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Available online at www.sciencedirect.com
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The Future of Physical Activity Research: Funding, Opportunities and Challenges Bo Fernhalla,⁎, Audrey Borghi-Silvab , Abraham S. Babuc a
College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA Cardiopulmonary Physiotherapy Laboratory – LACAP, Federal University of Sao Carlos, Sao Carlos (UFSCar), SP, Brazil c Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal – 576104, Karnataka, India b
A R T I C LE I N F O
AB ST R A C T The worldwide impact of physical activity (PA) on health consequences has received increasing attention. At this point in time, there is little disagreement that increasing levels of PA is an important aspect of public health worldwide. The world literature on PA, exercise and fitness has also grown exponentially since the early 1990’s. It is clear that there is a voluminous literature in this area of research and the exponential increase in the number of manuscripts has gained substantial momentum since the year 2000. Given the importance of PA research in regards to health outcomes, and apparent popularity of such research (based on the number of manuscripts published), one could argue that the viability and future of PA are indeed bright. However, one could also assume a different view, that although the field is popular, it is saturated and we already know what we need to know regarding the impact of PA on public health. Much of the future viability of PA research will also be dependent on funding sources available. It is also possible that the impact of PA may vary around the world, thus the “global” impact of PA research may be dependent on location. This review will discuss what we perceive as the current landscape and the future of PA research in three select areas of the world, the United States, South America and Asia. © 2014 Elsevier Inc. All rights reserved.
The worldwide impact of physical activity (PA) on health consequences has received increasing attention since the early studies of Morris et al.1,2 showing that London bus conductors had lower rates of myocardial infarction compared to the bus drivers, presumable because of the greater PA activity of the conductors. A recent prospective study of 416,175 individuals in Taiwan showed that an average of 92 min per week of PA was associated with a 3 year longer life expectancy compared to the inactive group.3 Furthermore, every additional 15 min increase in PA reduced all-cause mortality by 4%. Similarly, a large pooled cohort study in the United States (US)
showed up to a 4.5 year gain in life expectancy with PA levels equaling 450 min of brisk walking per week.4 Although these are only examples of large cohort studies showing the beneficial health effects of PA, there is little disagreement that increasing levels of PA is an important aspect of public health worldwide. The world literature on PA, exercise and fitness has also grown exponentially since the early 1990’s. A PubMed search of the terms “physical activity”, “exercise”, “fitness”, and “physical activity or exercise” since 1960 is depicted in Fig 1. It is clear that there is voluminous literature in this area
Statement of Conflict of Interest: None. ⁎ Address reprint requests to Bo Fernhall, Ph.D, Dean and Professor, College of Applied Health Sciences, MC 518, University of Illinois at Chicago, 808 South Wood Street, CMET 169, Chicago, IL 60612. E-mail address: [email protected] (B. Fernhall). http://dx.doi.org/10.1016/j.pcad.2014.09.003 0033-0620/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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Abbreviations and Acronyms
of research and the exponential increase CNPq = National Council for in the number of manScientific and Technological uscripts has gained DevelopmentCV, Cardiovascular substantial momenFAPESP = Foundation for tum since the year Research Support of the 2000. Given the imporState of São Paulo tance of PA research in regards to health outMCT = Ministry of Science comes, and apparent and Technology popularity of such reMET = Metabolic equivalent search (based on the number of manuscripts NHLBI = Heart, Lung and published), one could Blood Institute argue that the viability NIH = National Institutes of and future of PA are Health indeed bright. However, one could also assume NCDs = Non-communicable Diseases (NCDs) a different view, that although the field is PA = Physical activity popular, it is saturated US = United States and we already know what we need to know WHO = World Health Organization regarding the impact of PA on public health. Much of the future viability of PA research will also be dependent on funding sources available. It is also possible that the impact of PA may vary around the world, thus the “global” impact of PA research may be dependent on location. Consequently, we will discuss what we perceive as the future of PA research in three select areas of the world, the US, South America and Asia.
The US Perspective Much of the initial interest and work in the US on the impact of PA on health parameters can be attributed to Ralph Paffenbarger and the Harvard Alumni study. The 1978 manuscript published in American Journal of Epidemiology5 showed that men who expended less than 2000 kcals per week in PA were at 64% increased risk of myocardial infarctions. The 2000 kcal per week threshold was subsequently shown to decrease risk by 21–49% regardless of age in men aged 35–84 years.6 A multitude of studies has followed, including the recent pooled cohort study by Moore et al.4 cited above. Other important prospective epidemiological studies have shown that cardiovascular (CV) fitness is associated with reductions in risk of all-cause mortality of over 50%.7 Blair et al.8 have also shown that both fitness and PA provide substantial reductions in risk of mortality in both men and women. Thus, it was not surprising that the Surgeon General issued a report in 1996 providing suggested PA guidelines for the nation.9 More recently the US Department of Health and Human Services has issued PA guidelines, stating that adults should participate in at least 150 of moderate intensity PA per week, but additional benefits can be gained by participating in up to 300 min per week.10 Thus, achieving a certain level of PA is part of public health policy in the US, and there is little dispute that PA can provide significant health benefits. Despite the obvious benefits of PA, less than 50% of US adults meet the recommended PA guidelines.11 There is also an age effect, with fewer individuals meeting the recommended PA guidelines with increasing age, despite the fact that older adults exhibit a greater reduction in mortality risk by being active.6
Fig 1 – Number of PubMed indexed publications using physical activity-based search terms. Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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Thus, a large challenge remains; how can we successfully encourage and succeed in increasing PA levels of the US population? Furthermore, in populations with disabilities, the portion of individuals meeting the recommended guidelines is substantially lower.12 In fact, there are no large scale prospective studies investigating health outcomes in persons with disabilities, thus it is not known if PA participation will produce similar health benefits in individuals with disabilities. There are also many unanswered questions regarding the most precise (best) way of measuring PA, the impact of how PA is accumulated (long vs. short bouts, intensity of PA, etc), what types of PA may be more effective, and the economic impact of sedentary vs. physically active lifestyles, to name a few. Consequently, the need for continued research in PA is substantial. However, one of the main challenges to successful research in PA is available funding to conduct large scale outcome studies. The National Institutes of Health (NIH) funds the majority of health related research in PA in the US. Using the Research Portfolio Online Reporting Tool, using the key words “physical activity”, yielded a total of 3206 funded projects and 319 additional subprojects from 2012 to 2013. The total amount of funding for the main projects was reported to be $760,539,552 plus an additional $42, 659,787 for subprojects. The majority of funded projects were housed in the National Heart, Lung and Blood Institute (NHLBI) (441 funded projects plus an additional 30 funded sub-projects), with a total research funding of $208,605,128. This was twice the amount of funding (by dollar amount) than the National Institute of Aging, which funded the second largest amount for PA research. Although this level of funding sounds impressive, the decreasing level of funding support for the NIH in general has decreased the chances of securing a funded proposal over the past several years. The expected pay lines for 2014 are depicted in Table 1. 13 Since 2011, the pay line for standard RO1 applications has decreased from 16 to the 12th percentile and from the 26th to the 21st percentile. 14 Further complicating this decrease in pay line is the fact that NIH does not have a study section dedicated to review PA or exercise related applications.
