg  m72) Women  88 cm Women 4 88 cm
5. Special groups
Underweight <18.5 – –
The doses of activity recommended in the ABC of Normal 18.5–24.9 – –
Physical Activity for Health are associated with Overweight# 25.0–29.9 Increased High
Obese I 30.0–34.9 High Very high
substantial health benefits; however, some groups
Obese II 35.0–39.9 Very high Very high
should be encouraged to take part in greater amounts Extreme obese 40 Extremely high Extremely high
of activity, including children and adolescents, adults
who struggle to maintain normal weight, and other *Disease risk for type 2 diabetes, hypertension, and cardiovascular
adults with increased risk of chronic diseases. disease. #Increased waist circumference can also be a marker for
increased risk even in persons of normal weight. From Expert
Panel on the Identification, Evaluation, and Treatment of Over-
5.1. Children and adolescents weight in Adults (1998).

There is increasing evidence that physical activity in

childhood and adolescence is associated with a Table XIV. Classification of overweight and obesity by body mass
index (BMI), waist circumference, and associated disease risks in
number of health benefits, including greater bone
Asians*.
density (Hind & Burrows, 2007), reduced risk of
obesity (Ness et al., 2007), and reduced clustering of Risk of co-morbidities
cardiovascular disease risk factors (Andersen et al.,
Waist circumference
2006; Ferreira et al., 2007). Although more evidence
is needed, it is prudent to reiterate that all children and Men <90 cm Men 490 cm
adolescents aged 5–16 years should accumulate at BMI Women Women
Classification (kg  m72) <80 cm 480 cm
least 60 min of moderate-to-vigorous-intensity activ-
ity per day. A variety of activities should be encour- Underweight <18.5 Low# Average
aged, including vigorous-intensity aerobic activities Normal 18.2–22.9 Average Increased
that improve bone density and muscle strength. Overweight 23
Physical activity is beneficial at any age and active At risk 23–24.9 Increased Moderate
Obese I 25–29.9 Moderate Severe
play is important in physical, mental, and social
Obese II 30 Severe Very severe
aspects of growth and development. It is difficult to
assess physical activity in children, but there is some *Waist girth thresholds for obesity have been identified for specific
evidence that many children and adolescents take ethnic groups, including Chinese men (90 cm), Chinese women
part in considerably less activity than is recom- (80 cm), Japanese men (85 cm), and Japanese women
(90 cm) (Alberti, Zimmet, & Shaw, 2005). #The risk of type 2
mended (Reilly et al., 2004; Riddoch et al., 2007); diabetes, hypertension, and cardiovascular disease is low in
and there is some evidence that physical activity underweight individuals, but the risk of other clinical problems
levels decline between ages 9 and 15 years (Nader, is increased. From World Health Organization (2000).
Bradley, Houts, McRitchie, & O’Brien, 2008).

one individual to the next (Saris et al., 2003) and

5.2. Adults struggling to maintain normal weight
combined diet and exercise interventions are more
Body mass index and waist circumference are effective in reducing weight than either intervention
commonly used to define overweight and obesity alone (Curioni & Lourenco, 2005; Wu, Gao, Chen, &
and Table XIII includes definitions for Caucasians van Dam, 2009). The available evidence suggests that
and Table XIV includes definitions for Asians and adults who find it difficult to maintain a normal weight
other ethnic groups. Overweight and obesity are may need to reduce energy intake, minimize sedentary
associated with increased risk of depression, type 2 time, and may need to go beyond the levels of activity
diabetes, cardiovascular disease, and certain cancers recommended for ‘‘all healthy adults’’ and gradually
(Bianchini, Kaaks, & Vainio, 2002; Herva et al., 2006; progress towards meeting the recommendations for
F. B. Hu et al., 2004; G. Hu et al., 2005). The amount ‘‘conditioned individuals’’ to prevent overweight and
of activity required to prevent weight gain varies from obesity (that is, around 300 min or more of moderate-
584 G. O’Donovan et al.

