Volume 34, Issue 6 , Pages 486-494, June 2008
Worldwide Variability in Physical Inactivity:
A 51-Country Survey
Article Outline
Background
Physical inactivity is an important risk factor for chronic diseases, but for many (mainly developing) countries, no prevalence data have ever been published.
Objective
To present data on the prevalence of physical inactivity for 51 countries and for different age groups and settings across these countries.
Methods
Data analysis (conducted in 2007) included data from 212,021 adult participants whose questionnaires were culled from 259,526 adult observations from 51 countries participating in the World Health Survey (2002–2003). The validated International Physical Activity Questionnaire (IPAQ) was used to assess days and duration of vigorous, moderate, and walking activities during the last 7 days.
Results
Country prevalence of physical inactivity ranged from 1.6% (Comoros) to 51.7% (Mauritania) for men and from 3.8% (Comoros) to 71.2% (Mauritania) for women. Physical inactivity was generally high for older age groups and lower in rural as compared to urban areas.
Conclusions
Overall, about 15% of men and 20% of women from the 51 countries analyzed here (most of which are developing countries) are at risk for chronic diseases due to physical inactivity. There were substantial variations across countries and settings. The baseline information on the magnitude of the problem of physical inactivity provided by this study can help countries and health policymakers to set up interventions addressing the global chronic disease epidemic.
Introduction
Physical inactivity increases the risk of obesity, coronary heart disease and stroke, and type 2 diabetes, as well as colon and breast cancer, and is therefore recognized as one of the most important modifiable risk factors that is causing the rising global burden of chronic diseases.1, 2, 3, 4 Knowledge of the amount of physical activity performed in different populations worldwide is, however, limited.
See related Commentary by Bauman in this issue.
Many developing countries lack any data on physical activity levels in their populations.1, 5 Where surveys have been performed, data are difficult, if not impossible, to compare.6, 7 Only a few (mainly European) studies have used the same instrument to assess the prevalence of inactivity or the energy expenditure in a wide range of countries.8, 9, 10, 11
To prevent death and disability from chronic disease caused by physical inactivity, these gaps in knowledge need to be filled and the populations and subgroups at risk need to be identified. Country-level baseline information on the prevalence of physical inactivity is needed for governments to be able to formulate policies and programs aiming at the reduction of physical inactivity.4, 12
This study used data from the World Health Survey to estimate the prevalence of physical inactivity for the populations of 51 countries as well as for different subgroups across the countries. The term physical inactivity was chosen because it closely reflects what has been measured, that is, whether or not a person engages in physical activity. In contrast, sedentary behaviors such as number of hours spent sitting have not been assessed.
Methods
Study Population and Design
The World Health Survey, a large cross-sectional study, was launched by the WHO in 2001 and conducted in 70 countries in 2002–2003.13 The included countries were selected because they had a large proportion of the world's population; a wide geographic representation across WHO regions; and a spread among high-, middle-, and low-income countries. Countries could choose from a range of questionnaire modules, one of which contained the questions on physical activity from the International Physical Activity Questionnaire (IPAQ). Fifty-one mainly low- and middle-income countries included this module and submitted the questionnaire to 259,526 people. Participants were interviewed face-to-face by lay people with at least a high school-level education; interviewers were trained in a week-long course using a standard manual and audiovisual aids as well as role-plays. Practice field interviews were reviewed by supervisors before actual data collection. Random national samples, using a multistage cluster design, were drawn in all countries but China, Comoros, the Republic of the Congo, Côte d'Ivoire, India, and the Russian Federation. All respondents were selected using a Kish table for selection within a household.13, 14, 15 More detailed information about the World Health Survey is available on its website.13
Questionnaire
Questionnaires were translated through use of a WHO translation protocol involving a bilingual group with both translation and back-translation of the instrument. The translations were then independently reviewed by bilingual experts.14 Physical activity was assessed using the short form of the IPAQ, in which respondents are asked to report the number of days and the duration of the vigorous, moderate, and walking activities they undertook during the last week.16 Show-cards illustrating different types of vigorous and moderate activities were presented to the respondents in addition to brief explanations of what was meant by vigorous and moderate activity.
