In the 2008 animated film WALL-E, Pixar depicted a light-hearted but dystopian world of obese, immobile people whose needs are met by a bustling horde of robots and computers — a world that hardly seems like science fiction as we witness the precipitous decline in physical activity over the last generation. The Centers for Disease Control and Prevention estimates that approximately 80 percent of Americans don’t get the recommended amount of exercise they need each week for optimal health. So, did Pixar predict the future of humanity or is there a way for us to course correct?
Sedentary behavior is an intractable issue. Seemingly benign forces make it easier and easier for many of us to conduct our work, school and social lives from the comfort of a chair and an internet-connected gadget. Unfortunately, sedentary lifestyles are a driving force behind burgeoning health care costs, and they pose an alarming threat to the health and well-being of our children. Fortunately, there is cause for hope in lessons from the tobacco control movement and efforts to change smoking behavior.
Sitting Is the New Smoking
Dr. James Levine of the Mayo Clinic, and author of Get Up! Why Your Chair Is Killing You and What You Can Do About It, is credited with first declaring that “sitting is the new smoking.” He explores this in terms of negative impact on health, but there’s another interpretation of the analogy worth considering — a roadmap to tackling a major health issue that requires large-scale behavior change.
Mass behavior change is hard, but it’s been done before. Fifty years ago, smoking was a common, socially accepted habit ravaging the health of millions. That changed dramatically, thanks to a decades-long campaign to reverse the epidemic of smoking. The 1964 landmark Surgeon General’s report definitively linking smoking to lung cancer became a call to action that has since engaged health care, media, philanthropy, government and grassroots efforts in an epic battle to control tobacco use. That effort has reduced adult smoking rates in the U.S. from 42.4 percent to 18.1 percent. This successful multi-sector approach provides a template for mounting a similar effort to reverse the trend toward sedentary behavior.
Confronting a Prevention Paradox
Our health care system is characterized by a prevention paradox, where financial incentives favor high-cost treatment of disease over low-cost prevention. Failure to confront this paradox threatens the sustainability of our health care sector, which is spending 75 cents of every dollar on chronic conditions linked to sedentary behavior, like obesity, diabetes and heart disease. The tobacco control movement overcame the obstacle of misaligned financial incentives to great effect, shifting consumer behavior and rallying health care business interests to the cause. What can we learn?
Developing tools to help consumers change behavior is key. Smoking, like sedentary behavior, is an extremely complicated habit to change, with no silver bullet that works for everyone. Over time, smoking cessation programs, nicotine patches, gums and other products were developed to aid smokers in their efforts to quit. Today, insurers reimburse the cost of such tools as a way to prevent more costly health problems down the road. We need similar tools, made accessible in health care settings, to help shift patterns of sedentary behavior by motivating greater levels of physical activity.
Rigorous analysis of the cost of physical activity interventions as a preventive tool versus treatment of diseases where sedentary behavior is a factor is also essential. The Surgeon General’s 1964 report on tobacco helped catalyze the anti-smoking movement. The first Surgeon General’s report on physical activity and health was published in 1996. Similar to the Surgeon General’s 1964 report on tobacco, it illuminated the broad body of evidence linking sedentary behavior to a wide range of negative health outcomes including premature death, heart disease, diabetes, obesity, hypertension and cancer. The 1996 report also noted that “research on understanding and promoting physical activity is at an early stage.”
As one health care executive said to me recently, “If sitting is the new smoking, we are somewhere in the 1970s with sedentary behavior.” What began in the 70s for smoking is now unfolding for sedentary behavior in the wake of the Surgeon General’s report and a steady flow of new evidence on the preventive health benefits of physical activity. A heightened focus on prevention, advances in technology, and insights from behavior change science have led to a wave of innovation in products and services designed to motivate physical activity — a significant step in the right direction.
Real Progress, Future Prospects
One promising example of progress is the effort at Kaiser Permanente to bring physical activity into clinical practice through its Exercise as a Vital Sign (EVS) initiative. By elevating physical activity to the importance of body temperature, blood pressure and heart rate, Kaiser is taking an important step to diagnose sedentary behavior and open a dialogue with health care consumers about options for behavior change and treatment. This is only a first step: “Taking the temperature alone doesn’t make the fever go down; you have to try an intervention to lower it,” as Dr. Robert Sallis, the physician who brought EVS to Kaiser, notes in comparing exercise assessment to taking other vital measures.
Deciding what to do for sedentary patients is the frontier of this work today. The good news is that physical activity interventions — analogous to smoking cessation programs — are where tremendous innovation is occurring. Zamzee’s kid-friendly physical activity program is one of many approaches being tried at forward-thinking health care institutions. But these tools remain relatively inaccessible to consumers through a health care system more focused on treatment than prevention. These programs should be widely integrated into clinical practice and reimbursed through Medicare, Medicaid and private health plans, just as anti-smoking tools have been integrated over the last 50 years.
By following the successful path forged by the tobacco control movement and its anti-smoking campaigns, I’m confident the “anti-sitting” movement can be mobilized to similar success in reversing the epidemic of sedentary behavior. It will take sustained commitment across the private and public sectors to create the tools and assemble the evidence that will drive impact. By embracing the notion that sitting is the new smoking, we have actionable steps we can take to save lives and change behavior in the same way the tobacco control movement has saved the lives of millions during the last half century.