16
Examination of witnesses
Dr Kathryn Atherton, Professor Kim Edwards and Professor Dame Theresa Marteau.
Q47 The Chair: Good afternoon to our distinguished panel of witnesses. Thank you all very much indeed for coming. It would have been great to meet you in person, but I suspect you are all very used to this way of working at the moment.
We have with us Dr Kathryn Atherton, adviser on the Behavioural Insights Team, Professor Kim Edwards, professor of sports, exercise and nutritional education at the University of Nottingham, and Professor Dame Theresa Marteau, director of the Behaviour and Health Research Unit at the University of Cambridge. Thank you all for giving us your time.
Would it be all right to use your Christian names?
Dr Kathryn Atherton: Of course, please do.
Q48 The Chair: If not, it would mean I had to use everybody’s title, and that becomes very tedious.
Kathryn, how important is the science of behavioural change to get people to lead active and healthy lifestyles? We hear a lot of about those connections. Could you give us a little insight into what the research is telling us at the moment about how we encourage people to lead more active and healthy lifestyles, or is it just one of those pious things that academics and politicians say and do not have a way of actually delivering?
Dr Kathryn Atherton: Thank you very much for your excellent question. As you mentioned, I work at the Behavioural Insights Team. For anyone who does not know, it is a social purpose company that uses insights from academic research about human behaviour to inform policy, improve public services, and deliver positive results for people and communities.
In answer to your question, I think it is critical. In a broad sense, the science of behaviour change represents all that we know to date on how behaviour can be changed. It tells us how this kind of policy ought to be designed. As regards recommendations, we are likely to see the biggest health benefits if we can support inactive people to be somewhat active. Inactivity is very bad for our health and increases the risk of mortality. For example, a study from Denmark shows that sedentary people should expect to have about seven fewer quality-adjusted life years than physically active people. For comparison, obesity shortens quality-adjusted life years by almost three for men and six for women. Inactivity is a health crisis.
Analyses of the relationship between physical activity and mortality show that the greatest difference in risk occurs between the least active people, the least active quintile, and the next least active quintile. Moving activity a bit, not even as much as the recommendations, can make a big difference. Large-scale studies have shown that just an hour of physical activity per week in older adults is sufficient to decrease the risk of mortality by nearly 20%. One hour is a lot less than the 150 minutes per week recommended by the Government. It equates to just eight and a half minutes per day. The minimum level of activity required to see mental health benefits may be even less. Our research shows these benefits at a minimum level of at least 20 minutes a week.
The Chair: Let me stop you there. You make that point powerfully, but my question was: how do we get people to do it?
Dr Kathryn Atherton: Absolutely. I shall move on to that. That tells us what our goal is. On the question of how we do it, we should focus on making small levels of incidental physical activity easy for people. We should make physical activity part of daily life so that people do not experience it as effortful. We should make the active choice the easy choice.
Specific suggestions for how to embed physical activity in daily life, so that people do not have to motivate themselves to do something effortful, are things such as increasing the use of stairs. There is research showing that behaviourally informed signs and markings can increase the extent to which people use staircases. Importantly, that research, unlike quite a lot of research in this space, looked specifically at efficacy in different subgroups, including black people, and has been found to be effective for multiple groups. Importantly, the design matters. You can get backfire effects, but, if you involve a sample of the intended recipients in the development of the intervention, you can produce interventions that are really effective.
Another example is that new developments should be designed to maximise incidental physical activity, through things such as the positioning of stairs relative to lifts and escalators, and ensuring that there are safe walkable routes from housing to all local amenities.
Thirdly, you could look at ways to encourage people to park further from the door so that they have to walk further. One way of doing that might be to change the way car parks look. It could be anything from coloured zones and signage to making the spaces that are closer available only once the further ones are used up. Of course, spaces for disabled people should remain unchanged. Other things that you can do include—
The Chair: I will stop you there, because I would like to hear from our other guests. Kim, could you add to that? Indeed, do you agree with the basic premise that Kathryn has put forward?
Professor Kim Edwards: Both. I agree with what she has said, and I would definitely add to it. The nudging that Kathryn is talking about is really helpful and has been shown to be effective.