Data Processing
Of the 259,526 observations from 51 countries, 212,021 participants with complete and consistent information were included in the analysis conducted in 2007 (overall response percentage=81.7%). Data were cleaned according to recommendations for cleaning IPAQ data.16 The truncation-of-data rule (re-coding time variables exceeding 3 hours back to 3 hours) was not applied. Of the 47,505 excluded records, 42,727 were missing information on gender, age, setting, or physical activity; 3090 contained implausible values such as more than 7 days of activity per week; 1381 records were dropped due to inconsistencies in reporting (e.g., 0 days of activity per week, but not 0 for the corresponding time variables). Sixty-nine observations were excluded because of inconsistent information in the two variables capturing age, age in years, and age group, and 238 records had more than one of the above-mentioned problems. As the IPAQ is valid only for adults up to age 69, the age range for analysis was restricted to 18–69 years.16
Country prevalence estimates were obtained using the sampling weight of each individual, which was based on selection probability, nonresponse, and post-stratification. Data were analyzed using Stata SE version 9.2. The survey data commands of this package take the sampling weights into account. For pooled analyses including all countries, no weights were applied.
Definition of Physical Inactivity
According to existing guidelines, a person who did not meet any of the following three criteria was considered inactive16:
One MET is defined as the energy spent sitting quietly (equivalent to [4.184 kJ]
·kg−1·h−1).17 Taking the different intensities of the activity components into account, reported weekly minutes spent were multiplied by 8 METs for vigorous activities, by 4 METs for moderate activities, and by 3.3 METs for walking. Energy expenditure per individual was obtained by adding the MET-minutes of the three activity components.16
Results
Response Rates and Demographics
The overall response percentage was 81.7%. Country response percentages (Table 1) ranged from 31.0% (Mali) to 98.6% (Uruguay). The percentage of males in the sample was lowest for Guatemala and the Russian Federation (37.2%) and highest for the United Arab Emirates (72.1%). Mean age ranged from 32.4 years (Kenya) to 45.5 years (Croatia). The percentage of people living in urban areas was lowest for India (10.6%) and highest for the Republic of the Congo (94.3%). This information on setting was not collected for Slovenia. Except for the six countries with non-nationally representative samples, these percentages were close to the population estimates for 2003.18
Table 1. Sample size and demographics, by country and in total, World Health Survey, 2002–2003
| Country | Initial sample size | Final sample size (% of initial sample size) | % males in final sample | Mean age of final sample | % urban in final sample |
|---|---|---|---|---|---|
| Bangladesh | 6,249 | 5,166(82.7) | 51.8 | 34.9 | 24.6 |
| Bosnia-Herzegovina | 977 | 896(91.7) | 49.6 | 41.1 | 44.6 |
| Brazil | 4,636 | 4,458(96.2) | 48.8 | 37.1 | 83.2 |
| Burkina Faso | 4,834 | 4,341(89.8) | 47.5 | 33.1 | 17.7 |
| Chad | 4,776 | 3,604(75.5) | 48.8 | 34.5 | 23.0 |
| China | 3,664 | 3,596(98.1) | 48.8 | 42.2 | 28.8 |
| Comoros | 1,674 | 1,492(89.1) | 49.5 | 37.1 | 32.1 |
| Congo | 3,080 | 1,335(43.3) | 44.6 | 33.9 | 94.3 |
| Côte d'Ivoire | 3,193 | 2,437(76.3) | 57.5 | 33.3 | 71.4 |
| Croatia | 810 | 798(98.5) | 42.1 | 45.5 | 67.1 |
| Czech Republic | 1,631 | 777(47.6) | 49.6 | 41.7 | 71.5 |
| Dominican Republic | 5,779 | 4,042(69.9) | 50.8 | 36.8 | 58.8 |
| Ecuador | 5,691 | 1,826(32.1) | 53.2 | 36.0 | 65.6 |
| Estonia | 868 | 837(96.4) | 46.6 | 42.5 | 70.1 |
| Ethiopia | 4,910 | 4,430(90.2) | 50.5 | 33.7 | 15.1 |