3
The American Heart Association also funds a substantial number of projects, with a total funding of $135.6 million (all projects, not just PA projects) in 2013.15 However the size of each award is much smaller than NIH as 1314 proposals were funded from the last two funding cycles (summer 2013 and winter 2014). In 2012–13 (the most recent data available) only $2.9 million were dedicated to PA or physical inactivity research. The overall funding line was the 15th percentile over these funding cycles, but the funding varies greatly depending on the type of competition and the affiliate granting the award. Based on available data it is our opinion that there is a reasonable future for innovative PA research in the US. Considering the beneficial health effects of PA, the importance and relevance of PA research are difficult to dispute. Also, there are still many important aspects of PA that are unknown, thus, research to address these questions is needed. The main challenge appears to be availability of funding to conduct large scale trials required to generate new important information.
The South American Perspective Physical inactivity accounts for increasing morbidity and mortality in South America16,17 and there is convincing evidence that physical inactivity is becoming a major health concern for the entire continent. Recent nationwide surveys in Brazil found that a small portion of the population perform sufficient amounts of PA18,19 to realize health benefits. In Colombia, physical inactivity is the most prevalent of all CV risk factors in the adult population.20 Alarming results were also shown in Ecuador where an estimated 75% of children between 7 and 9 years old do not perform sufficient PA.21 For these reasons, behavior change aimed at increasing PA in South America is imperative.22 Both governmental and private sources of funding are available in Brazil. The National Fund of Scientific and Technological Development include two agencies that fund PA research; an innovation agency, Financier of Studies and Projects and The National Council for Scientific and Technological Development
Table 1 – NHLBI paylines in percentile or priority score: Grant Program
Percentile
R01 ESI R21 R15 R41, R42 R43, R44 P01 P01 subproject AIDS K awards T32/T35 F30 F31, F32, F33
12.0 22.0 ⁎ 12.0
Priority Score
20 24 28 15 25 22.0 25 25 15 30.0
Description Research Project Grant Early Stage Investigators Innovative Research Grants Academic Research Enhancement Awards (AREA) Small Business Technology Transfer (STTR) Grants Small Business Innovation Research (SBIR) Grants Program Project Grant Program Project: Subproject AIDS Grants Career Development Awards Institutional NRSA Training Pre-doctoral NRSA Pre and post-doctoral NRSA
⁎ Summary statement issues must be satisfactorily resolved on applications >17 percentile.
Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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(CNPq). In addition, institutional funding is also provided by the Ministry of Science and Technology (MCT). Area 21, which is designed specifically to fund research in physical education and physical therapy, CNPq and MCT expanded the investment from 2 million reals (US 880.000) in 2000 to $20 million reals (1.70 million of dollars) in 2014. However, area 21 is not designed to specifically provide funding for research in PA. Despite this significant growth in overall research support over the years, funding for PA research in Brazil still falls below of most developed countries.23 The Foundation of Institutional Support is a public institution that fosters academic research related to the Department of Higher Education of the Brazilian states. One of the most active health research agencies is the Foundation for Research Support of the State of São Paulo (FAPESP), which currently has funded $308.36 million reals (29.79% of the total disbursed by FAPESP) for health research in 2012.24 However, there are no available data of amount budgeted for PA research. In Brazil, current events, such as hosting the World Cup in 2014 and Olympics games in 2016, has had a positive impact on PA funding. CNPq invested $18 million reals in a 2013 request for proposals dedicated to sports.25 Other major investments have recently originated from the Brazilian Sport Ministry, which has made requests related to the development of activities and projects supporting sport, education, leisure, social inclusion and high performance sport.26 The Science Without Borders program, was created in 2011 to improve research in all health related areas with an estimated funding level of $5 billion reals by 2015.27 The aim of the program is to seek and promote consolidation, expansion and internationalization of science and technology, innovation and competitiveness through Brazilian exchange and international mobility. The project involves awarding up to 101,000 scholarships over four years to promote undergraduate and postgraduate internships abroad as well as attracting researchers from abroad who want to move to Brazil or establish partnerships with Brazilian researchers. A reorientation of models for the treatment of chronic conditions as well as health promotion and primary prevention is needed in most countries in South America.28,29 Although government initiatives and policies have recognized the importance of increasing population PA levels,30 there is an alarming lack of new research projects or high-impact strategies for population-level PA promotion. In Brazil, only a few multi-level, community-wide intervention programs have been directed toward increasing knowledge of the benefits of PA. One of the most prominent movements was Agita Sao Paulo involving a partnership between governmental and private efforts designed to promote participation in moderate-intensity exercise.31 Other movements that achieved regional recognition were the Espaços program in Curitiba32 and Academia da Cidade, in Aracaju, Brazil and the Muévete program in Bogota, Colombia.33 However, there is a lack of evaluation studies addressing the results of these PA promotion programs.34 In developing countries of South America where technology is in a growth phase (Brazil and Chile), rapid communication and dissemination of relevant information about recent scientific evidence to combat physical inactivity, as well as the importance of adopting a healthy lifestyle could prove valuable.35,28 Global models implemented in other countries
Table 2 – Future research areas needed to understand physical activity patterns and to evaluate the intervention programs in South America. To evaluate the behavior of PA related to social, environment, leisure time and work environments in different regions across the lifespan To implement and to analyze the impact of communication and dissemination campaigns related to relevant information regarding recent scientific evidence in PA To study the relationship between PA and the social environment, transportation, infrastructure, worksite wellness and overall lifestyles patterns in different countries of Latin America To promote, disseminate and evaluate the impact of PA programs in schools and the workplace To implement PA program on the community level To implement planning of assessment patterns of PA adherence and self-efficacy
(New Zealand, Norway and US) that incorporate internet and mobile-based technology could be used to evaluate and track population PA levels. In addition, these resources could also be used to promote interventions to help users to increase their PA levels.36 It would of course be important to direct research funding toward evaluating the effectiveness of these initiatives as they are implemented (Table 2). In summary, physical inactivity is prevalent and negatively impacting the health of citizens in South American countries. Funding for PA research and initiatives is growing; however, more structured and planned funding initiatives as well as greater funding levels centered on PA research are needed in South America.