What is important to remember with physical activity behaviour is that it is complex and people do whatever physical activity they do, whether lots or little, for lots of reasons. It is a behaviour that tends to persist, for good reasons, for functional reasons; it works for that person. As well as nudging, we need to look at different levels. There is behaviour at individual level, as well as family, community, school, workplace, policy, media and industry levels. There are all those different levels; we can talk about environment later. Interventions at all those levels have been shown to work when they are applied together coherently and cohesively, not against each other. By that, I mean that if you have a policy to increase physical activity, but another one that sells off school playing fields or reduces cycle paths, they are working against each other. Where you have cohesion at all those different levels, the evidence shows that it has the most effect for people.
The Chair: Theresa, perhaps you could add a few comments about tackling obesity in that respect. The Government’s recent policy paper Tackling Obesity: Empowering Adults and Children to Live Healthier Lives focused almost exclusively on healthier food choices, and physical activity was rather a by-product. Is that messaging right for the crucial epidemic of obesity that we are facing, alongside the pandemic we do not wish to talk about at the moment?
Professor Dame Theresa Marteau: That is a really good observation. It is important to think about both physical activity and diet when it comes to preventing obesity, tackling obesity and maintaining healthy weight.
I want to say a bit about physical activity and the routes through which physical activity can contribute towards healthier weight. The first is through maintaining a good energy balance. We do not have that in many of our children. The second important route is through physical activity having a significant effect on cognitive development. Translating that, it particularly affects the ability of children to control their thoughts, feelings and the behaviours important for attention and memory, so the ability to take advantage of schooling as well as shape the risk of becoming obese.
The third route through which physical activity can affect obesity is its effect on mental health. We have heard a couple of comments already about physical activity affecting mood. The evidence is quite clear that there is a causal relationship between physical activity and depression. It looks like there is a bidirectional relationship between obesity and depression; as people’s mood goes lower, they are likely to be at increased risk of obesity and, similarly, as they become obese, their mood may go down. It is not a simple answer, but one absolutely needs them both most.
May I make a comment on your first question about the importance of behavioural science?
The Chair: Of course.
Professor Dame Theresa Marteau: Behavioural science is one of the core disciplines, but not the only one, that contributes to our understanding of physical activity, particularly in our focus on children and young people. It provides a scientific basis for informing the design of effective interventions. What we often think changes our own behaviour, and that of others, is wrong. One way in which it is often out of kilter is that we overestimate the importance of knowledge and motivation and underestimate the impact of environment. We will come back to that. By environment, I mean physical environment, social environment, digital environment and economic environment.
We have already heard some talk about the physical environment, but I hope we can come on to talk about other kinds of environments that are important in shaping an increase in activity and decreasing the likelihood of children not meeting the government guidance for 60 minutes of physical activity per day.
The Chair: I think we will come back to that later.
Lord Knight of Weymouth: During the pandemic that Lord Willis does not want us to mention, we have observed the differential uptake among some ethnic minority groups of the vaccine, and the desire to have the vaccine. That suggests a distrust born of historical poor practice in research, as well as institutional and structural racism, and so on. Do we see the same sorts of problems when it comes to activity and nutrition? Is the research in behavioural science good enough at the moment to differentiate ethnic minority groups?
Professor Dame Theresa Marteau: I will swerve around the question of vaccines and vaccine hesitancy for the moment, if that is all right, and address the patterning of physical activity by ethnicity, by affluence and by gender. I am sure your Lordships have already seen the most recent data from Sport England.
The Chair: Last week’s, yes.
Professor Dame Theresa Marteau: Yes. You will be familiar with the fact that around 45% of children in this country meet the CMO guidance for 60 minutes of being physically active each day. It is most patterned by affluence; 53% of children in the most affluent households meet that, compared with 38% in the least affluent households. If we look at ethnicity, the figure for black children is 35%, and 47% for white British children. The gap between boys and girls, which is still important, is 47% versus 43%; that is a smaller gap, but we often hear more about it.
There was a really good report from Friends of the Earth on ethnicity. It talked about the green gap. If you look at the built environments in which different groups live, almost 40% of people in BAME groups live in areas of the country that are the most green deprived, compared with 14% of those in white groups. It affects people’s trust in government to be in marginalised communities living in areas of deprivation; ethnicity and affluence are patterned by environments that are least likely to enable physical activity, and we see that in our children.
The Chair: I will move on, with apologies to Lord Addington, who wanted to come in here, and ask Baroness Morris to put her question.
