Review

Economic burden of physical inactivity: healthcare costs associated with cardiovascular disease
Neil B. Oldridge
University of Wisconsin School of Medicine and Public Health, College of Health Sciences, University of Wisconsin and Cardiology Fellow Research, Comprehensive Cardiovascular Care Group, Milwaukee, Wisconsin, USA
Received 27 June 2007 Accepted 29 August 2007

Increasingly important objectives for developed and especially for developing countries include increasing the numbers of individuals who do not smoke, who eat healthy diets and who are physically active at levels that are health enhancing. In developing countries, deaths from chronic disease are projected to increase from 56% of all deaths in 2005 to 65% by 2030 (driven largely driven by deaths due to cardiovascular and coronary heart disease); in developed countries, however, the increase is only from 87.5 to 88.5%. The data on physical inactivity presented in this review were derived primarily from World Health Organization (WHO) publications and data warehouses. The prevalence of physical inactivity at less than the levels recommended for enhancing health is high; from 17 to 91% in developing countries and from 4 to 84% in developed countries. In developed countries, physical inactivity is associated with considerable economic burden, with 1.53.0% of total direct healthcare costs being accounted for by physical inactivity. Other than on some exciting work in Brazil, there is little information on the effectiveness and cost-effectiveness of physical activity-enhancement strategies in developing countries. The WHO has signaled a shift from the treatment of illness to promotion of health, with an emphasis on changing modifiable health-risk factors, including smoking, unhealthy diets and physical inactivity: the real question, especially for developing countries, is what is the future healthcare cost of not encouraging healthier lifestyles today? Eur J Cardiovasc c Prev Rehabil 15:130139 2008 The European Society of Cardiology
European Journal of Cardiovascular Prevention and Rehabilitation 2008, 15:130139 Keywords: cardiovascular disease, coronary heart disease, costs, physical inactivity

The vast majority of threats to health are more commonly found among poor people, in people with little formal education and those with lowly occupations y (but) y unfortunately, data are particularly scanty where they are needed most-in the poorest countries of the world [1].

Introduction
Controlling cardiovascular disease (CVD) risk factors reduces CVD and coronary (ischemic) heart disease (CHD) mortality as high cholesterol, high blood pressure, tobacco use and physical inactivity explain at least 75% of
Correspondence to Professor Neil B. Oldridge, PhD, College of Health Sciences, University of Wisconsin-Milwaukee, 6975 N. Elm Tree Rd, Glendale, WI 53217, USA Tel: + 1 414 540 2228; fax: + 1 414 229 6843; e-mail: neilb@uwm.edu This manuscript is based on a presentation made at the 11th World Sport for All Congress on Physical Activity: Benefits and Challenges held in Havana, Cuba in November 2006, and is to be published in the congress proceedings. c 1741-8267 2008 The European Society of Cardiology

the new occurrences of CHD; these figures encourage individuals to live healthier lifestyles. In other words, less smoking, healthier eating habits and more leisure-time physical activity can result in demonstrable benefits [2]. Two recent publications have examined the reasons for the approximately 40% increase in CHD mortality between 1984 and 1999 in China [3], and the approximately 50% decrease in CHD mortality between 1980 and 2000 in the USA [4]. Risk-factor increases (cholesterol, obesity and diabetes) accounted for approximately 77% of the increased mortality reported in China [3] and risk-factor decreases (cholesterol, blood pressure, smoking and physical inactivity) for approximately 44% of the observed decrease in mortality in the USA [4]. The majority of these healthier lifestyle benefits are long term, for example, in terms of less CVD burden, there are more immediate and short-term benefits, for example, reduced demand for acute healthcare services.

