National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 1. Lifestyle
Physical activity
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☰ Table of contents

Recommendations: Physical Activity

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

 All people Assess current level of physical activity and sedentary behaviours as per the Australian age-appropriate recommendations* (Box 1)

Useful tools for assessment of physical activity include the UK General Practice Physical Activity Questionnaire (refer to ‘Resources’)		 Opportunistic and as part of an annual health assessment IA 26,  36, 38, 37, 40

Behavioural

 All people For patients who are insufficiently active, give targeted advice and written information. This should include the following:
  • Determine existing preferred physical activities and invite patients to propose new activities
  • Ask the patient the amount/ frequency of activity they feel is achievable and set activity goals aiming to achieve Australian guideline recommendations (Box 1)
  • Record these goals and provide patients with a written copy
  • Consider cognitive behavioural support and follow-up
  • Consider additional social support (eg buddy system, involvement in a group activity)
  • Encourage active transport, which means physical activity undertaken as a means of transport and not merely as a form of recreation
For osteoporosis prevention, encourage regular weight-bearing and resistance exercise to maintain and increase bone density
(refer to Chapter 5: The health of older people)		 Opportunistic and as part of annual health assessment IB 27, 36, 37, 40, 42
Pregnant women All women who are pregnant should be encouraged to participate in physical activity to the levels in the Australian guideline recommendations
(Box 1)		 During antenatal visits IA 16
People with diabetes For sedentary people, a gradual introduction to initial low-intensity physical activity, with slow progressions in volume and intensity, is recommended

Those on insulin should be given individualised advice on avoiding hypoglycaemia when exercising (eg adjustment of carbohydrate intake, reduction of insulin dose, and choice of injection site)

Consider referral to an exercise program for coaching if facilities are available		 Opportunistic and as a part of annual diabetes assessment GPP 29,  43, 44
People with cardiovascular disease (CVD) Those with recent acute coronary syndrome event or revascularisation surgery (coronary artery bypass graft [CABG], percutaneous coronary intervention [PCI]) should be advised to participate in a short period (up to 12 weeks) of supervised exercise rehabilitation

If the condition is well compensated and clinically stable, recommend commencing initial low-intensity physical activity with slow progressions in volume and intensity

Consider referral to an exercise physiologist for coaching if facilities are available		 Opportunistic
 		 IA 17,  18,  44
People with other chronic diseases, mental health issues and cancer survivors IB 17, 18, 29

Environmental

 All people Refer to appropriate communitybased physical activity programs and encourage use of public facilities that promote activity (eg advocate for increased availability of sports and recreational facilities in remote communities)

Encourage health services to support physical activity by introducing practical measures such as walking meetings, provision of incentives for active transport, and making it easier for clients/staff to arrive by foot or bicycle

Consider a range of social and contextual factors that may uniquely influence an individual’s level of physical activity (refer to Chapter 1: Lifestyle, ‘Overweight and obesity’: Box 3)		 Opportunistic IB 45, 46, 47
* Moderate physical activity: Activity at a level that causes your heart to beat faster and some shortness of breath, but that you can still talk comfortably while doing.
  Vigorous physical activity: Activity at a level that causes your heart to beat a lot faster and shortness of breath that makes talking difficult between deep breaths – that is, physical activity at a     heart rate of 70–85% of maximum heart rate (MHR). MHR is calculated as 220 minus age.

Box 1. The Australian physical activity and sedentary behaviour guidelines – Recommendations by age group40

Age group

Recommendation

Aged  <5 years

Physical activity

For health development in infants (aged 0–1 year), physical activity – particularly supervised floor-based play in safe environments – should be encouraged from birth.

Toddlers (aged 1–3 years) and pre-schoolers (aged 3–5 years) should be physically active every day for at least three hours, spread throughout the day.

Sedentary behaviour

Children younger than two years of age should not spend any time watching television or using other electronic media (DVDs, computer and other electronic games).

For children aged 2–5 years, sitting and watching television and the use of other electronic media (DVDs, computer and other electronic games) should be limited to less than one hour per day.