Q49 Baroness Morris of Yardley: I want to ask about messaging and how effective it is in getting people more active, particularly those who are not active. I want to tie my question to some of the answers you gave to Lord Willis’s question about language. I think that sometimes the people who are developing the language do not speak the same language on sport and recreation as the people they want to hear it. There is a chasm. Everyone who is already active thinks it is a great slogan and cannot understand why it does not change anyone’s behaviour. Would you reflect on that?
I am really persuaded by the idea of changing the environment and making it easier for us to walk to work and go to the shops. It is powerful, but, thinking back, I think there is a danger. Am I right in thinking that years and years ago, a generation ago, people did that naturally because of the way society was built—its physical infrastructure? For instance, we did not have cars. We are now trying to be quite sophisticated at finding a language for something that people’s grandparents used to do naturally.
There is a bit of complexity between two worlds, with professionals developing the language and the messaging, and people thinking, “What the heck are they on about? It is about getting to work. It is about getting to the shops”. It is a bit of a messy question, but if you do not get the messaging right, no one listens to anything that follows. I think it is quite important. Kim, do you want to make a start on that, please?
Professor Kim Edwards: Kathryn has alluded to the messaging already. It is important to have a subgroup of your participants involved when you are designing a study. We would look to do that in the current time. Despite everything that Theresa said about what we know about the differences between different groups as regards physical activity, there is still less research done in those areas. We know less about how effective interventions are for those subgroups. More needs to be done involving them so that we get the messaging across. It might be information messaging or educational messaging. There are different ways of doing it, but we have to involve people.
We are very much looking at environment, the second part of your question. Going back to how things were, if you look at all the graphs that show over time how physical activity has reduced, and if you look at different types of physical activity since the 1950s—day‑to‑day life, household chores becoming easier—everything has gone down. Leisure time has gone up a teeny bit, but that is because everything else has come down so much. We need to be a little bit careful.
With children, we know that transportation networks are important. Traffic-type issues, such as whether there are places to cross the road, traffic density and the speed of traffic are very different from what they were a few decades ago. It is perceived to be less safe to let a child go from A to B on their own, because you are worried about cars, for example. If there was somewhere quieter, you might permit them to do that.
There is also facility access. What type of facilities do they have in the area? Theresa talked a little about green spaces. Is there access to green spaces and to leisure facilities? Where are all the different recreational facilities in proximity? We know that active travel to school reduces the further away you are from the school, understandably, because it gets harder and harder to walk there. We are not going to the village school any more or just down the street to the local school. They are further apart and further away.
Dr Kathryn Atherton: I thought your answer was fantastic, Kim. There is some evidence on the effect of public health messaging. A recent review by NIHR in 2019 concluded that there was moderate evidence for the positive effects of mass media campaigns on reducing sedentary behaviour. However, it is important to say that the evaluation of public health messaging campaigns is often rather lacking, which means that we are not best equipped to know what works best for whom, and how well, and therefore whether it is cost effective.
As an example, there is a widely celebrated and well-received campaign in the physical activity space called This Girl Can. I read online that 2.8 million more girls and women were active as a result of the campaign, but when I tried to dig into what data supported that figure I could not find it. I found a freedom of information request from a member of the public and eventually found out that it was from a survey where people had been asked if they knew about the campaign and if they felt they had been more active as a result. That is not an objective way of measuring behaviour change. That is not to say that This Girl Can did not work. It may well have done. We just do not know. It is a shame, obviously, because of all the money that was put into it. Hopefully, it did, but we would be much better off if we could do better evaluation.
It can be done. Even in real life and in the field, you can do stepped-wedge trials, where you do not roll the trial out everywhere at once but roll it out in different places and follow the behaviour changes. If it is online, you can randomise it. There are things that can be done. There are still some recommendations that we can make based on the available evidence, but I am conscious about not talking for too long.
Baroness Morris of Yardley: That is very interesting and helpful.
The Chair: We could spend a whole hour with one witness, so very briefly, Theresa.
Professor Dame Theresa Marteau: Public health campaigns are part of a mix. Generally, they do not change behaviour, and we would not expect them to. They can increase awareness of a threat and can increase the appeal of a target behaviour. The most recent review that I found of physical activity messaging looked at 123 studies. There is good evidence for a signal of effect in adults, and it is likely that it would work in children. It has two key messages. The first, as Kim has already said, is to target the message to the target audience, and, secondly, to frame the messages positively, emphasising immediate benefits that are social and affect mood. I think your expectations, Baroness, are unrealistic for what a media campaign can achieve. It is part of a mix.