intensity aerobic activity per week, or around 150 min a deterrent to future activity. To reduce the risk of heart
or more of vigorous-intensity aerobic activity per attack and death, we encourage health and fitness
week, or equivalent combinations of moderate- and professionals to use the Physical Activity Readiness
vigorous-intensity activity). It is important to stress Questionnaire (PAR-Q, available at www.csep.ca) and
that aerobic activity offers substantial health benefits to follow the detailed guidelines on screening and risk
even if weight is not lost (Hamer & O’Donovan, 2009; stratification of the American Heart Association and
Shaw et al., 2006). It is also important to stress that American College of Sports Medicine (Balady et al.,
substantial weight loss is difficult to achieve and health 1998; Fletcher et al., 2001). ‘‘Musculoskeletal injury’’
and fitness professionals should also consider more can be defined as an acute impairment that prohibits
realistic short-term goals for overweight and obese physical activity. A number of strategies may reduce the
individuals, such as reaching physical activity targets risk of musculoskeletal injury, including an active
and improving aerobic fitness. warm-up, the use of footwear that is appropriate to
the activity, the use of footwear that is appropriate to the
individual’s running technique, and the use of ankle
5.3. Adults with increased risk of chronic diseases
taping/bracing in sports where rapid changes of
Genetic factors and lifestyle factors interact to direction are commonplace (Bahr, 2006). Walking
determine one’s risk of chronic diseases and it is may be an appropriate form of exercise for beginners
possible to identify some groups with increased risk because it is associated with a lower risk of musculos-
of chronic diseases. Those with increased risk of keletal injury than running and sports participation
cardiovascular disease include smokers and those (Hootman et al., 2001). There is some evidence that the
with two or more of the following risk factors: risk of musculoskeletal injury is reduced with ‘‘injury
smoking, physical inactivity, total cholesterol 45 prevention programmes’’ consisting of various compo-
mmol  l71, diastolic blood pressure 85 mmHg or nents, such as warming-up, stretching, strength train-
systolic blood pressure 130 mmHg, overweight or ing, and balance training; however, it is impossible to
obesity (Emberson, Whincup, Morris, & Walker, distinguish the influence of each component.
2003; Emberson, Whincup, Morris, Wannamethee,
& Shaper, 2005; Vasan, Larson, Leip, Kannel, &
7. Special considerations for beginners
Levy, 2001). Adults with increased risk of type 2
diabetes include: those with impaired fasting glucose In the 2008 Health Survey for England, around 60%
or impaired glucose tolerance; those with a family of men and 70% of women aged 25–64 years
history of the disease; and overweight or obese reported taking part in less than 30 min of
individuals (as defined in Tables XIII and XIV). moderate-intensity physical activity on five or more
Although adults with increased risk of chronic days of the week (Roth, 2009). Levels of inactivity
diseases will derive substantial health benefits from are similar in Scotland, Wales, and Northern Ire-
taking part in the levels of activity recommended for land. Helping individuals with little or no experience
‘‘all healthy adults’’, the available evidence suggests of exercise to initiate a physical activity programme
that those with increased risk of cardiovascular and establish regular activity patterns in their lives is
disease or type 2 diabetes may benefit in particular a key priority for health professionals and policy
from going beyond the levels of activity recom- makers because physical activity may be particularly
mended for ‘‘all healthy adults’’ and gradually beneficial in those whose activity levels are very low
progressing towards meeting the recommendations (Department of Health, 2009). Establishing some
for ‘‘conditioned individuals’’ (that is, around exercise is also a necessary precursor to progressing
300 min or more of moderate-intensity aerobic to more frequent and more intense activity that can
activity per week, or around 150 min or more of bring additional health benefits. Here we present a
vigorous-intensity aerobic activity per week, or set of evidence-based considerations for helping the
equivalent combinations of moderate- and vigor- least active begin to achieve some regular activity.
ous-intensity activity). There is insufficient evidence
to identify doses of activity that might be especially
beneficial in those with a family history of breast 7.1. Who is doing little or no health-enhancing physical
cancer, colon cancer or prostate cancer. activity?
There is an age-related decline in physical activity
and females seem to be less active than males at
6. Screening and injury prevention
every age: on average, 53% of males and 35% of
The benefits of exercise far outweigh the risks females aged 16–24 years, 45% of males and 34%
(Thompson et al., 2007); however, the risks of injury of females aged 25–54 years, 26% of males and 23%
should not be ignored because injury poses a burden on of females aged 55–74 years, and nine percent of
the healthcare system, is emotionally costly, and may be males and six percent of females aged 75 years or
 The ABC of Physical Activity for Health 585