Infants, toddlers and pre-schoolers (all children aged 0–5 years) should not be sedentary, restrained, or kept inactive for more than one hour at a time, with the exception of when sleeping.

Aged 5–12 years

Physical activity

For health benefits, children aged 5–12 years should accumulate at least 60 minutes of moderate to vigorous intensity physical activity every day.

Children’s physical activity should include a variety of aerobic activities, including some vigorous intensity activity.

On at least three days per week, children should engage in activities that strengthen muscle and bone.

To achieve additional health benefits, children should engage in more activity – up to several hours per day.

Sedentary behaviour

To reduce health risks, children aged 5–12 years should minimise the time they spend being sedentary every day. To achieve this:

  • limit use of electronic media for entertainment (eg television, seated electronic games and computer use) to no more than two hours a day – lower levels are associated with reduced health risks
  • break up long periods of sitting as often as possible.

Aged 13–17 years

Physical activity

For health benefits, young people aged 13–17 years should accumulate at least 60 minutes of moderate to vigorous intensity physical activity every day.

Young people’s physical activity should include a variety of aerobic activities, including some vigorous intensity activity.

On at least three days per week, young people should engage in activities that strengthen muscle and bone. To achieve additional health benefits, young people should engage in more activity – up to several hours per day.

Sedentary behaviour

To reduce health risks, young people aged 13–17 years should minimise the time they spend being sedentary every day. To achieve this:

  • limit use of electronic media for entertainment (eg television, seated electronic games and computer use) to no more than two hours a day – lower levels are associated with reduced health risks
  • break up long periods of sitting as often as possible.

Aged 18–64 years

Physical activity

Doing any physical activity is better than doing none. If you currently do no physical activity, start by doing some, and gradually build up to the recommended amount.

Be active on most, preferably all, days every week.

Accumulate 150 to 300 minutes (2½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1¼ to 2½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week.

Do muscle strengthening activities on at least two days each week.

Sedentary behaviour

Minimise the amount of time spent in prolonged sitting.

Break up long periods of sitting as often as possible.

Aged ≥65 years

Older people should do some form of physical activity, no matter what their age, weight, health problems or abilities.

Older people should be active every day in as many ways as possible, doing a range of physical activities that incorporate fitness, strength, balance and flexibility.

Older people should accumulate at least 30 minutes of moderate physical activity on most, preferably all, days. Sedentary people may need to gradually build up to 30 minutes or more.

Older people who have stopped physical activity, or who are starting a new physical activity, should start at a level that is easily manageable and gradually build up to the recommended amount, type and frequency of activity.

Older people who continue to enjoy a lifetime of vigorous physical activity should carry on doing so in a manner suited to their capability into later life, provided recommended safety procedures and guidelines are adhered to.



Background

Physical activity is any bodily movement produced by skeletal muscles that results in energy expenditure.1 This definition importantly recognises that physical activity is not restricted to structured exercise programs. Lack of physical activity is an independent risk factor for a range of diseases, in particular cardiovascular disease (CVD), diabetes, some cancers and osteoporosis.2 In addition to premature morbidity and mortality, globally it has been estimated that physical inactivity cost healthcare systems $53.8 billion worldwide in 2013, of which $31.2 billion was paid by the public sector, $12.9 billion by the private sector, and $9.7 billion by households.3

Activity can be classified as sedentary, light, moderate and vigorous. Non-vigorous (light or moderate) physical activity reduces the risk of all-cause mortality, with the greatest benefits apparent in moving from no activity to low levels of activity. Two-and-a-half hours per week of moderate physical activity (equivalent to 30 minutes daily of moderate intensity activity on five days a week) compared with no activity is associated with a reduction in mortality risk of 19%, while seven hours per week of moderate activity compared with no activity reduced the mortality risk by 24%.4 Being based on self-reported data, this may be an underestimate of the true mortality benefit from physical activity. Other studies using objective measures of physical activity expenditure have shown up to a 69% reduction in mortality in the upper tertile of activity when compared with the lower tertile.5