As to why 80 years ago people might walk more than they do today, there are any number of explanations. It is important, as I think everybody would agree, that we shift the safety of travelling by bike so that it is safer than travelling by car, which currently is not the case. As well as having attractive spaces outside that encourage walking and cycling and playing, we want them to be safer places, too.
Q50 Lord Krebs: I would like to pick up on themes that we have already discussed: namely, the role of the environment versus the role of messaging and nudging. Going back 10 years, when I was chair of the Science and Technology Committee, we did an inquiry into behaviour change. One of our examples was modal shift in transport—active travel. We concluded from the evidence we heard that, although nudging and messaging had marginal effects, the big effects are the ones that our witnesses have already referred to and Theresa referred to in her very last comment. The big effects come from changing the infrastructure. An example that stuck with me was Copenhagen, where 50% of short journeys are made by bike or on foot, and the investment in cycling and pedestrian infrastructure is absolutely off the scale compared with anything in this country.
My question starts from that prejudiced point 10 years ago. The evidence may have changed. There are schemes such as active travel, to encourage people to walk or cycle instead of taking their car, and active environments, which encourage people to be active in other ways in their local community. Are those the important things rather than nudging and social messaging?
To pick up on the point that Theresa made about risk, the latest Department for Transport review shows that two‑thirds of adults feel that it is too dangerous to cycle on the roads. The review of the Government’s cycling and walking investment strategy, published in February, about a year ago, concluded that the £360 million investment was nowhere near enough, and that substantially more money is needed to get people to change their habits. The core of my question, and I will come to Theresa first, is this: is it really all about infrastructure?
Professor Dame Theresa Marteau: I am sure there is more, because there is never just one thing. Perhaps I could start with the evidence that has accumulated over the last 10 years on interventions in schools to increase levels of physical activity in children. Children in schools are a captive audience, if you like, so it is a very good way of trying to reach everybody.
There are some incredibly elegant, well-designed interventions, with very robust evaluations, not just self-reporting but using objective measures of physical activity. There is a recent systematic literature review bringing that all together, and more than 17 cluster-randomised control trials in schools. They tell us importantly, but disappointingly, that it is a flat line. We are not seeing any signal for an increase in physical activity from those interventions. There is a way in which one could always improve on them, but what they point to is what people speak of, using jargon, as a whole systems approach. People point to a whole systems approach in communities. That would be infrastructure—the built environment outside your home window that we have been talking about—as well as a whole systems approach in schools.
These have yet to be fully evaluated. It is entirely plausible that the very elegant interventions in schools to increase physical activity will show an effect if there are enabling environments, but at the moment we do not have them. I will say a little about what people talk about as the enabling environment in schools and creating an active schools framework. Colleagues at Leeds Beckett have described that.
It is about the physical environment, having space in schools, but critically also the social environment. Teachers and other staff are enabled to have a positive attitude to physical activity. Every opportunity is taken to be physically active during breaks. There is active homework. I will leave you to imagine what that might be like. There is opening of school grounds to families so that there is more physical activity there. That is in addition to the infrastructure that you were talking about, John, such as safe cycleways, safe and attractive places to walk, and lower volume and lower speed of traffic. We need to shift the affordability of getting around. It is very often cheaper to travel by car than it is to use public transport. All that systems thinking needs to happen as well.
Dr Kathryn Atherton: I support everything that Theresa has said. The problem is that the evaluation of existing infrastructure programmes is often not good enough for us to make firm conclusions. In the design of any new infrastructure, considerations about behaviour and active travel, and how to increase incidental physical activity, definitely need to be taken into account. I have not seen any data, for example, about the very expensive cycle paths in the UK. While there is an increase in cycling, I have not seen any evidence that it is not just among people who are already active and affluent.
We need to think carefully about the most cost‑effective approach for what we are trying to achieve. It should be to try to support people who are inactive to take the first steps towards being active. Being able to walk safely is important. While intuitively it feels that cycling should be too, I have not seen enough data on that yet to know that it would help reach the groups that we most want to reach. That would be my main point.