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Economic burden of physical inactivity Oldridge 131

The World Health Organization (WHO) [1,5,6] has signaled the need to shift from a focus on the treatment of illness to one on the promotion of health, with an emphasis on changing modifiable health-risk factors including smoking, unhealthy diet and physical inactivity. The shift in the major causes of death and disability from communicable (infectious) diseases to noncommunicable (chronic) diseases is linked to the changes in both economic development (e.g. industrialization) and social organization (e.g. urbanization) [7]. Ample evidence exists [8,9] that the health burden of the noncommunicable chronic diseases, particularly CVD and CHD, is on a rapidly escalating trajectory in developing countries, and can potentially be disastrous [10,11]. The real question, especially for developing countries, might be framed as what is the future healthcare cost of not encouraging healthier lifestyles today? The purposes of this report are (i) to document the prevalence of physical inactivity and (ii) to determine the costs of physical inactivity in developed countries and, of equal or greater future strategic importance for policy makers, in developing countries.

information on participation in physical activity in three settings, work, travel to and from places, and recreational activities [16]. Typically, the other surveys reported in the WHO Global InfoBase Online database are specifically designed (often not validated) with national and subnational data [14]. From the perspective of methodology, it is important to note that, as there is no universal definition of physical inactivity, intercountry comparisons of the prevalence of physical inactivity are a major challenge for various reasons including the following: 1. Physical inactivity is defined differently in different questionnaires and includes the following examples: doing very little or no physical activity, no participation plus sitting down for > 6 h/week, < 10% of leisure-time in activities r 4 metabolic equivalents. Consensus is growing that, for health benefits, some but insufficient activity is < 2.5 h/ week of moderate activity [1]. 2. Four major domains of physical activity have been identified, that is, work, transport, domestic and leisure-time activities. This creates challenges for intercountry comparisons. In many of the developing countries, there are restricted opportunities for leisure-time physical activity, as work, transport and domestic tasks naturally predominate [1]. 3. Statistics relating to the prevalence of physical inactivity are questionable, as the surveys are not strictly comparable: different surveys use different definitions of physical inactivity; they are carried out in different years; and the age groups sampled are different [1]. 4. Much of the available data pertain largely to voluntary leisure-time behavior in adult white men in developed countries [17], which further complicates comparisons between developed and developing countries. 5. Much of the published physical inactivity data and CVD disease data are at the national level, with varying degrees of scientific rigor; and little is available at the international level [18].
Healthcare expenditures

Methods
The terms physical activity, physical inactivity, sedentary, prevalence and costs were used to search the published literature and electronic data banks for relevant data.
Economic classification and chronic disease

The World Bank economic classification was used to identify countries as either developed (high income in 2005 was defined as US$ > 10 725 per capita) or developing (low and middle income in 2005 was defined as US$ < 10 726 per capita) [12]. Chronic disease trends for 2005 and 2030 are described on the basis of WHO data [13].
Prevalence of physical inactivity

The 2006 WHO Global InfoBase Online [14] provided prevalence data regarding physical inactivity in member states. These data were derived from both the International Physical Activity Questionnaire (IPAQ) [15] and the Global Physical Activity Questionnaire (GPAQ) [16] and from other survey questionnaires; other sources of data for the prevalence of physical inactivity, usually governmental or quasigovernmental, are also presented for both developed and developing countries. The IPAQ was developed for surveillance activities and to guide the development of policies relating to healthenhancing physical activity across various life domains; there are two versions that include different life domains including occupation, household activities, self-powered transportation and leisure-time activities [15]. The GPAC questionnaire was developed by WHO for surveillance of physical activity in countries with

Healthcare expenditure data (total direct healthcare costs and costs associated with CVD, CHD and/or hypertension) associated with physical inactivity were derived from peer-reviewed publications, which are based primarily on governmental or quasigovernmental databases.

Results
Chronic disease burden: cardiovascular disease trends

Death and disability-adjusted life years (DALY) data are available in the WHO report on global mortality and

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132 European Journal of Cardiovascular Prevention and Rehabilitation 2008, Vol 15 No 2

Table 1 Total deaths and disability-adjusted life years (DALYs) due to chronic, cardiovascular and coronary heart diseases, in developed and developing countries in 2005 and 2030 Developed countriesa 2005 Deaths (millions) Total Chronic disease Cardiovascular diseases Coronary heart disease DALYs (millions) Total Chronic disease Cardiovascular diseases Coronary heart disease 8.14 7.13 3.07 1.38 2030 9.59 8.49 3.39 1.50 Developing countriesa 2005 50.13 28.27 14.46 6.21 2030 64.77 42.06 19.64 8.24