The Asian Perspective The Asian region includes 36 countries from the World Health Organization (WHO) South East Asian and parts of the Western Pacific region (excluding Australia and New Zealand). This region has a high proportion of non-communicable diseases (NCDs), including cardiovascular disease (CVD), metabolic syndrome, hypertension and stroke, partly a consequence of physical inactivity. The incidence and prevalence of these NCDs would be positively impacted by PA interventions. The INTERHEART study identified sedentary behavior ranging between 41.3% and 31.5% for low and middle income countries.37 The pivotal study on the Global Burden of Diseases found that physical inactivity was responsible for 6% of the burden of disease from coronary heart disease, 7% of type 2 diabetes and 10% of breast cancer.38 In addition to this, physical inactivity was also seen to be responsible for 9% of all premature deaths. Lee et al38 also projected that if PA could be improved by 10 or 25%, the estimated deaths that could be prevented would be >533,000 and >1.3 million respectively. This elucidates the importance of promoting PA for health benefits. In 2006, the WHO conducted a workshop in Manila with the goal of implementing the Global strategy on Diet, Physical Activity and Health in Asian countries.39 The workshop report noted there had been significant progress in nutrition and PA interventions in Australia and New Zealand, and among the wealthier Asian countries like Japan, Singapore and the
Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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Republic of Korea. Countries like China, the Philippines and Malaysia, reported some progress with regard to being able to promote public awareness and political influence for focusing on NCD prevention. However, not much information was available from other countries. Since that time, there have been significant improvements in the region with regard to government policy and publications. Lachat et al.40 recently reported that several governments in Asia have developed policies for promoting PA. Eight countries (e.g., Bhutan, Indonesia, Sri Lanka, India, Mongolia, Malaysia, Cambodia and China) have a policy on PA promotion for the general public. Seven countries, Bhutan, Sri Lanka, Mangolia, Vietnam, Philippines, Cambodia and China have a policy targeting PA as policy through their respective governments. However, only three countries (Malaysia, Philippines and China) in the Asian region have established national targets for PA: 1) Malaysia focused on 30 min of PA per day, three days a week; 2) The Philippines set a goal to reduce physical inactivity by 9.7%; and 3) China set a goal to increase the proportion of the population participating in regular exercise to > 32%. A detailed summary of the various targets of PA is provided by Lachat et al.40 A search of the literature on NCDs found that the East Asian and Pacific regions published 23% (n = 121/525) of the articles while the South Asian region published only 9% (n = 47) of the total number of articles published in the region between 2000 and 2011.41 A systematic review on PA interventions in the Asia-Pacific region on obesity related outcomes found 16 trials, of which only seven were conducted from the mainland Asia.42 Despite the lower number of related publications being included in systematic reviews, it is encouraging to see a rising trend in publications indexed in PubMed (up to July 1st, 2014) from Asia in the area of PA (Fig 2) with a total of 3027 publications focusing on PA and its positive effects on various NCDs. In terms of number of publication in the area of PA, Japan has been leading the way (Table 3). Studies have focused on healthy adults, children and various patient populations (i.e., those with CVD, chronic
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Table 3 – Countries leading in PA research from Asia as identified from publications indexed on PubMed and government funding agencies in these countries. Country
Funding agencies available
Japan
Japan Society for the Promotion of Science; Ministry of Education, Culture, Sports, Science & Technology National Institute of Medical Science Ministry of Science and Technology National Science Council Ministry of Health; Ministry of Education Indian Council of Medical Research; Department of Science and Technology; Department of Biotechnology Hong Kong Research Grants Council; The Food and Health Bureau Ministry of Science, Technology and Innovation Sultan Bin Abdulaziz Al-Saud Foundation
China Korea Taiwan Iran India
Hong Kong Malaysia Saudi Arabia
obstructive pulmonary disease/asthma, cancer, obesity, metabolic syndrome and the elderly). Most of the studies have been observations through cross-sectional, cohort or case-control designs, validation studies and a few intervention trials. Observational studies have used common survey tools like the International Physical Activity Questionnaire to estimate PA while there have been studies that have also worked on obtaining objective data on PA. Pedometer driven interventions to improve PA have also been utilized in certain settings. However, recently, it has been seen that energy expenditure in the South Indian population for common activities like stair climbing vary from what has been reported in the compendium of PA.43,44 Thus, making it necessary to establish energy expenditure for the Asian region. Research in PA from this region has been growing as mentioned earlier. An interesting study from Sri Lanka found that 87.1% of 272 South Asian urban women who were maintaining PA levels of >1000 metabolic equivalent (MET)-min/week were newly diagnosed dysglycemics.45 In addition to this study, the
Number of publications 350 300 250 200 150 100 50 0