Professor Kim Edwards: I completely agree with Lord Krebs. Walkability is a consideration. We do better in the UK for that than some countries such as the States. We have pavements and road crossings, although they could be better. Safety is a big issue—not just factual safety, such as crime rates, but perceived safety. Parents will not let their children go to the park and play if they think that it is not safe for them to do that. Is the street lighting good enough to be walking backwards and forwards? I have already mentioned access to leisure facilities and green spaces.
We see that these things are different in deprived areas and wealthy areas, plus people are in a different circumstance. Do they have access to a car? Do they have to use public transport? What are the public transport links like? There is good evidence that people, particularly children, are more active where there are good public transportation links. That will vary between a rural and an urban area. They can have an impact on how active people are and whether they make that change. You have to address the social and cultural aspects of the environment as well as the physical aspects of the environment, but you need it all together.
The Chair: Thank you very much.
Q51 Lord Moynihan: I want to go into a little more detail about how effective we are in our schools at delivering an active and healthy lifestyle. How can schools better encourage and foster lifelong behaviours for an active and healthy lifestyle? Is the PE national curriculum fit for purpose? What could schools be doing differently?
Theresa focused in her opening remarks on the energy balance. We do not have that in many of our children, as she said, and I would like her to elaborate on that. Has behavioural science been sufficiently built into the national curriculum for PE? Is that the right place for it? I would appreciate your comments on that across the board, beginning with Theresa.
Professor Dame Theresa Marteau: I do not feel able to comment on PE and the national curriculum—Kim might be able to comment on that—other than to say that levels of physical activity in our children are suboptimal. Clearly, more needs to be done, whether it is through PE or through other interventions. I doubt that PE on its own will do it.
Going back to what I said, it is important that we establish routines and habits in young people, because we know that how physically active young people are in school is a predictor of how physically active they are later. We need to think about enabling environments, as I have already said, a whole systems approach, both within the school and outside the school. We need to think about enabling populations. I come back to the stark difference between the least affluent families, and the levels of physical activity there, and the most affluent families. Those differences will translate into poorer life chances, given, as we have rehearsed, the health effects as well as other consequences of being less physically active.
As to how we might enable populations, one of the key things we need to think about is tackling poverty. I draw the committee’s attention to Michael Marmot’s 2020 report, published in February, on health equity. It draws attention to the lamentable situation we find ourselves in but has some very practical solutions about how to tackle it. That is important as a recommendation for this inquiry. It is relevant to both physical activity and obesity, which is far more common in children in areas of high deprivation. I do not think I precisely answered your question.
Lord Moynihan: What is very interesting is that you made a clear distinction between PE in the national curriculum—physical education—and physical activity. It begs the question whether there should be that distinction in the modern world and whether the two should be much more aligned in designing the curriculum.
Professor Dame Theresa Marteau: I hope they are much more aligned. Physical activity is the key outcome of interest. PE will contribute to that, but the main goal is to have children who are physically active for 60 minutes a day. If we look at what that comprises, the main activity is informal play, so having spaces where children can engage in it is absolutely vital.
Professor Kim Edwards: Part of the PE national curriculum is to ensure that children lead healthy and active lifestyles. It is in the curriculum. Increasingly, and I am firmly in this camp, there is a belief that to make lifelong habits for healthy physical activity patterns we need to target younger children, at primary school age rather than at secondary school age, which was a more popular perspective. Primary age is the crucial stage.
We need to remember the groups that Theresa and Kathryn have been talking about. School is often the crucial area. If the family does not encourage sporting and physical activity, it happens for the child through the school environment. It amplifies the inequality between children who are in a more active family and those who are not. While maths and literacy have been seen as the key academic subjects, and key vehicles to address disadvantage, we increasingly need to lean towards PE in the agenda on social injustice to help to address that for children.
There are two hours of physical activity in the curriculum, but research has shown that a lot of that time is not spent being active. At first that seems counterintuitive. I am fairly supportive, however, because, particularly in the obesity research that has been done, we see that one of the reasons why children do not participate in sport is that they perceive themselves as not very good at it. You need to spend time teaching children skills and rules, and then they can interact and play and do it better. You have to remember that not all PE time is activity time, but it is still important.
There are some worrying pedagogical papers about PE teachers. For primary schools lucky enough to have PE specialists, it is great, but if you look at what is actually happening in schools, it is not a specialist teaching PE; it is often a generalist or the class teacher. They might have no experience in PE. They might not have high self-efficacy in being able to teach PE to children. They have often had bad experiences themselves, which are perpetuated. They do not have training. There is work to be done on training for PE, particularly for the primary age, where they tend not to have that specialty.