WHO member states, is probably the most extensive single source for data on the prevalence of physical inactivity (both leisure-time physical inactivity and total physical inactivity, generally categorized as unspecified), in both developed and developing countries. The data on the prevalence of physical inactivity are derived from two distinct sources: (i) the IPAQ and/or the GPAQ and (ii) other survey instruments. Developed countries Prevalence data on physical inactivity are available in the WHO Global InfoBase Online database for 30 of the 56 developed countries; no country reports IPAQ or GPAQ data on leisure-time physical inactivity; only two countries report total IPAQ or GPAQ data on physical inactivity; data on leisure-time physical inactivity are reported by 17 countries; and 12 countries report data on total physical inactivity using the other survey questionnaire category (Table 2). With the other survey questionnaires, the mean and median prevalence rates of leisure-time physical inactivity in developed countries were 35.7 and 36.0%, respectively, and 50.7 and 53.4%, respectively, for total physical inactivity (Table 2). Developing countries The WHO Global InfoBase Online database provides prevalence data for physical inactivity for 49 of the 153 developing countries. IPAQ or GPAQ survey data are provided by 28 countries, by two on leisure-time physical inactivity and by 26 on total physical inactivity; 12 countries report data on leisure-time physical inactivity and 10 report data on total physical inactivity, using the other survey questionnaires (Table 3). The mean and median prevalence rates in developing countries for IPAQ or GPAQ total physical inactivity are reported as 37.3 and 32.5%, respectively; with the other survey questionnaires, the mean and median prevalence rates in developing countries for leisure-time physical inactivity are reported as 56.1 and 56.2%, respectively, and 53.9 and 50.1%, respectively, for total physical inactivity (Table 3).
Other data sources

119.36 102.31 18.15 7.50

118.31 105.72 15.96 6.46

1363.70 632.20 135.18 54.00

1532.32 832.75 167.17 65.35

Summarized from the World Health Organization Updated Projections of Global Mortality and Burden of Disease, 20022030 [13]. aAccording to the World Bank economic classification of countries [12].

burden of disease in 2005 and 2030 [13]. The highestranking projected cause of death in the world for both 2005 and 2030 is CHD (Table 1). In developing countries, deaths from chronic disease were projected to increase from 56% of all deaths in 2005 to 65% by 2030; however, the corresponding projected increase was only from 87.5 to 88.5% in developed countries. The increase in mortality due to chronic disease in developing countries will be driven largely by a 36% increase in CVD deaths and a 33% increase in CHD deaths. An important, but frequently disregarded, observation is that the number of CHD deaths for 2005 in developing countries is already more than four times that in developed countries. As an indicator of the burden of premature death and disability that can be attributed to a disease, DALYs might be a more meaningful measure of the impact of chronic diseases than mortality [19]. CHD was projected to be the sixth leading cause of DALYs in the world in 2005; its ranking is expected to increase to the third, by 2030. Between 2005 and 2030, the numbers of DALYs associated with CVD and CHD in developing countries are projected to increase by 24 and 21%, respectively; whereas, they are projected to decrease in developed countries.
Physical inactivity: international prevalence

Additional data are available on the prevalences of physical inactivity, in both developed and developing countries, from sources other than the WHO Global InfoBase Online database. Developed countries Government or quasigovernmental databases are available in a number of developed countries peer-reviewed publications using these data are available (Table 4). As seen in the examples below, there are considerable differences in the definitions of physical inactivity in the different reports, making all comparisons tenuous at best. Australia: In 1999, 43% (40% of the men and 46% of the women) of adults (n = 3000) reported not being sufficiently physically active for health benefits

The WHO 2002 World Health Report suggests that the global estimate for the prevalence of physical inactivity is 17% (1123% across subregions) [1], with the prevalence of some but insufficient physical activity (i.e. < 2.5 h/ week of moderate activity) being 41% (3151%). These prevalences are estimated to be associated with 1.9 million deaths, 19 million DALYs and about 22% of CHD prevalence globally [1].
2006 WHO Global InfoBase Online

The WHO Global InfoBase Online database [14], a data warehouse on chronic diseases and their risk factors for all

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Economic burden of physical inactivity Oldridge 133