Fig 2 – Trend of publications in physical activity from Asia: 1966–2014. ⁎Publications up to July 1st, 2014. Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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recent review by Macniven et al.46 suggest the potential difference in terms of outcome measurement and methods of analysis for PA data, thereby creating a need for more standardized research in this region. Thus, there is a need to promote PA research in order to determine the feasibility and physiological benefits for chronic disease prevention through cost effective means in this region. A number of research projects have been funded by their respective national scientific bodies (Table 3) in the region and from international agencies including the National Institute of Health, Nestle Foundation, WHO, Wellcome Trust, British Heart Foundation and Cancer Research UK. These agencies funded clinical research and capacity building in the lower-middle income countries of the Asian region. Thus there seems to be growing support to fund research in PA in this area. Recently, Macniven et al46 showed that most countries in the Asia-Pacific region do collect population level PA data. However, there are numerous factors (i.e., outcome measures and measurement methods) that account to the variability observed in PA levels. Lack of identical sampling and analytical methods along with the use of self-reported outcome measures across the various studies in the region further contribute to the variations in prevalence of physical inactivity. Variations among Asian countries as a result of numerous factors, such as cultural differences (e.g., understandability of questions), are responsible for the variations seen in population surveillance of PA.47 Therefore, it is difficult to perform multi-center studies in this region. For instance, a recent survey from South India discovered that, out of 378 participants, no one reported any perceived health benefits of PA for CVD and stroke while 75.1% did not perceive any health benefits of PA for any NCD. This emphasizes the need for creating awareness among the public on the health benefits of PA. This should also be a major focus for researchers and funding agencies; trials that focus on the efficacy of promoting the potential benefits of PA. Most funding agencies in the Asian region do not have a focused thrust area for PA research. Nevertheless, there is a focus on NCD, especially diabetes, CVD and obesity related research. There is also a need to promote lab- and field-based energy expenditure studies on PA from this region to assess differences in body habitus across the region.48 Unfortunately, these kinds of studies may not currently be attractive to funding agencies, thus resulting in a majority of research continuing to be unfunded (anecdotal evidence). For long term success, it is essential that researchers and PA professionals advocate for the importance of national policies on PA coupled with the importance of increased funding for PA research.
Conclusions The benefits of PA from a global health perspective cannot be disputed. However, much more research is needed to determine the unique benefits of PA as well as optimal PA intervention models, from the individual to societal level. We have highlighted the current funding environment for PA in three areas of the world, the US, South America and Asia. While there are certainly positive trends, we feel that considerably more support is needed to fund PA research on a global level.
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20. Patiño-Villada FA, Arango-Vélez EF, Quintero-Velásquez MA, Arenas-Sosa MM. Cardiovascular risk factors in an urban Colombia population. Rev Salud Publica (Bogota). 2011;13(3):433-445. 21. Abril V, Manuel-y-keenoy B, Solà R, et al. Prevalence of overweight and obesity among 6-to 9-year-old school children in Cuenca, Ecuador: relationship with physical activity, poverty, and eating habits. Food Nutr Bull. 2013;34(4):388-401. 22. Finck Barboza C, Monteiro SM, Barradas SC, et al. Physical activity, nutrition and behavior change in Latin America: a systematic review. Glob Health Promot. 2013;20(4 Suppl):65-81. 23. Investimentos do CNPq e CT&C http://fomentonacional.cnpq.br/ dmfomento/home/fmtvisualizador.jsp?UA=401&UC=3&Facil=S& Visualizar=S&Corte1=002&Corte2=016. 24. Agência FAPESP http://agencia.fapesp.br/18063. 25. CNPQ http://www.cnpq.br/web/guest/chamadas-publicas? p_p_id=resultadosportlet_WAR_resultadoscnpqportlet_ INSTANCE_0ZaM&filtro=encerradas&startPage=2&busca Chamada=&ano=. 26. Ministério do Esporte http://www.esporte.gov.br/index.php/ institucional/alto-rendimento/chamada-publica. 27. Ciências sem fronteiras http://www.cienciasemfronteiras. gov.br/web/csf/o-programa. 28. A.P.Belon AP, C.Nykiforuk C. Possibilities and challenges for physical and social environment research in Brazil: a systematic literature review on health behaviors. Cad Saude Publica. 2013;29(10):1955-1973. 29. Borghi-Silva A, Mendes RG, Trimer R, Cipriano Jr G. Current trends in reducing cardiovascular disease risk factors from around the world: focus on cardiac rehabilitation in Brazil. Prog Cardiovasc Dis. 2014;56(5):536-542. Cipriano Jr G, Neves LM, Cipriano GF, Chiappa GR, Borghi-Silva A. Cardiovascular disease prevention and implications for worksite health promotion programs in Brazil. Prog Cardiovasc Dis. 2014;56(5):493-500. 30. Matsudo VK, Matsudo SM, Araújo TL, Andrade DR, Oliveira LC, Hallal PC. Time Trends in Physical Activity in the State of Sao Paulo, Brazil: 2002–2008. Med Sci Sports Exerc. 2010;42(12):2231-2236. 31. Siqueira Reis R, Hino AA, Ricardo Rech C, Kerr J, Curi Hallal P. Walkability and physical activity: findings from Curitiba. Brazil Am J Prev Med. 2013;45(3):269-275, http://dx.doi.org/10.1016/j.amepre.2013.04.020. 32. Mendonça BC, Oliveira AC, Toscano JJ O, et al. Exposure to a community-wide physical activity promotion program and leisure-time physical activity in Aracaju. Brazil J Phys Act Health. 2010;7(Suppl 2):S223-S228. 33. Gámez R, Parra D, Pratt M, Schmid TL. Muévete Bogotá: promoting physical activity with a network of partner companies. Promot Educ. 2006;13(2):138-143. [164-9]. 34. Brazil. Decret no. 719 (GM/MS). Instituted the Academy of Health under the National Health System. April 7, 2011. 35. Blanchard C, Shilton T, Bull F. Global Advocacy for Physical Activity (GAPA): global leadership towards a raised profile. Glob Health Promot. 2013;20(4 Suppl):113-121.