older reported taking part in at least 30 minutes of demanding and embarrassing. Some ethnic mino-
moderate-intensity physical activity on five or more rities, particularly women, face serious cultural
days of the week in the 2008 Health Survey for barriers to a more active lifestyle. An increase in
England (Roth, 2009). Adherence to contempora- physical activity may also be difficult and unlikely in
neous physical activity guidelines was lower than low socio-economic groups and those of lower
average in the obese (Zaninotto, Head, Stamatakis, educational level because these groups tend to have
Wardle, & Mindell, 2009), those with chronic limited capacity to self-manage, they may face
disease (Stamatakis, Hamer, & Primatesta, 2009), financial stresses, and they tend to attach little value
those with low household income, and all ethnic or priority to healthy behaviours. The environment
minorities other than Black Caribbean and Irish where an individual resides and works must also be
populations (Department of Health, 2009). considered when encouraging beginners to become
more active. At a simple level, making the active
choice the easy choice is only possible when the
7.2. Challenges to beginners
environment is considered: for example, asking a
Well-recognized challenges to undertaking more person to consider walking part of the way to work is
activity apply to the general population. The most only feasible when public transport or parking is
common barriers stated by those in the working age easily available in the environment (National In-
population are time related and refer to work stitute for Health and Clinical Excellence, 2008a).
commitments, lack of leisure time, and caring
responsibilities (Craig & Shelton, 2008; Trost,
7.3. Activity promotion principles
Owen, Bauman, Sallis, & Brown, 2002). Other
commonly reported factors are not having enough Socio-behavioural approaches have been developed
money, nobody to exercise with, and no suitable and adopted to help people, especially those who are
places to exercise. There is a modest relationship initially very inactive, build regular physical activity
throughout the lifespan between physical self-per- patterns. These approaches have involved contact
ception and exercise and sport participation, with with an exercise professional (often called a facilitator)
those perceiving low physical competence or con- using principles of behaviour change derived from
fidence being less likely to be active. Some middle- motivational interviewing, cognitive behavioural ther-
aged adults and some older adults associate physical apy, and health counselling. They are theory rich and
activity with ‘‘athleticism’’ or ‘‘being sporty’’, and call upon attitudinal/belief, self-perception, self-de-
those who do not identify with these notions may be termination, self-efficacy, social support models and
less likely to become more active. theories, and offer the best bet for assisting in the
A number of other barriers must be overcome if process of helping people change their behaviours
needy and inactive groups are to become more (Biddle & Mutrie, 2008; Kirk, Barnett, & Mutrie,
active. Many older adults face real and perceived 2007; Rollnick et al., 2005). These techniques are all
barriers to becoming more active, including physical recognized as appropriate, theoretically driven ap-
limitations and a lack of confidence. Older adults proaches to behaviour change in health settings
and overweight adults may also find physical activity (Abraham & Michie, 2008) and are recommended

Box 2. Strategies that may help initiate and sustain physical activity.

. Help participants develop realistic expectations and a sense of patience and commitment.
. Help participants understand that the most important factor is building and sustaining regular
engagement in physical activity. This should be prioritized and rewarded and celebrated through
strategies and interactions. Fitness change and weight loss are secondary and more long-term goals.
. Help participants achieve steady progression through careful setting of short-term goals that have an
element of flexibility. It does not matter how small the increment is from one goal to another so long
as it shows improvement.
. Focus on building confidence, competence, and pride in achievements through steady progression.
. Focus on helping the participant take responsibility in decision making and experience ownership for
change to encourage self-determination and confidence.
. Help participants understand the importance of social support and explore ways in which they can
find it.
. Help participants identify activity opportunities in their daily lives and the localities in which they live
and work.
586 G. O’Donovan et al.