Table 2

Prevalence of physical inactivity among adults in the developed countries (World Bank high income) by WHO Global Infobase Online and region [14]; (n = number with data/number of countries in region), physical activity survey questionnaire (IPAQ, International Physical Activity Questionnaire; GPAQ, Global Physical Activity Questionnaire) and type of activity reported [leisuretime; total (frequently unspecified)]
IPAQ or GPAQ Leisure-time (%) Total (%) Other Leisure-time (%) 3.9 71.5 80.8 25.2 78.8 16.3 36.0 35.0 40.0 20.8 28.0 73.0 40.0 18.0 70.4 16.0 27.8 60.0 65.5 18.5 36.8 41.0 46.9 69.0 34.0 76.6 78.2 13.1 Only one country Only two countries 75.1 37.4 (20.8) 37.0 47.1 (22.4) 46.8 55.6 51.2 37.8 Total (%)

Table 3 Prevalence of physical inactivity among adults in the developing countries (World Bank low and middle income) by WHO Global Infobasis online and region [14]; (n = number with data/ number of countries in region), by physical activity survey questionnaire (IPAQ, International Physical Activity Questionnaire; GPAQ, Global Physical Activity Questionnaire) and type of activity reported [leisure-time; total (frequently unspecified)] Questionnaire Type of activity Africa (n = 12/45) Algeria Cameroon Congo Ethiopia Gambia Kenya Mauritius Nigeria Seychelles South Africa Tanzania Zimbabwe East Mediterranean (n = 6/15) Egypt Iran Jordan Lebanon Oman Tunisia Europe (n = 12/30) Bosnia Bulgaria Croatia Czech Republic Estonia Hungary Krygyzstan Latvia Lithuania Poland Russia Uzbekistan Americas (n = 12/30) Argentina Bolivia Brazil Chilea Costa Rica Cuba Guatemala Guyana Mexico Trinidad & Tobago Uruguay Venezuela South-East Asia (n = 3/11) Bangladesh India Indonesia Western Pacific (n = 6/22) China Fiji Mongolia Nauru Philippines Vanuatu Grand mean ( SD) Median
a

Questionnaire Type of activity East Mediterranean (n = 3/6) Bahrain Saudi Arabia United Arab Emirates Europe (n = 20/23) Austria Belgium Denmark Finland France Germany Greece Iceland Ireland Israel Italy Luxembourg Malta Netherlands Norway Portugal Spain Sweden Switzerland UK Americas (n = 2/5) Canada USA Western Pacific (n = 5/5) Australia Japan Korea New Zealand Singapore Grand mean ( SDa) Median
a

IPAQ or GPAQ Leisure-time (%) Total (%) 25.6 71.1 52.4 22.7 56.6 21.9 44.8 1.9 95.6 67.6 39.5 ( + work) 34.4

Other Leisure-time (%) Total (%)

96.8

81.0 67.5 47.4 40.3 87.9 29.6 36.0 52.3 29.7 30.9 15.4 23.9 90.8

59.6

64.0 52.7 31.2 22.9 24.2 24.1 50.1 51.1 89.4 36.8 80.4 9.7 36.7 40.8 60 70

Standard deviation.

(< 150 min of physical activity in at least five sessions/ week) [20]. New Zealand: Of 7862 adults, 39% (38% of the men and 39% of the women) reported not participating in sufficient physical activity to improve health and wellbeing ( Z 30 min of moderate levels of physical activity nearly every day) [21]. Pan-European Union: Of 15 239 adults screened in 15 EU countries in 1997, 31% did not participate in sufficient physical activity for health benefits ( < 1.5 h/week) [22]. Prevalence of physical inactivity ( < 10% of leisure time spent in activities of Z 4 metabolic equivalents) ranged from as high as 62% (low of 43% in Sweden to a high of 88% in Portugal) to as low as 15% (no participation, in addition to sitting down for > 6 h/week; low of 6% in Sweden to a high of 24% in Portugal) [23]. In 2002, 69%

32.9 22.4 65.3

36.7

33.7 50.1 79.8 16.5 8.8 53.9 (25.6) 50.1

22.6 Only two countries 37.1 (19.8) 31.9 56.1 (34.0) 56.2

Specifically excludes work. Standard deviation.