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36. Antypas K, Wangberg SC. An internet- and mobile-based tailored intervention to enhance maintenance of physical activity after cardiac rehabilitation: short-term results of a randomized controlled trial. J Med Internet Res. 2014;16(3): e77.38. 37. Held C, Iqbal R, Lear SA, et al. Physical activity levels, ownership of goods promoting sedentary behaviour and risk of myocardial infarction: results of the INTERHEART study. Eur Heart J. 2012;33(4):452-466. 38. Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219-229. 39. World Health Organization. Workshop on the implementing the Global strategy on Diet, Physical Activity and Health in Asian countries. WHO Western Pacific Region. 2006. 40. Lachat C, Otchere S, Roberfroid D, et al. Diet and physical ativity for the prevention of non communicable diseases in low- and middle-income countries: a systematic policy review. PLoS Med. 2013;10(6):e1001465. 41. Jones AC, Geneau R. Assessing research activity on priority interventions for non-communicable disease prevention in low- and middle-income countries: a bibliometric analysis. Glob Health Action. 2012;5:1-13. 42. Khoo S, Morris T. Physical activity and obesity research in the Asia-Pacific: a review. Asia Pac J Public Health. 2012;24(3): 435-449. 43. Veluswamy SK, Maiya AG, Babu AS, Nair S, Guddattu V. PW228 should physical activity questionnaires include information on stair climbing?—a mixed methods pilot study. Glob Heart. 2014;9(1)(Suppl 1):e303-e304. 44. Ainsworth BE, Haskell WL, Herrmann SD, et al. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;43(8): 1575-1581. 45. Waidyatilaka I, Lanerolle P, Wickremasinghe R, Atukorala S, Somasundaram N, deSilva A. Sedentary behaviour and physical activity in South Asian women: time to review current recommendations? PLoS One. 2013;8(3):e58328. 46. Macniven R, Bauman A, Abouzeid M. A review of population-based prevalence studies of physical activity in adults in the Asia-Pacific region. BMC Public Health. 2012;12:41, http://dx.doi.org/10.1186/1471-2458-12-41. 47. Veluswamy SK, Maiya AG, Nair S, Guddattu V, Nair NS, Vidyasagar S. Awareness of chronic disease related health benefits of physical activity among residents of a rural South Indian region: a cross-sectional study. Int J Behav Nutr Phys Act. 2014;11(1):27, http: //dx.doi.org/10.1186/1479-5868-11-27. 48. Guthold R, Ono T, Strong KL, Chatterji S, Morabia A. Worldwide variability in physical inactivity: a 51 country survey. Am J Prev Med. 2008;34(6):486-494.
Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
Available online at www.sciencedirect.com
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The Future of Physical Activity Research: Funding, Opportunities and Challenges Bo Fernhalla,⁎, Audrey Borghi-Silvab , Abraham S. Babuc a
College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA Cardiopulmonary Physiotherapy Laboratory – LACAP, Federal University of Sao Carlos, Sao Carlos (UFSCar), SP, Brazil c Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal – 576104, Karnataka, India b
A R T I C LE I N F O
AB ST R A C T The worldwide impact of physical activity (PA) on health consequences has received increasing attention. At this point in time, there is little disagreement that increasing levels of PA is an important aspect of public health worldwide. The world literature on PA, exercise and fitness has also grown exponentially since the early 1990’s. It is clear that there is a voluminous literature in this area of research and the exponential increase in the number of manuscripts has gained substantial momentum since the year 2000. Given the importance of PA research in regards to health outcomes, and apparent popularity of such research (based on the number of manuscripts published), one could argue that the viability and future of PA are indeed bright. However, one could also assume a different view, that although the field is popular, it is saturated and we already know what we need to know regarding the impact of PA on public health. Much of the future viability of PA research will also be dependent on funding sources available. It is also possible that the impact of PA may vary around the world, thus the “global” impact of PA research may be dependent on location. This review will discuss what we perceive as the current landscape and the future of PA research in three select areas of the world, the United States, South America and Asia. © 2014 Elsevier Inc. All rights reserved.
The worldwide impact of physical activity (PA) on health consequences has received increasing attention since the early studies of Morris et al.1,2 showing that London bus conductors had lower rates of myocardial infarction compared to the bus drivers, presumable because of the greater PA activity of the conductors. A recent prospective study of 416,175 individuals in Taiwan showed that an average of 92 min per week of PA was associated with a 3 year longer life expectancy compared to the inactive group.3 Furthermore, every additional 15 min increase in PA reduced all-cause mortality by 4%. Similarly, a large pooled cohort study in the United States (US)
showed up to a 4.5 year gain in life expectancy with PA levels equaling 450 min of brisk walking per week.4 Although these are only examples of large cohort studies showing the beneficial health effects of PA, there is little disagreement that increasing levels of PA is an important aspect of public health worldwide. The world literature on PA, exercise and fitness has also grown exponentially since the early 1990’s. A PubMed search of the terms “physical activity”, “exercise”, “fitness”, and “physical activity or exercise” since 1960 is depicted in Fig 1. It is clear that there is voluminous literature in this area
Statement of Conflict of Interest: None. ⁎ Address reprint requests to Bo Fernhall, Ph.D, Dean and Professor, College of Applied Health Sciences, MC 518, University of Illinois at Chicago, 808 South Wood Street, CMET 169, Chicago, IL 60612. E-mail address: [email protected] (B. Fernhall). http://dx.doi.org/10.1016/j.pcad.2014.09.003 0033-0620/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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Abbreviations and Acronyms
of research and the exponential increase CNPq = National Council for in the number of manScientific and Technological uscripts has gained DevelopmentCV, Cardiovascular substantial momenFAPESP = Foundation for tum since the year Research Support of the 2000. Given the imporState of São Paulo tance of PA research in regards to health outMCT = Ministry of Science comes, and apparent and Technology popularity of such reMET = Metabolic equivalent search (based on the number of manuscripts NHLBI = Heart, Lung and published), one could Blood Institute argue that the viability NIH = National Institutes of and future of PA are Health indeed bright. However, one could also assume NCDs = Non-communicable Diseases (NCDs) a different view, that although the field is PA = Physical activity popular, it is saturated US = United States and we already know what we need to know WHO = World Health Organization regarding the impact of PA on public health. Much of the future viability of PA research will also be dependent on funding sources available. It is also possible that the impact of PA may vary around the world, thus the “global” impact of PA research may be dependent on location. Consequently, we will discuss what we perceive as the future of PA research in three select areas of the world, the US, South America and Asia.
