National Guide

Chapter 2 | Healthy living and health risks

Physical activity and sedentary behaviour







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      2. Physical activity and sedentary behaviour

Healthy living and health risks | Physical activity and sedentary behaviour 

Mr Ray Kelly   

Key messages

  • Regular physical activity is an important part of maintaining physical and mental health and wellbeing.1
  • Regular physical activity reduces the risk of many non-communicable diseases, including type 2 diabetes, cardiovascular disease, stroke, dementia and some cancers.2,3
  • Regular physical activity improves musculoskeletal conditions such as bone health (eg osteoporosis), muscle loss (sarcopenia), risk of falls and obesity, and can have co-benefits, such as reducing pollution (eg active transport).
  • All physical activity contributes to health benefits and reduces all-cause mortality.2,4
  • Long periods of sitting (sedentary time) can reduce the benefits of being physically active.
  • Physical activity should be fun, safe and accessible.
Type of preventive activity - Screening
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people Assess current level of physical activity and sedentary behaviour, including screen time (Box 1), as per the Australian age-appropriate recommendations (see Useful resources, Clinical guidelines)

Useful tools for the assessment of physical activity include the General Practice Physical Activity Questionnaire (see Useful resources )		 Opportunistically Good practice point Australian guideline5 Regular physical activity supports health and wellbeing and can prevent many health conditions

High levels of sedentary behaviour are associated with an increased risk of many chronic conditions
Type of preventive activity - Behavioural
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people Provide targeted age-appropriate advice and written information (see Box 2)
Consider the range of social and contextual factors that may uniquely influence an individual’s level of physical activity

Consider any complications that may restrict mobility (eg back, knee or foot issues, neuropathy) when providing advice on physical activity		 Opportunistically Good practice point Australian guideline5 Physical activity introduced in a measured way supports behaviour change, protects against injury and is more likely to be sustained

Patients are more likely to participate in physical activity if they find something they enjoy

Exercise physiologists are tertiary-qualified exercise professionals educated and experienced in helping patients with complex health conditions
All people Encourage active transport, which means physical activity undertaken as a means of transport and not merely as a form of recreation Opportunistically Good practice point Systematic review6 Fitting physical activity around daily activities may be easier for some patients than designating a set period of each day for exercise
All people Encourage regular weight-bearing and resistance exercise to maintain and increase bone density and muscle mass Opportunistically Good practice point Australian position statement7 Resistance training has been shown to maintain or increase bone density and muscle mass
All people Encourage adults to reduce the time spent sitting and to break up long periods of sitting with movement

Encourage children and young people to limit time spent sitting or lying down (sedentary behaviour), especially in front of screens (see Box 1)		 Opportunistically Good practice point Australian guideline5 Sedentary behaviours can reduce the benefits of physical activity
Pregnant women Encourage all women who are pregnant to participate in physical activity to the levels in the Australian guideline recommendations (see Useful resources) During antenatal visits Good practice point Australian guideline and position statement5,8 Regular physical activity improves the health of the mother and child
People with diabetes Provide individualised advice to those on insulin on avoiding hypoglycaemia when exercising (eg adjustment of carbohydrate intake, reduction of insulin dose and choice of injection site)

Consider referral to an exercise physiologist for coaching, if available (see Useful resources)

Consider any complications that may restrict mobility (eg back, knee or foot issues, neuropathy) when providing advice on physical activity		 Opportunistically and as a part of annual diabetes assessment Good practice point Australian resource9 Physical activity improves metabolic processes associated with diabetes, including a reduction of blood glucose levels
People with cardiovascular disease Advise those with recent acute coronary syndrome event or revascularisation surgery (coronary artery bypass grafting, percutaneous coronary intervention) to participate in a short-term program (up to 12 weeks) of supervised, tailored exercise rehabilitation with an exercise physiologist and/or healthcare team Opportunistically Good practice point Australian guidelines and resource10,11 Exercise physiologists are tertiary-qualified clinical exercise professionals educated and experienced in helping patients with complex health conditions
People with other chronic disease, disability, mental health issues and cancer survivors Recommend commencement of initially low-intensity physical activity, with slow progressions in volume and intensity, for people whose condition is clinically stable

Consider referral to an exercise physiologist for coaching, if facilities are available		 Opportunistically Good practice point Australian guideline5 Exercise physiologists are tertiary-qualified clinical exercise professionals educated and experienced in helping patients with complex health conditions
Type of preventive activity - Environmental
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people Refer to appropriate community-based, culturally safe physical activity programs and encourage the use of public facilities that promote activity (eg advocate for increased availability of sports and recreational facilities in remote communities)