Sedentary activities are defined as activities incurring no more than 1.5 metabolic equivalents and include the specific behaviours of sitting and lying down.6 One metabolic equivalent is defined as an energy expenditure of 1 kcal/kg/hour and is roughly equivalent to the energy cost of sitting quietly. Common sedentary activities include television viewing, recreational screen time, sitting during leisure time, sitting in a car, sitting during main activities (work, school, housework) and occupations that involve prolonged sitting. High amounts of sedentary behaviour are associated with increased risks of several chronic conditions (especially CVD, diabetes and cancer) and all-cause mortality. These associations appear to be independent of the level of physical activity. Consequently, sedentary behaviour, even when accompanied by adequate levels of physical activity, still confers an increased risk of developing chronic conditions.6,7

The 2011 Australian Burden of Disease Study found that physical inactivity contributed to around 6% of the total disease burden experienced by Aboriginal and Torres Strait Islander peoples.8 By contrast with most other risk factors, physical inactivity is equally and highly prevalent among Aboriginal and Torres Strait Islander peoples when compared with non-Indigenous people. The 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey found the following:9

  • 47% of Aboriginal and Torres Strait Islander adults (aged ≥18 years) in non-remote areas met the target of 30 minutes of moderate activity on most days, which is similar to the rates observed in non-Indigenous adults
  • more males than females met the target of moderate physical activity per week (52% compared to 42%) in non-remote areas
  • a higher proportion of women across all age groups in remote areas were physically inactive compared to males (68% compared to 53%).


Interventions

Physical activity behaviours are influenced by individual (eg biological and psychological attributes), social (eg family, affiliation group, and work) and environmental opportunities and constraints (eg built environment and policy factors).10 There is strong evidence that interventions to increase physical activity in both children and adults can lead to significant risk reductions in morbidity and mortality, particular from chronic diseases such as CVD and diabetes.11–14

Further, a health benefit accrues to people who increase their physical activity levels, even in the absence of weight reduction.15 There is also strong evidence from systematic reviews16 to suggest multiple benefits of physical activity/exercise for pregnant women, including improved muscular strength and cardiovascular function; reduced rates of hypertension and pre-eclampsia; and reductions in pelvic and back pain, gestational weight gain, stress and depression, and delivery-related complications. Most ordinary physical activities such as walking, jogging, cycling and swimming are all considered safe. Activities generally considered unsafe include weight lifting, contact sports, sports with high risk of falling, sports with high changes in pressure (eg scuba diving), and altitude training.16 Secondary prevention interventions for people with diabetes and both post-acute and stable CVD are also effective.17,18 There have been eight Cochrane reviews on the benefits of exercise interventions for a range of other chronic conditions, including falls risk, depression, arthritis, back pain and other chronic pain conditions, all revealing mixed evidence of effectiveness and with limited high-quality studies on which to make any firm conclusions.19

Targeted interventions involving professional guidance and continued support can lead to moderate short- and mid-term increases in self-reported physical activity, achievement of a pre-determined level of physical activity and improved cardiorespiratory fitness.20–22 It is important to note that although the evidence for these interventions is strong, there appears to be a substantial reduction in the effectiveness of those interventions when translating clinical, trial-based interventions into real-world settings, and few studies have examined the long-term impact of these interventions beyond 12 months.22,23
The specific components of successful interventions are difficult to discern owing to large heterogeneity in the types of interventions previously studied; however, primary care–based interventions seem to be beneficial without the need to refer to specific exercise or counselling services.24–26 A World Health Organization (WHO)  systematic review of 67 studies examining 29 primary care–based strategies concluded that the most effective interventions need to be moderately intensive and include three key components:27

  1. At least one session involving a health-risk appraisal with a healthcare professional, with brief negotiation or discussion to decide on reasonable, attainable goals, and a follow-up consultation with trained personnel
  2. Support with targeted information
  3. Intervention linked to and/or coordinated with other stakeholders such as community sports organisations, ongoing mass media physical activity campaigns, and integration with social support measures (eg buddy system, contracts for exercise, group activities)28