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Table 4

Prevalence of physical inactivity (overall, men and women) in selected developed and developing countries
Prevalence of physical inactivity (%) Reference # Definition of physical inactivity < 150 min of physical activity, < five sessions/week < 30 min of moderate levels of physical activity nearly every day < 1.5 h/week < 10% of leisure time spent in activities Z 4 metabolic equivalents No participation in addition to sitting down for > 6 h/week < 30 min a day, activity of moderate intensity, < 5 days/week OR activity of vigorous intensity, < 20 min a day, < 3/week, < 30 min, activity of moderate intensity, < 5 days/week < 30 min of at least moderate exercise on most days of the week Moderate exercise on < 3 days/week < approximately 1 mile/day of walking A. < 30 min of moderate-intensity activity, < four times/week; B. < 20 min of activity of vigorous-intensity, < 3 days a week < 150 min walking/week in leisure time < 1000 kcal/week < 150 min all domains walking/week < 30 min of daily activity of moderate- or vigorous-intensity < 30 min of activity, < four times/week < 36 min brisk walking/day < 30 min of moderate-activity, < 4/week Total 43 39 33 62 15 69 70 62 68 49 51 73 96 85 81 60 34 74 71 71 Men 47 38 30 62 14.5 62 63 56 74 47 49 68 96 86 69 57 30 75 NA 66 Women

Developed countries Australia New Zealand Europe

[20] [21] [22] [23] [23] [24]

39 37 62 15.6 74 76 67 63 51 52 76 96 84 89 61 36 74 NA 75

UK Scotland Ireland Canada USA Developing countries Brazil

[27] [28] [30]

[32,33] [34] [33] [35] [37] [38]i [39]

China India NA, not available.

of the Eurobarometer Wave 58.2 study population (15 selected countries; n = B15 000; 15 years and above, using the IPAQ) reported less than the recommended levels of physical activity for health benefits [24]. UK: Of 14 791 UK adults, 70% (63% of the men and 76% of the women) reported not meeting current recommended physical activity targets (moderate intensity for at least 30 min on at least 5 days/week) [25]; 62% of the 8148 Scottish adults (56% of the men and 67% of the women) reported that they were not sufficiently active to achieve health benefits (30 min of at least moderate exercise on most days of the week) [26]. Ireland: Of 5992 Irish adults, 68% (74% of the men and 63% of the women) reported they did not meet current recommended physical activity targets (moderate exercise three or more times a week) [27]. Canada: Among adults aged 20 years and above, the prevalence of leisure-time physical inactivity (walking less than approximately 1 mile/day) in 2005 was 49.3% (47% in men and 51% in women) [28], with 20-year trends in Canadian adults documenting a significant increase (P < 0.01) in the prevalence of physical activity (walking an average of 1 h/day over a year), from 21% in 1981 to 41% in 2001 [29]. USA: In 2005, 51% of adults, 18 years of age and above, did not meet the recommended level of physical activity of moderate intensity (at least 5 days/week for 30 min/ day), with 73% not meeting the alternative recommended level of physical activity of vigorous intensity (at least

3 days/week for 20 min/day) [30]. The percentage of US adults who were physically inactive in their leisure time (answering no to During the past month, other than your regular job, did you participate in any physical activities or exercise, such as running, calisthenics, golf, gardening, or walking for exercise?) decreased from 30% in 1999 to 24% in 2004 (P < 0.001) [31]. Developing countries A major source of data on the prevalence physical inactivity in developing countries is Brazil. Publications on physical inactivity from China and India are included, as more than 33% of the worlds population live in these two developing countries and, as they, together, account for about 60% more CHD deaths than in all the developed countries combined [9]. Brazil: The range of Brazilian adults participating in less than the recommended leisure-time physical activity, to achieve health benefits, ranges from as high as 96 [32] and 85% [33] ( < 30 min of physical activity on 5 or more days/week) and 81% (expending < 1000 kcal/week) [34] to as low as 60% for all-domain walking [33]. China: In 2001, 34% of Chinese adults (30% of the men and 36% of the women) were physically inactive, with as many as 75% not being engaged in leisure-time physical activity (< 30 min of daily moderate or vigorous activity) [35]. Some evidence exists of an important upward population shift in the prevalence of physical inactivity from 66% in 1989 to 81% in 1997 [36]. Although Hong Kong, a special administrative region of China, is considered to be a developed country, data are included