Encourage health services and workplaces to support physical activity by introducing practical measures such as walking meetings, providing incentives for active transport and making it easier for clients/staff to arrive by foot or bicycle		 Opportunistically Good practice point Aboriginal and Torres Strait Islander single study12 External health programs can provide additional support for the patient
 

Box 1. Screen time by age
Age Recommendation
Up to 5 years For children aged <2 years, no screen time is recommended13,14
For those aged 2–4 years, screen time should be no more than one hour; less is better13,14
5–17 years Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time15
 
18–64 years Limit sedentary time to eight hours or less, which includes no more than three hours of recreational screen time
Break up long periods of sitting as often as possible16
≥65 years

Box 2. Targeted advice: To be age-appropriately adapted
  • Provide information about the benefits of physical activity and the harms of sedentary behaviour
  • Determine existing preferred physical activities and invite patients to propose new activities
  • Ask the patient about the amount/frequency of activity they feel is achievable and set activity goals aiming to achieve Australian guideline recommendations
  • Advise gradual introduction and initial light intensity of physical activity, with slow progressions in volume and intensity
  • Record activity 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)
  • Consider referral to an exercise physiologist for coaching, if available
  • Advice to patients should depend on their individual circumstances; however, targeting known barriers can increase the likelihood of patient success.
  • To help attain health goals, referral to an allied health professional is a viable option, including an exercise physiologist or physiotherapist for physical activity, or a podiatrist or physiotherapist for pain and mobility issues. Programs and services provided by other health professionals may be considered, based on their engagement with the Aboriginal and Torres Strait Islander community and history of success in providing improved health outcomes. Always try to find allied health professionals that have a strong history of achieving good health outcomes with Aboriginal and Torres Strait Islander peoples.

Clinical guidelines

Other resources for health professionals

Patient resources

Background

Physical activity can be any bodily movement produced by skeletal muscles that results in energy expenditure, and does not have to be restricted to a structured exercise program.17 Regular physical activity supports health and wellbeing, and has been proven to prevent many non-communicable diseases such as type 2 diabetes, heart disease, stroke and some cancers.1,2 Regular physical activity also improves musculoskeletal conditions such as bone health (eg osteoporosis), muscle loss (sarcopenia), risk of falls and obesity, and can have co-benefits such as reducing pollution (eg active transport). It contributes to maintaining healthy weight and can have a positive effect on mental health.1 Insufficient physical activity (ie failure to meet physical activity guidelines recommended for health) is an independent risk factor for a range of diseases, in particular cardiovascular disease, diabetes, some cancers, dementia and osteoporosis.2,3 In addition to premature morbidity and mortality, it has been estimated that in 2013 physical inactivity cost healthcare systems INT$ (equivalent to US$) 53.8 billion worldwide.18

Any physical activity is better than none at all.4 Activity can be classified as light (eg standing, slow walking), moderate (eg brisk walking) and vigorous (eg jogging or activity that results in ‘huff and puff’; see Box 3). Even non-vigorous (light or moderate) physical activity reduces the risk of all-cause mortality,1 with the greatest benefits apparent in moving from no activity to low levels of activity.19 Physical activity has a protective effect against cardiovascular mortality, regardless of age, sex or history of cardiovascular disease,20 and therefore plays an integral role in maintaining health as we age.

Sedentary behaviour has been defined as any waking behaviour characterised by an energy expenditure ≤1.5 metabolic equivalents while in a sitting, reclining or lying posture.21 Sedentary behaviour can have a negative impact on health,22 affecting cognitive function, mood/depression, function and disability, as well as physical activity levels.23 Common sedentary behaviours include television viewing, recreational screen time, sitting during leisure time, sitting in a car and sitting for work, school and housework. High levels of sedentary behaviour are associated with increased risks of several chronic conditions (especially cardiovascular disease, type 2 diabetes and some cancers) and all-cause mortality.24 These associations with sedentary behaviour are most evident in people who are also physically inactive. Consequently, sedentary behaviour, even when accompanied by moderate levels of physical activity, still confers an increased risk of developing certain chronic conditions.22,25 Excessive screen time in children and adolescents can have an impact on weight, motor and cognitive development, behavioural problems, anxiety, hyperactivity, attention, self-esteem and psychosocial health.26

The 2021 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 people and that Aboriginal and Torres Strait Islander people were 18% less likely to have met the recommended level of physical activity and 26% more likely to be inactive than non-Indigenous Australian adults.27 The 2018–19 Australian Aboriginal and Torres Strait Islander Health Survey found that:

  • 89% of people aged 15 years and over (in non-remote areas) did not meet the physical activity guidelines for their age
  • 22% of people (in non-remote areas) had done no physical activity at all in the past week
  • the proportion of men (20%) and women (23%) who had done no physical activity was about the same.28

Box 3. Definitions of activity intensity

Light physical activity: Activity that may not cause a significant increase in heart rate or shortness of breath but works within your current physical limitations and provides a foundation for more intense physical activity.