Another aspect that has been shown to be effective is teaching children to take responsibility. That relates to the social agenda of schools. Do they have sports ambassadors? What is their social policy? That side of physical activity in schools is also important.
Dr Kathryn Atherton: I want to chip in to support Kim’s comments. Previously, I was a primary school teacher and my post‑doctoral research in Oxford was on PE in schools. It is not as active as we sometimes assume, and sometimes there are very good reasons for that. I support the point that PE is not consistently prioritised across primary schools. Primary school teachers often find themselves in a position where they are pressured to prioritise other things, so it sometimes gets squeezed, sometimes it does not happen at all, and, because they are underconfident in teaching PE, the pupils are not as active as they could be during those lessons.
My recommendations would be, just as Theresa was saying, not to limit physical activity to PE but to build more physical activity into the day. That could be the wider rollout of the Daily Mile programme, which does not require resources or specialist training. It is already being used very effectively, and is being enjoyed in over 6,000 schools, but it could be rolled out to more. Interventions to support the delivery of PE, especially in primary schools, would be brilliant. There could be more training for primary teachers or more specialists, although specialists often tend to be men[1], and that could be negative for girls’ sense of belonging in physical activity. There could be things such as tips for less confident teachers about never standing still and whether it is possible to have children running on the spot while they are receiving instructions, the dos and don’ts, that sort of thing.
Speaking to one of Theresa’s earlier points, the evidence firmly suggests that we should try to involve families and communities, as that can have a positive effect on activity. After-school time is critical in differences in children and physical activity. If we could involve parents, perhaps with timely after-school text message prompts to parents, scaling up to more intensive things, that could be promising.
Q52 Lord Addington: My question is based on trying to avoid the idea that people stop doing activities at certain points in their lives. The old cliché that most people have heard is that it is 16, 18 and 21, when they leave various stages of education. The question notes that at other points in your life you have more pressures and stop doing physical activity.
I will start with Kim on this one, purely at random. What sort of structures help to avoid that? If you have been an active sportsman and are used to keeping yourself fit, what sort of activities and structures can avoid that happening and the stopping of those types of inactivity.
Professor Kim Edwards: We see ebbs and flows in physical activity through a person’s lifetime. In the epidemiological evidence, we see key drop‑off stages in physical activity—teenagers, young people, leaving home. You might think we would see an effect from physiological changes as we age, how the metabolism changes. I would put 30, 50, 70 as key ages when you have to try a bit harder. Looking at the panel, perhaps Kathryn is not in this group, but—
The Chair: Be careful now.
Professor Kim Edwards: You cannot get away with what you got away with before. My students all know not to say in class that you gain weight as you age, because, yes, we see that trend, and we see it in the data, but it is not a given. You do not have to. You will gain weight as you age if you do not modify your behaviour, if you do not learn to adapt. What works for you when you are 20 does not work for you when you are 60, and you need to take that into account and modify. That is part of what is happening, as well as the drop‑offs.
There is good literature on the childhood drop‑offs, the 16, 18, 21 year‑olds. After that, parenthood is very well written about. A lot of individuals see reductions in physical activity behaviour after having children, for obvious reasons. When you are tired, your desire to do healthy behaviours is diminished. We see clustering of good behaviour and clustering of bad behaviour, or healthy behaviour and unhealthy behaviour, I should say; yet it is a time to be active and it does not have to last for ever.
The way to deal with it is to instil lifelong behaviours, habits of physical activity, from a young age. You might ebb and flow, but you will keep coming back to it. It is about having flexibility. We talk about obesogenic environments, but you want active environments where making the active choice is the easy choice, the safe choice, the choice you want to make, and the natural choice. Often our environments are such that it is easier to jump in the car or to sit and watch telly, or whatever it is we are doing when we should be more active. That circles us back to influencing at a young age.
Lord Addington: Are things like the membership of sports clubs, et cetera, which are seen traditionally as a way of creating a culture where you will continue with that activity even if it is not as intense—the first team to the fourth—still regarded as an effective way of dealing with this?
Professor Kim Edwards: It depends on whether you enjoy it. Typically, in the old world, when we were allowed to go to the gym and could mix, January is lethal in the gym, because all the new members join, they all turn up to classes and you cannot book on to anything. But it does not last long and, by February, you can get back to your favourite class. You have to enjoy it. You will keep doing things that you enjoy.