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Economic burden of physical inactivity Oldridge 135

here for comparisons with mainland China; prevalence of leisure-time physical inactivity ( < 30 min of activity, < 4 times/week) in Hong Kong is estimated to be 74% [37]. India: In a 2000 study of physical activity and CHD risk in India, 52% reported not participating in leisure-time physical activity, and an additional 19% engaged in > 0 to < 36 min brisk walking/day [38]. In a different geographic location in India and in a low socioeconomic population, prevalence of leisure-time physical inactivity ( < 30 min of moderate activity, < 4/week) was reported to be 71% in 1995, decreasing to 66% in 2002 in men, with an increase in the prevalence of inactivity in women from 72 to 75% over the same time period [39].
Costs of physical inactivity

Using an arbitrary 1990 publication date, six publications (Table 5), all from developed countries, provide data on the economic burden of physical inactivity-associated with CVD, CHD and/or hypertension, with data at the national level; one publication was from Switzerland [40], two from Canada [41,42], two from the USA [43,44] and one from the UK [45]. 1. The total direct costs attributable to physical inactivity (absence of leisure-time activity and BMI > 30) in the 1995 adult US population were estimated to account for approximately 9.4% (BUS$94.3 billion) of the total direct healthcare costs in the USA [43]. With an estimated prevalence of physical inactivity of 28.8%, the direct costs (diagnosis and treatment) attributable to a sedentary lifestyle and to lack of physical activity conservatively amounted to US$24.3 billion (2.4% of total direct USA healthcare costs) (Table 5). Of the total direct casts of physical inactivity, US$8.9 billion were associated with CHD and an additional US$2.3 billion with hypertension,

with an estimated cost per inactive person of approximately US$760 (2004$) [43]. In conclusion, Colditz suggests that growing levels of both inactivity and obesityy require focused strategies to increase the level of energy expenditure, with substantial benefits likely to accrue through reduced healthcare costsy andy also through reduction in the indirect costs as well as gains in quality of life [43]. 2. Having recognized physical inactivity as a substantial public health burden, a reduction of 10% in the inactivity levels was established as a Canadian national objective for 2003 [41]. The estimated prevalence of not meeting recommended levels of physical activity for health enhancement among Canadians ( Z 18 years) in 1997 was 62%, and the healthcare costs directly attributable to physical inactivity in 1999 were estimated at C$2.12 billion (2.5% of the 1999 total direct healthcare costs). Of this healthcare cost, C$0.89 and C$0.31 billion were due to CHD and hypertension, respectively (Table 5). The estimated cost per inactive person was approximately US$170 (2004$). Assuming that a reduction of 10% in the prevalence of physically inactivity in adult Canadians does occur, the savings would amount to an estimated C$150 million per year: the conclusion was that even a modest reduction would have a significant effect on the health of Canadians [41]. 3. Martin et al. [40], reporting on behalf of the Swiss Federal Offices and the Swiss National Accident Insurance Organization, estimated that approximately 37% of the Swiss population did not meet the physical activity recommendations for enhancing health in 1999 (Table 5). The estimated 1999 total direct healthcare costs attributable to insufficient physical activity were SFr1.58 billion; the total direct costs for CHD were SFr113 million (7.2%) and for hypertension, SFr293 million (18.6%) [40]. The estimated cost per inactive person was approximately

Table 5

Summarized data from four countries (presented by date of data from Canada, Switzerland, UK and USA) for the impact of physical inactivity on national medical care expenditures (b = billion) associated with cardiovascular disease (CVD), coronary heart disease (CHD) and hypertension (HTN)
Direct medical costs associated with physical inactivity Annual direct medical costs due to physical inactivity (B) CVD CHD HTN Annual cost per inactive person National currencya US$460 C$150 SFr590 C$70 US$270 d35 US$ 2004b $760 $170 $630 $70 $430 $70

Author Colditz [43] Katzmarzyk [41] Martin [40]

Country (date of data) USA (1995) Canada (1997) Switzerland (1999)

Prevalence of physical inactivity (A, %) 28.8 62.0 37.0 53.5 47.4 70

Katzmarzyk and Canada (2001) Janssen [42] Wang [44] USA (1996) Allender [45]
a

UK (2002)

US$24.3 b (total) (2.4% US$8.9 b US$2.3 b total direct costs) C$2.12 b (total) (2.5% C$0.89 b C$0.31 b total direct costs) SFr1.58 b (total) (1.75% SFr0.113 b SFr0.293 b total direct costs) C$1.62 b (total) (1.5% C$0.47 b C$0.21 b total direct costs) US$23.91 b (CVD costs) US$5.39 b (3.0% total direct costs) d1.062 b (1.5% total direct d0.526 b costs)

B/(A*population) in year of data provided. bConsidering the growth rate of national per capita health expenditures [65].