The UK National Institute for Health and Care Excellence (NICE) has issued guidelines recommending against exercise referral programs for people who are sedentary or inactive in the absence of any other risk factors. They have recommended that policy makers only fund such programs for people with comorbid health conditions such as CVD or diabetes, where the program incorporates the elements similar to those listed above in the WHO review.29
Use of pedometers has been shown to lead to an absolute short-term increase in physical activity of around 2000–2500 steps per day, reductions in blood pressure and mild reductions in body mass index.30 It is likely that the processes of engaging users and goal-setting are important factors in this potential positive benefit from pedometers.30 Long-term effects, however, are not known.

The 2012–13 Aboriginal and Torres Strait Islander Health Survey included a pedometer study. Of the individuals (49%) who participated in using the pedometer, the average number of steps per day was 6963. The recommended daily steps for an adult is 10,000 or more; 17% of participants met this threshold.9 Although there is much interest in the use of web and mobile interventions to increase physical activity and some trials have demonstrated positive outcomes, the current evidence base remains limited and no definitive conclusions can be made.31,32 Similarly, the use of wearable devices as a means of promoting physical activity is of considerable interest given the surge in uptake of these devices on the market. The evidence base, however, is limited and early trials have demonstrated mixed results (both superiority and inferiority to standard treatments).
Therefore, wearable devices cannot be recommended for routine use at this stage.33,34

Environmental policies targeting the built environment, in particular increased access to public transport, increased recreational space opportunities, reduction in environmental barriers to physical activity and pointof-decision prompts to increase use of stairs have been shown to be effective.27,28 Facilities for sporting and recreational activities are lacking in many remote Aboriginal and Torres Strait Islander communities and surveys have reported that the need for such facilities is ranked as a high priority among community members.35 Health promotion strategies in the school and workplace are also effective in increasing physical activity,27,28 but have not been well studied in Aboriginal and Torres Strait Islander community settings.
The 2014 Australian physical activity and sedentary behaviour guidelines were informed by two systematic reviews on physical activity and sedentary behaviours for children and young adults and a 2012 commissioned report on developing new recommendations for adults aged 18–64 years.36,37 These updated recommendations complement an existing discussion document developed for older Australians in 2006.38 The recommendations are broadly similar to other international guidelines.26,39 The rationale for changes in the adult guidelines are underpinned by the following statements (which are all level I–II, strength A–B statements):36

  • The relationship between physical activity and health benefit is curvilinear. The greatest benefit is from moving from no activity to some activity, and there are increasing benefits from greater activity up to levels well beyond the current guideline recommendations.
  • There is no clear evidence on the optimal frequency of physical activity, but there is strong support for recommending that adults should accumulate their physical activity across the week. Being active on most, if not all, days each week, is likely to provide increased metabolic benefits.
  • The scientific data on the relationship between total volume (frequency x duration x intensity) of activity and health benefits are more convincing and consistent than those for frequency, duration or intensity of activity considered in isolation.
  • For most health outcomes, additional benefits occur with more physical activity. In particular, more activity is required for prevention of weight gain and some cancers. This higher amount of physical activity can be achieved through longer duration (more minutes) or greater frequency (more often) or doing activities of higher intensity.
  • Resistance training (muscle strengthening) activities are important for metabolic, cardiovascular and musculoskeletal health (including prevention of falls), and for maintaining functional status and ability to conduct activities of daily living.
  • Although there is emerging evidence that extended sitting time is associated with increased risk of diabetes and all-cause mortality, there is insufficient evidence at the time of writing on the minimal or optimal duration of sitting and therefore no specific recommendations can currently be made.