The US Perspective Much of the initial interest and work in the US on the impact of PA on health parameters can be attributed to Ralph Paffenbarger and the Harvard Alumni study. The 1978 manuscript published in American Journal of Epidemiology5 showed that men who expended less than 2000 kcals per week in PA were at 64% increased risk of myocardial infarctions. The 2000 kcal per week threshold was subsequently shown to decrease risk by 21–49% regardless of age in men aged 35–84 years.6 A multitude of studies has followed, including the recent pooled cohort study by Moore et al.4 cited above. Other important prospective epidemiological studies have shown that cardiovascular (CV) fitness is associated with reductions in risk of all-cause mortality of over 50%.7 Blair et al.8 have also shown that both fitness and PA provide substantial reductions in risk of mortality in both men and women. Thus, it was not surprising that the Surgeon General issued a report in 1996 providing suggested PA guidelines for the nation.9 More recently the US Department of Health and Human Services has issued PA guidelines, stating that adults should participate in at least 150 of moderate intensity PA per week, but additional benefits can be gained by participating in up to 300 min per week.10 Thus, achieving a certain level of PA is part of public health policy in the US, and there is little dispute that PA can provide significant health benefits. Despite the obvious benefits of PA, less than 50% of US adults meet the recommended PA guidelines.11 There is also an age effect, with fewer individuals meeting the recommended PA guidelines with increasing age, despite the fact that older adults exhibit a greater reduction in mortality risk by being active.6
Fig 1 – Number of PubMed indexed publications using physical activity-based search terms. Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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Thus, a large challenge remains; how can we successfully encourage and succeed in increasing PA levels of the US population? Furthermore, in populations with disabilities, the portion of individuals meeting the recommended guidelines is substantially lower.12 In fact, there are no large scale prospective studies investigating health outcomes in persons with disabilities, thus it is not known if PA participation will produce similar health benefits in individuals with disabilities. There are also many unanswered questions regarding the most precise (best) way of measuring PA, the impact of how PA is accumulated (long vs. short bouts, intensity of PA, etc), what types of PA may be more effective, and the economic impact of sedentary vs. physically active lifestyles, to name a few. Consequently, the need for continued research in PA is substantial. However, one of the main challenges to successful research in PA is available funding to conduct large scale outcome studies. The National Institutes of Health (NIH) funds the majority of health related research in PA in the US. Using the Research Portfolio Online Reporting Tool, using the key words “physical activity”, yielded a total of 3206 funded projects and 319 additional subprojects from 2012 to 2013. The total amount of funding for the main projects was reported to be $760,539,552 plus an additional $42, 659,787 for subprojects. The majority of funded projects were housed in the National Heart, Lung and Blood Institute (NHLBI) (441 funded projects plus an additional 30 funded sub-projects), with a total research funding of $208,605,128. This was twice the amount of funding (by dollar amount) than the National Institute of Aging, which funded the second largest amount for PA research. Although this level of funding sounds impressive, the decreasing level of funding support for the NIH in general has decreased the chances of securing a funded proposal over the past several years. The expected pay lines for 2014 are depicted in Table 1. 13 Since 2011, the pay line for standard RO1 applications has decreased from 16 to the 12th percentile and from the 26th to the 21st percentile. 14 Further complicating this decrease in pay line is the fact that NIH does not have a study section dedicated to review PA or exercise related applications.
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The American Heart Association also funds a substantial number of projects, with a total funding of $135.6 million (all projects, not just PA projects) in 2013.15 However the size of each award is much smaller than NIH as 1314 proposals were funded from the last two funding cycles (summer 2013 and winter 2014). In 2012–13 (the most recent data available) only $2.9 million were dedicated to PA or physical inactivity research. The overall funding line was the 15th percentile over these funding cycles, but the funding varies greatly depending on the type of competition and the affiliate granting the award. Based on available data it is our opinion that there is a reasonable future for innovative PA research in the US. Considering the beneficial health effects of PA, the importance and relevance of PA research are difficult to dispute. Also, there are still many important aspects of PA that are unknown, thus, research to address these questions is needed. The main challenge appears to be availability of funding to conduct large scale trials required to generate new important information.
The South American Perspective Physical inactivity accounts for increasing morbidity and mortality in South America16,17 and there is convincing evidence that physical inactivity is becoming a major health concern for the entire continent. Recent nationwide surveys in Brazil found that a small portion of the population perform sufficient amounts of PA18,19 to realize health benefits. In Colombia, physical inactivity is the most prevalent of all CV risk factors in the adult population.20 Alarming results were also shown in Ecuador where an estimated 75% of children between 7 and 9 years old do not perform sufficient PA.21 For these reasons, behavior change aimed at increasing PA in South America is imperative.22 Both governmental and private sources of funding are available in Brazil. The National Fund of Scientific and Technological Development include two agencies that fund PA research; an innovation agency, Financier of Studies and Projects and The National Council for Scientific and Technological Development
Table 1 – NHLBI paylines in percentile or priority score: Grant Program
Percentile
R01 ESI R21 R15 R41, R42 R43, R44 P01 P01 subproject AIDS K awards T32/T35 F30 F31, F32, F33
12.0 22.0 ⁎ 12.0
Priority Score
20 24 28 15 25 22.0 25 25 15 30.0
Description Research Project Grant Early Stage Investigators Innovative Research Grants Academic Research Enhancement Awards (AREA) Small Business Technology Transfer (STTR) Grants Small Business Innovation Research (SBIR) Grants Program Project Grant Program Project: Subproject AIDS Grants Career Development Awards Institutional NRSA Training Pre-doctoral NRSA Pre and post-doctoral NRSA
⁎ Summary statement issues must be satisfactorily resolved on applications >17 percentile.
Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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(CNPq). In addition, institutional funding is also provided by the Ministry of Science and Technology (MCT). Area 21, which is designed specifically to fund research in physical education and physical therapy, CNPq and MCT expanded the investment from 2 million reals (US 880.000) in 2000 to $20 million reals (1.70 million of dollars) in 2014. However, area 21 is not designed to specifically provide funding for research in PA. Despite this significant growth in overall research support over the years, funding for PA research in Brazil still falls below of most developed countries.23 The Foundation of Institutional Support is a public institution that fosters academic research related to the Department of Higher Education of the Brazilian states. One of the most active health research agencies is the Foundation for Research Support of the State of São Paulo (FAPESP), which currently has funded $308.36 million reals (29.79% of the total disbursed by FAPESP) for health research in 2012.24 However, there are no available data of amount budgeted for PA research. In Brazil, current events, such as hosting the World Cup in 2014 and Olympics games in 2016, has had a positive impact on PA funding. CNPq invested $18 million reals in a 2013 request for proposals dedicated to sports.25 Other major investments have recently originated from the Brazilian Sport Ministry, which has made requests related to the development of activities and projects supporting sport, education, leisure, social inclusion and high performance sport.26 The Science Without Borders program, was created in 2011 to improve research in all health related areas with an estimated funding level of $5 billion reals by 2015.27 The aim of the program is to seek and promote consolidation, expansion and internationalization of science and technology, innovation and competitiveness through Brazilian exchange and international mobility. The project involves awarding up to 101,000 scholarships over four years to promote undergraduate and postgraduate internships abroad as well as attracting researchers from abroad who want to move to Brazil or establish partnerships with Brazilian researchers. A reorientation of models for the treatment of chronic conditions as well as health promotion and primary prevention is needed in most countries in South America.28,29 Although government initiatives and policies have recognized the importance of increasing population PA levels,30 there is an alarming lack of new research projects or high-impact strategies for population-level PA promotion. In Brazil, only a few multi-level, community-wide intervention programs have been directed toward increasing knowledge of the benefits of PA. One of the most prominent movements was Agita Sao Paulo involving a partnership between governmental and private efforts designed to promote participation in moderate-intensity exercise.31 Other movements that achieved regional recognition were the Espaços program in Curitiba32 and Academia da Cidade, in Aracaju, Brazil and the Muévete program in Bogota, Colombia.33 However, there is a lack of evaluation studies addressing the results of these PA promotion programs.34 In developing countries of South America where technology is in a growth phase (Brazil and Chile), rapid communication and dissemination of relevant information about recent scientific evidence to combat physical inactivity, as well as the importance of adopting a healthy lifestyle could prove valuable.35,28 Global models implemented in other countries
Table 2 – Future research areas needed to understand physical activity patterns and to evaluate the intervention programs in South America. To evaluate the behavior of PA related to social, environment, leisure time and work environments in different regions across the lifespan To implement and to analyze the impact of communication and dissemination campaigns related to relevant information regarding recent scientific evidence in PA To study the relationship between PA and the social environment, transportation, infrastructure, worksite wellness and overall lifestyles patterns in different countries of Latin America To promote, disseminate and evaluate the impact of PA programs in schools and the workplace To implement PA program on the community level To implement planning of assessment patterns of PA adherence and self-efficacy
(New Zealand, Norway and US) that incorporate internet and mobile-based technology could be used to evaluate and track population PA levels. In addition, these resources could also be used to promote interventions to help users to increase their PA levels.36 It would of course be important to direct research funding toward evaluating the effectiveness of these initiatives as they are implemented (Table 2). In summary, physical inactivity is prevalent and negatively impacting the health of citizens in South American countries. Funding for PA research and initiatives is growing; however, more structured and planned funding initiatives as well as greater funding levels centered on PA research are needed in South America.