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 (ie physical activity at a heart rate of 70–85% of maximum heart rate). Maximum heart rate is calculated as 220 minus age.

Physical activity behaviours are influenced by individual (eg biological and psychological attributes), social (eg family, affiliation group, work) and environmental (eg built environment and policy factors) opportunities and constraints.29 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, particularly from chronic diseases such as cardiovascular disease and type 2 diabetes.30–32 Further, a health benefit accrues to people who increase their physical activity levels, even in the absence of weight reduction.33

There is also strong evidence from systematic reviews to suggest multiple benefits of physical activity/exercise for pregnant women, including improved muscular strength, cardiovascular function, reduced rates of hypertension and pre-eclampsia, reduced pelvic and back pain, reduced gestational weight gain, reduced stress and depression and reduced delivery-related complications.8 Common physical activities such as walking, jogging, cycling and swimming are all considered safe.8 Activities generally considered unsafe for those who are pregnant include weight lifting, contact sports, sports with a high risk of falling, sports with high changes in pressure (eg scuba diving) and altitude training.8

Secondary prevention interventions for people with type 2 diabetes and both post-acute and stable cardiovascular disease are also effective.34,35 There are many 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, with all revealing mixed evidence of effectiveness with limited high-quality studies on which to make any firm conclusions.36

Targeted interventions for Aboriginal and Torres Strait Islander peoples involving health professional guidance and continued support can lead to moderate short- and mid-term increases in self-reported physical activity, achievement of physical activity levels that meet current Australian physical activity and sedentary behaviour guidelines and improved cardiorespiratory fitness.37–39 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.39,40

The 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.41 It is likely that the process of engaging users and the accompanying goal-setting processes are important factors in this potential positive benefit from pedometers.41 However, the long-term effects are not known. The 2012–13 Aboriginal and Torres Strait Islander Health Survey included a pedometer study.42 Among individuals (49%) who used the pedometer, the average number of steps per day was 6963. The recommended daily steps for an adult at that time was 10,000 or more; 17% of participants met that threshold.42 A recent review reported a reduction in all-cause mortality for an increasing number of steps per day up to 6000–8000 steps per day for those aged 60 years and older, and up to 8000–10,000 steps per day for those aged less than 60 years.43 Although there is much interest in the use of web-based and mobile interventions to increase physical activity, and some trials have demonstrated positive outcomes for such interventions, the current evidence base remains limited and no definitive conclusions can be made.44–46 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. However, the evidence base is limited and early trials have demonstrated mixed results (both superiority and inferiority to standard treatments); therefore, these devices cannot be recommended for routine use at this stage.46–48

Australian physical activity and sedentary behaviour guidelines

The Australian physical activity and sedentary behaviour guidelines were informed by a rigorous review of scientific evidence from around the world and are age specific.5 The guidelines recommend:

  • any physical activity is better than none
  • regular age-appropriate muscle-strengthening activities should be undertaken
  • the right mix of physical activity, sedentary time and sleep in each 24-hour period is important at all ages
  • optimal time to spend on moderate and vigorous activities
  • limiting sedentary behaviours, including specific age-appropriate guidance regarding screen time (see Box 1)
  • long periods of time spent sedentary can offset the benefits of being physically active.

Various barriers to and facilitators of physical activity and exercise for Aboriginal and Torres Strait Islander people have been well described (see Boxes 4 and 5). These should be considered when providing advice on physical activity because they may impact engagement and attendance. See Implementation tips for further ways to support facilitators and address barriers.