 

Resources

Assessment of physical activity

• Department of Health, UK, General Practice Physical Activity Questionnaire

Heart Foundation

Department of Health/Department of Health and Ageing

Other

 

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
  1. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: Definitions and distinctions for health related research. Public Health Rep 1985;100:126–31.
  2. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: An analysis of burden of disease and life expectancy. Lancet 2012;380(9838):219–29.
  3. Ding D, Lawson KD, Kolbe-Alexander TL, et al. The economic burden of physical inactivity: A global analysis of major noncommunicable diseases. The Lancet. 2016;388(10051):1311–24.
  4. Woodcock J FO, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: Systematic review and meta-analysis of cohort studies. Int J Epidemiol 2010;40(1):121–38.
  5. Manini TM, Everhart JE, Patel KV, et al. Daily activity energy expenditure and mortality among older adults. JAMA 2006;296(2):171–79.
  6. van der Ploeg HP, Chey T, Korda RJ, Banks E, Bauman A. Sitting time and all-cause mortality risk in 222,497 Australian adults. Arch Intern Med 2012;172(6):494–500.
  7. Biswas A, Oh PI, Faulkner GE, et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: A systematic review and meta-analysis. Ann Intern Med 2015;162(2):123–32.
  8. Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011 – Summary report. Canberra: AIHW, 2016.
  9. Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey: First results, Australia, 2012–13: Exercise levels. Cat no. 4727.0.55.001. Canberra: ABS, 2013. [Accessed 3 November 2017].
  10. Heath GW, Sarmiento OL, Andersen LB, et al. Evidence-based intervention in physical activity: Lessons from around the world. Lancet 2012;380(9838):272–81.
  11. Berlin JA, Colditz GA. A meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol 1990;132(4):612.
  12. Shaw K, Gennat H, O’Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev 2006;Oct 18;(4):CD003817.
  13. Okely AD SJ, Vella SA, Cliff D, et al. A systematic review to update the Australian physical activity guidelines for children and young people. Report prepared for the Australian Government Department of Health. Canberra: Department of Health, 2012.
  14. Ruotsalainen H, Kyngäs H, Tammelin T, Kääriäinen M. Systematic review of physical activity and exercise interventions on body mass indices, subsequent physical activity and psychological symptoms in overweight and obese adolescents. J Adv Nurs 2015;71(11):2461–77.
  15. Hupin D, Roche F, Gremeaux V, et al. Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: A systematic review and meta-analysis. Br J Sports Med 2015;49:1262–67.
  16. Sports Medicine Australia. Exercise in pregnancy and the postpartum period – A position statement 2016. Available at http://sma.org. au/wp-content/uploads/2016/09/SMA-Position-Statement-Exercise-Pregnancy.pdf [Accessed 3 November 2017].
  17. Briffa TG, Maiorana A, Sheerin NJ, et al. Physical activity for people with cardiovascular disease: Recommendations of the National Heart Foundation of Australia. Med J Aust 2006;184(2):71–5.
  18. Anderson L, Thompson DR, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2016(1):CD001800. doi: 10.1002/14651858.
  19. Department of Veterans’ Affairs Consolidated Library of Information and Knowledge. Cochrane Reviews regarding therapeutic exercise programs. Department of Veterans’ Affairs, 2015. Available at http://clik.dva.gov.au/reports-studies-research-papers-library/research-andhealth-studies/benefits-gymnasium-pool-programs/cochrane-reviews-regarding-therapeutic-exercise-programs [Accessed 3 November 2017].
  20. Eden KB, Orleans CT, Mulrow CD, Pender NJ, Teutsch SM. Does counseling by clinicians improve physical activity? A summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2002;137(3):208.
  21. Foster C, Hillsdon M, Thorogood M. Interventions for promoting physical activity. Cochrane Database Syst Rev 2009(1):CD003180.
  22. Richards J, Hillsdon M, Thorogood M, Foster C. Face-to-face interventions for promoting physical activity. Cochrane Database Syst Rev 2013(9):CD010395.
  23. Cardona-Morrell M, Rychetnik L, Morrell S, Espinel P, Bauman A. Reduction of diabetes risk in routine clinical practice: Are physical activity and nutrition interventions feasible and are the outcomes from reference trials replicable? A systematic review and metaanalysis. BMC Public Health 2010;10(1):653.