The Asian Perspective The Asian region includes 36 countries from the World Health Organization (WHO) South East Asian and parts of the Western Pacific region (excluding Australia and New Zealand). This region has a high proportion of non-communicable diseases (NCDs), including cardiovascular disease (CVD), metabolic syndrome, hypertension and stroke, partly a consequence of physical inactivity. The incidence and prevalence of these NCDs would be positively impacted by PA interventions. The INTERHEART study identified sedentary behavior ranging between 41.3% and 31.5% for low and middle income countries.37 The pivotal study on the Global Burden of Diseases found that physical inactivity was responsible for 6% of the burden of disease from coronary heart disease, 7% of type 2 diabetes and 10% of breast cancer.38 In addition to this, physical inactivity was also seen to be responsible for 9% of all premature deaths. Lee et al38 also projected that if PA could be improved by 10 or 25%, the estimated deaths that could be prevented would be >533,000 and >1.3 million respectively. This elucidates the importance of promoting PA for health benefits. In 2006, the WHO conducted a workshop in Manila with the goal of implementing the Global strategy on Diet, Physical Activity and Health in Asian countries.39 The workshop report noted there had been significant progress in nutrition and PA interventions in Australia and New Zealand, and among the wealthier Asian countries like Japan, Singapore and the
Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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Republic of Korea. Countries like China, the Philippines and Malaysia, reported some progress with regard to being able to promote public awareness and political influence for focusing on NCD prevention. However, not much information was available from other countries. Since that time, there have been significant improvements in the region with regard to government policy and publications. Lachat et al.40 recently reported that several governments in Asia have developed policies for promoting PA. Eight countries (e.g., Bhutan, Indonesia, Sri Lanka, India, Mongolia, Malaysia, Cambodia and China) have a policy on PA promotion for the general public. Seven countries, Bhutan, Sri Lanka, Mangolia, Vietnam, Philippines, Cambodia and China have a policy targeting PA as policy through their respective governments. However, only three countries (Malaysia, Philippines and China) in the Asian region have established national targets for PA: 1) Malaysia focused on 30 min of PA per day, three days a week; 2) The Philippines set a goal to reduce physical inactivity by 9.7%; and 3) China set a goal to increase the proportion of the population participating in regular exercise to > 32%. A detailed summary of the various targets of PA is provided by Lachat et al.40 A search of the literature on NCDs found that the East Asian and Pacific regions published 23% (n = 121/525) of the articles while the South Asian region published only 9% (n = 47) of the total number of articles published in the region between 2000 and 2011.41 A systematic review on PA interventions in the Asia-Pacific region on obesity related outcomes found 16 trials, of which only seven were conducted from the mainland Asia.42 Despite the lower number of related publications being included in systematic reviews, it is encouraging to see a rising trend in publications indexed in PubMed (up to July 1st, 2014) from Asia in the area of PA (Fig 2) with a total of 3027 publications focusing on PA and its positive effects on various NCDs. In terms of number of publication in the area of PA, Japan has been leading the way (Table 3). Studies have focused on healthy adults, children and various patient populations (i.e., those with CVD, chronic
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Table 3 – Countries leading in PA research from Asia as identified from publications indexed on PubMed and government funding agencies in these countries. Country
Funding agencies available
Japan
Japan Society for the Promotion of Science; Ministry of Education, Culture, Sports, Science & Technology National Institute of Medical Science Ministry of Science and Technology National Science Council Ministry of Health; Ministry of Education Indian Council of Medical Research; Department of Science and Technology; Department of Biotechnology Hong Kong Research Grants Council; The Food and Health Bureau Ministry of Science, Technology and Innovation Sultan Bin Abdulaziz Al-Saud Foundation
China Korea Taiwan Iran India
Hong Kong Malaysia Saudi Arabia
obstructive pulmonary disease/asthma, cancer, obesity, metabolic syndrome and the elderly). Most of the studies have been observations through cross-sectional, cohort or case-control designs, validation studies and a few intervention trials. Observational studies have used common survey tools like the International Physical Activity Questionnaire to estimate PA while there have been studies that have also worked on obtaining objective data on PA. Pedometer driven interventions to improve PA have also been utilized in certain settings. However, recently, it has been seen that energy expenditure in the South Indian population for common activities like stair climbing vary from what has been reported in the compendium of PA.43,44 Thus, making it necessary to establish energy expenditure for the Asian region. Research in PA from this region has been growing as mentioned earlier. An interesting study from Sri Lanka found that 87.1% of 272 South Asian urban women who were maintaining PA levels of >1000 metabolic equivalent (MET)-min/week were newly diagnosed dysglycemics.45 In addition to this study, the
Number of publications 350 300 250 200 150 100 50 0
Fig 2 – Trend of publications in physical activity from Asia: 1966–2014. ⁎Publications up to July 1st, 2014. Please cite this article as: Fernhall B, et al. The Future of Physical Activity Research: Funding, Opportunities and Challenges. Prog Cardiovasc Dis (2014), http://dx.doi.org/10.1016/j.pcad.2014.09.003
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recent review by Macniven et al.46 suggest the potential difference in terms of outcome measurement and methods of analysis for PA data, thereby creating a need for more standardized research in this region. Thus, there is a need to promote PA research in order to determine the feasibility and physiological benefits for chronic disease prevention through cost effective means in this region. A number of research projects have been funded by their respective national scientific bodies (Table 3) in the region and from international agencies including the National Institute of Health, Nestle Foundation, WHO, Wellcome Trust, British Heart Foundation and Cancer Research UK. These agencies funded clinical research and capacity building in the lower-middle income countries of the Asian region. Thus there seems to be growing support to fund research in PA in this area. Recently, Macniven et al46 showed that most countries in the Asia-Pacific region do collect population level PA data. However, there are numerous factors (i.e., outcome measures and measurement methods) that account to the variability observed in PA levels. Lack of identical sampling and analytical methods along with the use of self-reported outcome measures across the various studies in the region further contribute to the variations in prevalence of physical inactivity. Variations among Asian countries as a result of numerous factors, such as cultural differences (e.g., understandability of questions), are responsible for the variations seen in population surveillance of PA.47 Therefore, it is difficult to perform multi-center studies in this region. For instance, a recent survey from South India discovered that, out of 378 participants, no one reported any perceived health benefits of PA for CVD and stroke while 75.1% did not perceive any health benefits of PA for any NCD. This emphasizes the need for creating awareness among the public on the health benefits of PA. This should also be a major focus for researchers and funding agencies; trials that focus on the efficacy of promoting the potential benefits of PA. Most funding agencies in the Asian region do not have a focused thrust area for PA research. Nevertheless, there is a focus on NCD, especially diabetes, CVD and obesity related research. There is also a need to promote lab- and field-based energy expenditure studies on PA from this region to assess differences in body habitus across the region.48 Unfortunately, these kinds of studies may not currently be attractive to funding agencies, thus resulting in a majority of research continuing to be unfunded (anecdotal evidence). For long term success, it is essential that researchers and PA professionals advocate for the importance of national policies on PA coupled with the importance of increased funding for PA research.
Conclusions The benefits of PA from a global health perspective cannot be disputed. However, much more research is needed to determine the unique benefits of PA as well as optimal PA intervention models, from the individual to societal level. We have highlighted the current funding environment for PA in three areas of the world, the US, South America and Asia. While there are certainly positive trends, we feel that considerably more support is needed to fund PA research on a global level.
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