It might be gym membership. It might be that racket sports are your thing. It might be that you want to go cycling or running or hiking or swimming. Whatever it is, it is about having access to what you enjoy. For families, it can be difficult, if you have children of different ages in tow, to find something that everybody can do and everybody wants to do. Things need to be family friendly as well if you are to get activity done at the weekends or in the evenings. It is about balance. Gym membership is a solution, but only if a person is going to enjoy it and will keep doing it.
Dr Kathryn Atherton: I completely agree that instilling lifelong habits, if we can achieve it, is incredibly powerful, and, obviously, starting early is the way to do that. It is worth saying, though, that the transition points are key. Any point when there is a disruption of your habitual behaviours is an opportunity for behaviours to be lost. But these transition points are also an opportunity for new behaviours to be developed. If we can take advantage of that, we can sustain physical activity across these transition points.
As regards specific ideas for what could be done, an example would be in schools. As young people approach the time when they will be leaving school, tutor time or PHSE time could be specifically devoted to giving them an opportunity to plan physical activity at their destination. They know what their destination is. They know the college they are going to, for example. They can think, “What do I do now that is active, and what is the corresponding thing I could do at my next destination? I’m going to physically sign up for it”. That is something you can do and it is an opportunity to promote the uptake of new habits.
In other transitions, such as moving house, you could put information in estate agent correspondence, or mortgage communications, such as invitations to sign up for physical activity offerings in your new local area. It could also be an opportunity for an invitation to plan an active travel route from your new home to your work. Getting a first job is another transition point. Employer induction materials could include personalised active travel recommendations from your home to your work. Starting a family can also be a drop‑off point for physical activity. We could make use of 12‑week and 20‑week scans as touchpoints with people who are going to become new parents, with suggestions on how to stay active as they go into the next stage of their life.
Professor Dame Theresa Marteau: It comes back to what feels like a chorus line for me. From behavioural science, we know that the past predicts the future, although not completely, so starting early and having good routines is important. That is more likely in enabling environments, in enabled populations.
I come back to the inequalities in our country that have been widened by Covid. There is an opportunity in the many policy goals of the current Government. The levelling-up agenda would be a real opportunity to scale up what we are talking about, having those enabling environments. If we look, for instance, at students going to our universities, poorer students are less likely to engage in sports and be physically active. In those environments, we see the inequalities writ large. Tackling inequalities in physical activity will also lead to changes and a lessening of inequalities in other areas that I think we all care about.
The Chair: We are coming to our last, but certainly not least, question.
Q53 Baroness Grey-Thompson: I am interested in different interventions and how effective technology is in promoting and encouraging an active and healthy lifestyle. There are so many different wearables around—apps that sync to machines and equipment, and apps that encourage you to be more active. Are they game-changers or gimmicks? Purely because you are first on my screen, I will start with you, Kim.
Professor Kim Edwards: You all keep moving around.
The Chair: It is to keep you active.
Professor Kim Edwards: Great. Yes, there are a lot of apps. There are hundreds, if not thousands. Interestingly, the evidence shows that the free ones are just as good, or as bad, as the paid-for ones. There is probably a difference in that, if you are paying for something, you might value it more, but not in what you get. That levels the playing field somewhat. There are lots. They can be effective at making differences to physical activity levels. We lack long-term studies and evidence of long‑term effect. We can see a short-term effect, even a medium-term effect, but once you get out to a year, that kind of length, it is difficult.
Because the number of apps and improvement in the apps is quite rapid, one thing that the literature has not quite caught up with yet is looking at how they are written and the behavioural change techniques that the different apps use. If you go back even five years, typically, they might only have had one, if any. More recently, the average has gone up, so there might be four or five behavioural change techniques within an app. As the apps improve and combine more behavioural change techniques, and as they address evidence-based physical activity guidelines—often they do not and probably are not attached directly to some kind of measure of physical activity, which will probably be on the phone on a different app—and you pull it all together, there is potential for them to work in a multifaceted approach.