Box 4. Facilitators of physical activity
  • Support/inclusion of family, friends and program staff: this improves cultural safety, connection and support49–52
  • Opportunities to connect with community or culture: like other cultures, many Aboriginal and Torres Strait Islander people are motivated by, and feel comfortable around, others from their community and with the opportunity to practice culture12,49,53–55
  • Having role models and desiring to be a role model: seeing others have success motivates some community members to want to achieve similar goals. When they achieve them, they want others they care for to have the same experience49,50,52,55,56
  • Gender-specific/women-only activities: some women feel more comfortable completing physical activity around other women. This could be due to feeling more comfortable chatting openly; having less feeling of shame about their fitness or health; or just enjoying spending more time around other women49
  • Group-based physical activity: group-based activities reduce feelings of ‘shame’ for some people, make physical activity more fun and increase motivation12,50,57
  • Cultural safety: many Aboriginal and Torres Strait Islander people have experienced, and continue to experience, racism, including in healthcare settings. Cultural safety is essential12,54

Box 5. Barriers to physical activity

Barrier

Strategy
Lack of transport Try to organise physical activity programs that do not require travel, unless access to transport is provided. Physical activity can be completed around the house, walking the streets or at a local park.49,52,55,56
Costs/financial constraints Provide options that do not require additional expense. There may be free programs in the area or, if the patient qualifies for a chronic disease management plan, you may be able to refer them to an exercise physiologist who bulk bills.12,49,50,52,55
Competing work, family or cultural commitments, including a perceived lack of time or timing issues Refer patients to physical activity programs that are not only offered during business hours, or that allow parents to bring their children along.12,49,52,55,56
Poor mental health Refer patients to programs that provide greater support and have mental health workers in attendance. Socialising can improve mental health, so encourage physical activities with people the patient would like to spend time with.49
Racism Aboriginal and Torres Strait Islander peoples should only be referred to culturally safe programs. Ensure program providers have completed a cultural safety program and/or are trusted by the local Aboriginal and Torres Strait Islander community.49,54
Gender Women may have additional barriers to men, including child rearing and household obligations, as well as environmental safety concerns.12,49,50,58,59 Promote women-only physical activity sessions. This may make the sessions more inclusive, safe and sought after by women. It may also reduce feelings of anxiety or shame associated with physical activity in some communities.
Climate (heat, wet season) Promote physical activity in the early morning or evening in hot weather. Advise using covered areas to exercise in during wet periods. This could include creative programs that can be completed at home.50,56
Sedentary behaviour and screen time for children Because school-aged children spend much of their day sitting at school, they should be encouraged to perform some form of physical activity during after-school hours, with a limit on screen time as per guidelines.
Lack of equipment, sporting facilities or programs A referral to an exercise physiologist can help the patient find creative ways to complete physical activity without the need for equipment. Referrals can be made within both a GP management plan and team care arrangements. Exercise and Sports Science Australia provides a directory to find an exercise physiologist in your area (see Useful resources). Exercise programs can be based around body weight exercises (eg squats, push-ups) and abdominal-strengthening exercises, and include cardiovascular component such as walking or jogging. There are many variations on these that can be adjusted to suit an individual’s strength/fitness level.12,50,56
Exercising with an injury Refer the patient to an exercise physiologist or physiotherapist, and encourage the patient to work within their pain and/or mobility limitations. Begin with low-volume, low-intensity exercises, and increase both volume and intensity steadily.12
Shyness, embarrassment, shame Encourage the patient to exercise with a group of family or friends. This could also be done in a less public environment, such as their yard or inside their house.50,52,55,56
Self-perception of ‘not being good enough’ Encourage the patient to exercise with a group of family or friends. This could also be done in a less public environment, such as their yard or inside their house.56
Not understanding what to do After you discuss physical activity options with your patient, ask them to repeat back to you what physical activity they will be doing each day and how they will complete it (eg ‘I will walk on Monday to Friday, from my house to the shops and back. On Saturdays I will do laps of the oval while my son is at the footy.’).56
Travel away from community Provide advice on ways the patient could fit physical activity in when they travel. For example, taking a break on long trips and doing a short walk will help them stay alert as they drive; when visiting family and friends, walk from house to house when possible; or go for a walk with the family/friends you are visiting.52

Overall, for the best opportunity for great outcomes from physical activity programs come from programs that are culturally safe; low or no cost and; at a location that requires minimal transport, child/family friendly; provide sessions in- and outside of business hours; provide group-based activities; ideally have some women-/men-only sessions; and provide sessions that cater to all levels of mobility and fitness. Physical activity sessions should:

  • start with low volume and low intensity
  • build to higher volume, low intensity
  • then low volume, high intensity
  • then higher volume, high intensity.

In short, physical activity sessions should be fun, safe and accessible!

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