as general behaviour change principles (National neighbourhoods, but that greater attention needs to
Institute for Health and Clinical Excellence, 2007). In be given to designing attractive and convivial
the exercise field, these techniques have manifested in neighbourhoods and facilities.
physical activity consultation (Kirk et al., 2007) and Neighbourhood design is also a powerful determi-
exercise facilitation approaches (Fox, 1992). They nant of physical activity in young people. There is
combine supportive communication styles and strate- substantial evidence that the active transport beha-
gies that facilitate behaviour change, and many of the viours of children in developed countries have
principles and strategies have become standard features declined in the last two decades (Bradshaw, 2001;
of websites, self-help guides, and books (Blair, Dunn, Harten & Olds, 2004). Between 1984 and 1993, for
Marcus, Carpenter, & Jaret, 2001b; Hunt & Hillsdon, example, kilometres walked per year declined by
1996). With these developments, subtle changes in 20% in children under 15 years of age in the UK
semantics and phrasing have emerged: for example, (particularly in girls) (Roberts, 1996), and these
‘‘prescription’’ has been replaced by ‘‘facilitation’’ or trends appear to have continued (Andersen, 2007).
‘‘negotiation’’, and the emphasis in programming has Children who actively commute to school accumu-
shifted from physiological parameters such as exercise late more daily physical activity than others (Faulkner,
intensity and percentage of capacity, to social psycho- Buliung, Flora, & Fusco, 2009) and children’s active
logical principles to guide interactions with partici- transport is influenced by traffic congestion and real
pants. Box 2 identifies strategies to help initiate and and perceived parental concerns about safety (Centers
sustain physical activity and Appendix 1 provides a case for Disease Control and Prevention, 2002; Jago &
study. Biddle and Mutrie (2008) provide a more Baranowski, 2004; Lam, 2001a, 2001b). In primary
detailed explanation of the behaviour change strategies school children, important impediments to parents
that might be used to help individuals and groups allowing their children to use active modes of transport
become more physically active. include their concerns or dissatisfaction with traffic
danger (Centers for Disease Control and Prevention,
2002; Harten & Olds, 2004), lack of safe crossings
infrastructure (Timperio, Crawford, Telford, &
8. The built environment
Salmon, 2004), and concerns for personal safety
The built environment has been defined as ‘‘the (Centers for Disease Control and Prevention, 2002;
neighbourhoods, roads, buildings, food sources and DiGuiseppi, Roberts, Li, & Allen, 1998). Moreover,
recreational facilities in which people live, work, are girls aged 10–12 years whose parents perceived there
educated, eat and play’’ (Sallis & Glanz, 2006, p. were several roads to cross, limited public transport,
90). There is a growing body of cross-sectional and no parks nearby were less likely to walk or cycle
evidence to suggest that the built environment regularly to destinations (Timperio et al., 2004). In
impacts on physical activity, particularly walking. boys, only parental perceptions of no traffic lights/
Studies consistently show that adults are more likely crossings decreased their likelihood of being active.
to walk for transport in compact, pedestrian-friendly The best available evidence on the impact of the built
neighbourhoods characterized by connected street environment on physical activity relates to walking for
networks, access to mixed-use planning, the pre- transport. However, there are many forms of physical
sence of places to walk to (such as public transport activity (such as walking for recreation, team sport
hubs, delicatessens, and newsagents), and in neigh- participation, active play, and cycling) and, unless
bourhoods with higher population densities (Duncan carefully planned for, many of these may not be
& Mummery, 2005; Owen, Humpel, Leslie, Bau- supported by infrastructure in highly urbanized, walk-
man, & Sallis, 2004; Transportation Research Board, able neighbourhoods (Giles-Corti & King, 2009).
2005). Fewer studies have considered environmental Although specific evidence on each of these behaviours
factors associated with recreational walking, which may not be available at the present time, it is critical to
appear to be related to a neighbourhood’s aesthetics plan neighbourhoods that cater for multiple forms of
(Owen et al., 2004) rather than its ‘‘walkability’’ (that physical activity across the life course. For example,
is, neighbourhoods characterized by higher connec- numerous studies have shown that the presence of
tivity of street networks, the presence of mixed-use public spaces is associated with higher moderate-to-
planning, and higher population density) (Owen vigorous-intensity physical activity in young people
et al., 2007). Moreover, high levels of walking have (especially parks with sports pitches, sports centres, and
been shown to be associated with access to high- recreation centres), whether behaviour is objectively
quality large public open space (Giles-Corti et al., measured (Cohen et al., 2006; Epstein et al., 2006;
2005), but not access to public open space irrespec- Evenson, Scott, Cohen, & Voorhees, 2007) or self-
tive of its size or quality (Pikora et al., 2006). This reported (Brodersen, Steptoe, Williamson, & Wardle,
suggests that encouraging more physical activity in 2005; Frank, Kerr, Chapman, & Sallis, 2007; Gordon-
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 The ABC of Physical Activity for Health 591