It depends on what you are measuring. In all these things, are we measuring increases or changes in physical activity, or are we measuring changes in sedentary behaviour? Both are important. When we talk about physical activity guidelines, we often focus on what we call MVPA—moderate and vigorous physical activity. That has been a keystone of the guidelines for a long time. When they changed back in 2011, strength work was added to them; it is not often talked about, but it is very important for its metabolic benefits. We see in a tiny corner of the infogram reducing your sedentary behaviour that there is an increasing field of research showing that it does not matter if you go out for an hour’s run every day; if you are sitting or sleeping for the other 23 hours of the day, you are meeting the guidelines in one area, but you are not meeting them in the other area. We need to think about both those aspects. The apps can be used to measure both.
Dr Kathryn Atherton: There is some evidence that technologies can be effective. The evidence base is strongest now for pedometers, which have been around longer, but is currently less strong for some of the newer things, including mobile applications. There is evidence that technologies can be encouraging for the people who use them, but there is potential for the exacerbation of inequalities. It will tend to be more active people who are already interested in their physical activity, and are often more affluent, who buy the technologies. That will help make them more active but will not necessarily reach people who are more inactive to start with.
Professor Dame Theresa Marteau: I like the question. I do not think it is a game-changer. Nothing in this field is a game-changer, unfortunately. It will need multiple interventions. Neither are the apps gimmicks. There have been two recent systematic literature reviews, as the evidence is now accumulating. There are randomised control trials, one in healthy adults and another in adults with chronic conditions. Between them, there are about 48 trials now. They show quite a good signal of an effect that an app can increase physical activity and steps. I could only find one recent review looking at increasing physical activity in children and adolescents. There were just seven trials and there is no signal of an effect. That could be because of the quantity and quality of studies. I do not know.
We have to be very careful about techno-optimism. I absolutely agree with Kathryn; there is potential for what are called IGIs—intervention-generated inequalities. I would see the apps as part of a broader mix. At the moment, there is a reason to dampen down the techno-optimism from some quarters and to see that, if you really want to make a difference, this is not where you would start. It is lower down the list.
Q54 The Chair: Thank you very much indeed. Finally, I have a question for all three of you. You are now writing the report and you have to make one killer recommendation to the Government about what they should do. What is the one thing that you would say, in perhaps no more than a minute or two, should be our key recommendation? I will start with you, Kim, because you have had a rest since you last spoke.
Professor Kim Edwards: If I had to do just one thing, I would target primary school age children. Yes, that means that I am throwing some older adults in the bin because I am choosing to start with children, but, hopefully, it will follow them through. I would work on environments to help them be more active throughout the day, before school, during school and after school, and involve families, and communities. Think back to the Jamie Oliver studies on the telly. He had to involve the families. Remember them passing fish and chips through the school gates and things like that. It is absolutely crucial to have involvement. It cannot just be the school. We know there is more that can be done in the playground to address social policies in schools. Are the children allowed to play outside when it is raining? “Put a coat on. You’ll be fine”. That is where I would start if I could only do one thing.
Dr Kathryn Atherton: If it is literally one intervention, I would say a wider rollout of the Daily Mile[2] and moderate to vigorous physical activity intervention in primary schools. If it is the general approach that Government takes, I would say make the active choice the easy choice. Do what we can to change the environment, (as Theresa said earlier, not just the physical environment but all aspects of our environment) so that being active does not require people to motivate themselves to do something effortful - instead, it is baked into our daily lives. Putting the burden on the individual is not only unrealistic but unfair, because the crisis of inactivity is not equally spread throughout our society. We need to make the active choice the easy choice.
The Chair: Theresa, you have the final word.
Professor Dame Theresa Marteau: I would build back greener and fairer. I would redesign our public spaces so that they are greener and there is more nature in them. I would start with the most deprived corner of our sceptred isle. In that way, I would persuade the Government that it would hit the levelling-up agenda and the cleaner air agenda, and it would tackle childhood obesity, as well as increasing healthy life expectancy across the population, let alone increasing physical activity in children and their families.
Professor Kim Edwards: Could we add some cycle paths to your greener spaces?
Professor Dame Theresa Marteau: It should be greener and attractive, with all the cycleways that Lord Krebs will design for us. That is where everybody will be playing and spending their time.
The Chair: Thank you very much indeed. You would agree with that, Kim?
Professor Kim Edwards: Very much so.
The Chair: On that note of accord, I thank each of you for your contributions this afternoon. The committee has really enjoyed the contributions you have made. It has been a worthwhile session. My apologies if I have rushed you in your answers or cut you off short, but an hour is very short indeed to use three witnesses as brilliant as you have been. Thank you all very much indeed.