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US$630 (2004$). The authors concluded both for reasons of public health and expenditure, that any further increase in inactivity is unacceptable and that a high priority should be given to attempts to increase the proportion of the population physically active [40]. 4. Using 2001 data, Katzmarzyk and Janssen [42] estimated the total impact (direct + indirect costs) of physical inactivity among Canadians aged 12 years and older on healthcare costs of CHD and hypertension (Table 5). With an estimated prevalence of physical inactivity of 53.5%, the expenditures attributable to physical inactivity were an estimated C$1.62 billion (1.5% of the 2001 total direct healthcare costs in Canada), of which expenditures of C$0.47 billion were due to CHD and of C$0.21 billion to hypertension. The estimated cost per inactive person was approximately US$430 (2004$). The conclusion drawn is that the importance of promoting a physically active lifestyle and maintaining a healthy body weighty underscore the importance of public health efforts aimed at combating the current epidemics of physical activity and obesity in Canada [42]. 5. Wang et al. [44] reported that the total medical expenditures of the 7.3 million persons with CVD in the USA in 1996 were $41.3 billion and that expenditures of $5.39 billion (13.1%) were associated with physical inactivity. With 47.4% of the adults aged 19 years and above in the USA not meeting recommended levels of physical activity, the estimated number of CVD patients associated with physical inactivity was 1.11 million: with an estimated medical expenditure per patient of $4,837, this amounts to a total expenditure of approximately $5.39 billion, or 22.5% of the total medical expenditures for persons with CVD (3.0% of total direct healthcare costs in 2001) (Table 5). The estimated cost per inactive person was approximately US$430 (2004$). The authors conclusion was that these findings suggest a critical need to promote physical activity in the U.S. populationy (and)y CVD that is secondary to sedentary behavior will lead to even higher national health expenditures while adding to premature disability, suffering, and death [44]. 6. Allender et al. [45] estimated the burden of ill-health related to physical inactivity in the UK and the associated direct costs to the National Health Service: they estimated that d6.48 billion of the 2002 National Health Service costs were associated with the five diseases defined by the WHO as having some relationship with physical inactivity. The costs associated with ischemic heart disease (or CHD), directly attributable to physical inactivity, amounted to an estimated d1.06 billion, of which 49.5% (d526 million) was due to ischemic heart disease (Table 5).

Assuming a prevalence of 70% of UK adults who do not meet the government physical activity recommendations [25], this would suggest an estimated cost of US$70 (2004$) per inactive person. The authors conclude that there is a considerable public health burden due to physical inactivity in the UKy (and)y that accurately establishing the financial cost of physical inactivity is an important step in developing national public health strategy [45]. A number of additional peer-reviewed manuscripts and other reports are available on the costs of physical inactivity, for example, in Australia [46], Canada [47], China [48], the UK [49] and the USA [5053]. It is important to note that (perhaps, as expected) all of the publications cited above, except one, are from developed countries.

Discussion
Prevalences of physical inactivity in developing countries range from about 10 to 96% for leisure-time inactivity, and from about 12 to 91% for total physical inactivity; in developed countries, prevalence of leisure-time inactivity ranges from about 4 to 75% and of total physical inactivity from about 13 to 81%. Physical inactivity is associated with a considerable economic burden in terms of the direct healthcare costs associated with CVD, CHD and/or hypertension, in each of the analyses reported above. It is also important to note, that although physical inactivity is a modifiable risk factor for CHD and hypertension, it is also an established risk factor for a number of other conditions including stroke, colon and breast cancers, type-2 diabetes and osteoporosis. The prevalence of physical inactivity and the analyses of the economic burdens of CVD, CHD and hypertension reviewed in this chapter are not directly comparable for a number of reasons: the results should not be interpreted as if they were comparable. In particular, the reports on the economic burden are based on data from four different countries with different healthcare systems; the dates of the data analyzed are different; the definitions of physical inactivity are different and different prevalences of physical inactivity and different relative risks of physical inactivity for CVD, CHD and hypertension have been used. Therefore, the estimated population-attributable risks were different. All this makes it difficult to establish unequivocally that the estimates of the economic burden of physical inactivity in the four countries are directly comparable. Despite these important caveats, the physical inactivityassociated economic burdens of CVD, CHD and hypertension in each of the four countries are considerable. The public health message is consistent and can be