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Nutrition, Physical Activity, and Metabolism and the Council on
Edith
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Timperio, A., Crawford, D., Telford, A., & Salmon, J. (2004). In recent years, 50-year-old Edith has experienced
Perceptions about the local neighborhood and walking and
more and more bouts of prolonged unhappiness. She
cycling among children. Preventive Medicine, 38, 39–47.
Transportation Research Board (2005). Does the built environment has not been diagnosed with clinical depression, but
influence physical activity? Examining the evidence. Washington, her GP has recommended she becomes physically
DC: TRB. active. She has done little if no purposeful exercise
Trost, S. G., Owen, N., Bauman, A. E., Sallis, J. F., & Brown, W. since her teenage years when she used to hate sport and
(2002). Correlates of adults’ participation in physical activity: physical education at school, finding it threatening
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34, 1996–2001. and embarrassing. Edith is on the borderline between
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US Department of Health and Human Services (2008). 2008 The start point for Edith is to construct an activity
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www.health.gov/paguidelines/
programme with the help of an exercise professional
van Gool, C. H., Kempen, G. I., Penninx, B. W., Deeg, D. J., using a person-centred approach. The first step is to
Beekman, A. T., & van Eijk, J. T. (2003). Relationship between discuss with Edith her past history in sport and
changes in depressive symptoms and unhealthy lifestyles in late exercise and help her to work out which activities she
middle aged and older persons: Results from the Longitudinal might be interested in starting. During this discus-
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sion in non-hypertensive participants in the Framingham Heart day recall of activity revealed less than 10 min of
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Wisloff, U., Nilsen, T. I., Droyvold, W. B., Morkved, S., Slordahl, enjoyed team games such as hockey at school. She
S. A., & Vatten, L. J. (2006). A single weekly bout of exercise
may reduce cardiovascular mortality: How little pain for cardiac says she might consider some group activity but feels
gain? ‘‘The HUNT study, Norway’’. European Journal of she is not confident to join a group at the moment.
Cardiovascular Prevention and Rehabilitation, 13, 798–804. She would like to think she could join a group of
Wojtaszewski, J. F., Pilegaard, H., & Dela, F. (2008). Resistance women with similar kinds of issues at some point.
exercise training and the management of diabetes. In J. A.
The second step is to weigh up the pros and cons
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Edith perceives in becoming more active. Edith agrees
173). Champaign, IL: Human Kinetics. that being more active is important for her and might
Wojtaszewski, J. F., & Richter, E. A. (2006). Effects of acute exercise help her feel more positive about herself and life in
and training on insulin action and sensitivity: Focus on molecular general, as well as help her lose some weight and get her
mechanisms in muscle. Essays in Biochemistry, 42, 31–46. blood pressure down. However, Edith does not feel
World Health Organization (2000). The Asia–Pacific perspective:
Redefining obesity and its treatment. Sydney, NSW: Health very sporty or athletic and finds it difficult to see ways in
Communications. which she can be more active, so the conversation turns
Wu, T., Gao, X., Chen, M., & van Dam, R. M. (2009). Long- to regular walking as a starting strategy.
term effectiveness of diet-plus-exercise interventions vs. diet- The next important task is short-term goal setting
only interventions for weight loss: A meta-analysis. Obesity that can provide a sense of steady but safe improve-
Reviews, 10, 313–323.
Zaninotto, P., Head, J., Stamatakis, E., Wardle, H., & Mindell, J.
ment. Short-term goals have to have a flavour of
(2009). Trends in obesity among adults in England from 1993 to where, when, and what. They need to be specific and
2004 by age and social class and projections of prevalence to 2012. agreed (following the SMART principle of being
Journal of Epidemiology and Community Health, 63, 140–146. Specific, Measurable, Agreed, Realistic, and Time-
phased). The discussion moves to time difficulties, as
Edith is still holding a demanding full-time job and
Appendix 1: Case study using strategies that
finding her mental state makes it difficult to cope. The
may help initiate an increase in physical activity
key motivational issue, then, is to ensure small goals
The following illustrative case study suggests how for the early weeks that are achievable but that will
Edith could be encouraged to become more active move her forwards. Goals that are too demanding at
through the application of a social cognitive approach this point may undermine confidence and disappoint
to behaviour change. It could be argued that this if they are not reached. It is important to emphasize
approach is appropriate for any exercise professional that mental health or mood benefits may be experi-
attempting to help any individual, regardless of the enced fairly quickly and there will be changes in
risks they are facing from remaining inactive. exercise capacity in a matter of a few weeks.