  24. Orrow G, Kinmonth A-L, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: Systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344:e1389.
  25. Pavey TG, Taylor AH, Fox KR, et al. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: Systematic review and meta-analysis. BMJ 2011;343:d6462.
  26. National Institute for Health and Care Excellence. Physical activity: Brief advice for adults in primary care(PH44). NICE, 2013.  [Accessed 28 February 28 2017].
  27. World Health Organization. Interventions on diet and physical activity: What works: Summary report. Geneva: World Health Organization; 2009.
  28. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity. Am J Prev Med 2002;22(4S):73–107.
  29. National Institute for Health and Care Excellence. Physical activity: Exercise referral schemes (PH54): NICE, 2014.   [Accessed 28 February 2017].
  30. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health. JAMA 2007;298(19):2296–304.
  31. Muntaner A, Vidal-Conti J, Palou P. Increasing physical activity through mobile device interventions: A systematic review. Health Informatics J 2016;22(3):451–69.
  32. Foster C, Richards J, Thorogood M, Hillsdon M. Remote and web 2.0 interventions for promoting physical activity. Cochrane Database Syst Rev 2013(9):CD010395.
  33. Finkelstein EA, Haaland BA, Bilger M, et al. Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): A randomised controlled trial. Lancet Diabetes Endocrinol 2016;4(12):983–95.
  34. Salmon J, Ridgers N. Is wearable technology an activity motivator, or a fad that wears thin? Med J Aust 2017;206(3):119–20.
  35. Macniven R, Wade V, Canuto K, Page K, Dhungel. Action area 8: Aboriginal and Torres Strait Islander peoples. In: Blueprint for an active Australia. Melbourne: National Heart Foundation of Australia, 2014.
  36. Brown WJ, Bauman AE, Bull FC, Burton NW. Development of evidence-based physical activity recommendations for adults (18–64 years) – Report prepared for the Australian Government Department of Health, 2012. [Accessed 3 November 2017].
  37. Okely T, Salmon J, Vella S, et al. A systematic review to update the Australian physical activity guidelines for children and young people – Report prepared for the Australian Government Department of Health, 2013.  [Accessed 3 November 2017].
  38. Sims J, Hill K, Hunt S, et al. National physical activity recommendations for older Australians: Discussion document. Canberra: Australian Government Department of Health and Ageing, 2006.  [Accessed 3 November 2017].
  39. National Institute for Health and Care Excellence. Physical activity for children and young people (PH17). NICE, 2009. Accessed 28 February 2017].
  40. Department of Health. Australia’a physical activity and sedentary behaviour guidelines. Canberra: Department of Health, 2014.  [Accessed 3 November 2017].
  41. LeFevre ML, US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. Ann Intern Med 2014;161(8):587–93.
  42. Orrow G, Kimmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: Systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344(1389).
  43. Scottish Intercollegiate Guidelines Network. Management of diabetes. Guideline No. 116. Edinburgh: SIGN, 2010.  [Accessed 3 November 2017].
  44. Lin JS, O’Connor EA, Evans CV, et al. Behavioral counseling to promote a healthy lifestyle for cardiovascular disease prevention in persons with cardiovascular risk factors: An updated systematic evidence review for the US Preventive Services Task Force. Rockville,MD: Agency for Healthcare Research and Quality (US), 2014. Available at www.ncbi.nlm.nih.gov/books/NBK241537 [Accessed 28 February 2017].
  45. Bauman A, Bellew B, Vita P, Brown W, Owen N. Getting Australia active: Towards better practice for the promotion of physical activity. Melbourne: National Public Health Partnership, 2002.
  46. Shanahan DF, Franco L, Lin BB, Gasto KJ, Fuller RA. The benefits of natural environments for physical activity. Sports Med 2016;46(7):989–95.
  47. National Institute for Health and Care Excellence. Physical activity and the environment (PH8). NICE, 2008. [Accessed 28 February 2017].

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