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Economic burden of physical inactivity Oldridge 137

summarized from each analysis as follows: from Canada, that even modest reductions in inactivity could result in substantial cost savings [41] and that the results provide convincing evidence that reducing physical inactivityy would substantially reduce healthcare spending [42]; from Switzerland, that the promotion of health-enhancing activity is of great importance not only for reasons of individual quality of life and health, but also on economic grounds [40]; from the UK, that accurately establishing the financial cost of physical inactivity is an important step in developing national public health strategy [45] and from the USA, that inactivity represents a major avoidable contribution to the costs of illness [43] and that the economic burden of inactivity-associated CVD demonstrates the need to promote physical activity [44]. On the basis of the admittedly selective WHO Online Global database, developing countries report considerably more leisure-time physical inactivity (median = 56%) than do developed countries (median = 36%); in contrast, the developing and developed countries report similar total (often unspecified) physical inactivity median prevelances. In general, the developed/developing country differences in leisure-time physical activity both prevalences are consistent with less discretionary time is available and the changes in occupational, transportation and domestic physical activity demands in the developing countries with increasing industrialization and urbanization. The large IPAQ/GPAQ and the other surveys discrepancy in total physical inactivity prevelance in the developing countries needs further exploration. The implementation of local, national and international efforts to increase the prevalence of physical activity has not been addressed in this review. It is, however, clear that the effectiveness of strategies to increase the levels of physical activity in individuals and populations is crucial to decreasing the associated economic burdens on healthcare. Programmatic areas of work, for example, in the Global Alliance for Physical Activity, for increasing physical activity levels include (i) advocacy to make the case, (ii) communication to disseminate information, (iii) networking to build partnerships, (iv) policy development and program implementation and evaluation and (v) surveillance and communication [54]. In addition, there are a number of systematic reviews on the impacts of various approaches designed to increase physical activity [5559]. The increasing numbers of people who smoke, eat unhealthy diets and are physically inactive is of special concern in developing countries, with their rapidly increasing industrialization and urbanization. Associated with this are major shifts in the burden of disease from infectious to chronic diseases such as CVD, which is the largest cause of death globally [9,60]. With the initiation of effective public health strategies, however, even small

reductions in these CVD risk behaviors will lead to population-level reductions in risk and in the associated economic burdens of CVD and CHD [11]. It is important for policy makers in developing countries, more so for resource-poor areas in these countries, to note that there is evidence of intervention effectiveness, which impacts policy decisions when addressing health priorities [61]. Unfortunately, other than some exciting work in Brazil [6264], there is little information on the effectiveness and cost-effectiveness of physical activity-enhancement strategies in developing countries; certainly, fewer financial resources are available for discretionary public health than are required to make the necessary changes.

Conclusion
The potential public health impact of reducing the levels of physical inactivity and the health and economic effects associated with heart disease have been documented primarily, if not exclusively, in developed countries. The increasing prevalence of physical inactivity in developing countries is a real concern. It is important to note that there is ample evidence to demonstrate that the burden of chronic diseases particularly CVD and CHD in developing countries is on a rapidly escalating, potentially disastrous, trajectory [8,10,11]. The real question, especially for developing countries, is what is the future healthcare cost of not encouraging healthier lifestyles today? To reduce the economic burden of unhealthy lifestyles, especially in developing countries, increased personal, corporate and governmental responsibility for healthier lifestyles must be enthusiastically advocated. As has been eloquently pointed out by K.S. Reddy, an empowered community, an enlightened policy and an energetic coalition of health professionals must ensure that development (of developing countries) is not accompanied by distorted nutrition and disordered health [10].

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