| Georgia | 2,496 | 2,105(84.3) | 47.7 | 40.8 | 52.9 |
| Ghana | 5,338 | 3,362(63.0) | 49.3 | 34.7 | 45.9 |
| Guatemala | 4,576 | 4,148(90.6) | 37.2 | 37.5 | 34.8 |
| Hungary | 1,182 | 1,154(97.6) | 48.5 | 42.0 | 64.8 |
| India | 9,785 | 7,945(81.2) | 52.5 | 36.3 | 10.6 |
| Kazakhstan | 4,352 | 4,263(98.0) | 48.8 | 39.0 | 55.9 |
| Kenya | 5,095 | 3,888(76.3) | 48.8 | 32.4 | 41.0 |
| Laos | 4,814 | 4,640(96.4) | 49.5 | 35.1 | 20.2 |
| Malawi | 5,391 | 4,752(88.1) | 48.4 | 34.4 | 15.5 |
| Malaysia | 7,228 | 5,563(77.0) | 50.7 | 37.2 | 64.6 |
| Mali | 4,772 | 1,478(31.0) | 51.0 | 34.4 | 27.2 |
| Mauritania | 3,710 | 2,726(73.5) | 47.8 | 34.5 | 62.9 |
| Mauritius | 4,151 | 3,597(86.7) | 49.7 | 38.5 | 42.1 |
| Mexico | 37,027 | 34,942(94.4) | 48.2 | 36.2 | 75.4 |
| Myanmar | 5,707 | 5,517(96.7) | 49.2 | 36.5 | 28.9 |
| Namibia | 4,386 | 3,418(77.9) | 46.0 | 35.5 | 33.6 |
| Nepal | 8,369 | 7,945(94.9) | 50.6 | 35.4 | 15.3 |
| Pakistan | 6,548 | 5,610(85.7) | 50.3 | 34.9 | 33.9 |
| Paraguay | 4,952 | 4,721(95.3) | 49.8 | 35.4 | 56.5 |
| Philippines | 9,700 | 9,535(98.3) | 50.0 | 35.8 | 61.7 |
| Russian Federation | 3,491 | 3,422(98.0) | 37.2 | 44.7 | 88.0 |
| Senegal | 3,492 | 1,610(46.1) | 48.6 | 34.0 | 44.8 |
| Slovakia | 2,427 | 1,595(65.7) | 42.5 | 40.0 | 55.1 |
| Slovenia | 1,239 | 492(39.7) | 46.8 | 42.5 | Missing |
| South Africa | 2,560 | 2,028(79.2) | 48.0 | 36.0 | 57.9 |
| Spain | 10,547 | 4,811(45.6) | 49.9 | 41.3 | 77.8 |
| Sri Lanka | 6,439 | 5,864(91.1) | 52.7 | 38.2 | 19.7 |
| Swaziland | 2,929 | 1,705(58.2) | 41.5 | 34.2 | 26.1 |
| Tunisia | 4,806 | 4,332(90.1) | 49.6 | 36.4 | 64.5 |
| Turkey | 10,683 | 9,073(84.9) | 51.0 | 36.6 | 66.3 |
| Ukraine | 2,491 | 1,840(73.9) | 46.5 | 41.7 | 67.3 |
| United Arab Emirates | 1,163 | 1,104(94.9) | 72.1 | 37.2 | 89.1 |
| Uruguay | 2,651 | 2,614(98.6) | 49.2 | 40.1 | 92.5 |
| Vietnam | 3,991 | 3,099(77.6) | 49.2 | 36.1 | 22.3 |
| Zambia | 4,190 | 3,518(84.0) | 49.2 | 33.8 | 33.9 |
| Zimbabwe | 4,076 | 3,570(87.6) | 49.2 | 33.4 | 36.4 |
| TOTAL | 259,526 | 212,021(81.7) | 44.3 | 38.0 | 49.7 |
Country Prevalence of Physical Inactivity
Age-standardized country prevalence of physical inactivity ranged from 1.6% (Comoros) to 52.6% (Mauritania) for men, and from 3.8% (Comoros) to 72.0% (Mauritania) for women (Figure 1, Figure 2). Values were heterogeneous across countries located in the African region for both men and women, while Eastern European and Southeast Asian, as well as Western Pacific countries, with few exceptions, showed a relatively similar prevalence of inactivity.
Figure 1.
Prevalence of physical inactivity for men in 51 countries, grouped by WHO region, World Health Survey, 2002–2003. Age-adjusted to WHO standard population.
Figure 2.
Prevalence of physical inactivity for women in 51 countries, grouped by WHO region, World Health Survey, 2002–2003. Age-adjusted to WHO standard population.
Crude prevalence values of physical inactivity for 51 countries for men and women are presented in Table 2. For all countries, women were more likely to be inactive than men, with the exception of the Eastern European countries of Croatia, the Czech Republic, Hungary, Kazakhstan, the Russian Federation, Slovakia, and the Ukraine. For the six countries of Bangladesh, Mauritania, Namibia, Pakistan, Turkey, and the United Arab Emirates, the difference in prevalence between men and women was greater than 10%.
Table 2. Crude prevalence of physical inactivity for men and women, by country, World Health Survey, 2002–2003
| Country | Men | Women |
|---|---|---|
| % physical inactivity (95% CI) | % physical inactivity (95% CI) | |
| Bangladesh | 6.5(5.1–7.9) | 25.2(21.7–28.7) |
| Bosnia-Herzegovina | 12.5(6.4–18.6) | 16.7(4.6–28.8) |
| Brazil | 25.4(23.0–27.7) | 30.2(27.6–32.9) |
| Burkina Faso | 5.8(4.3–7.4) | 7.4(5.9–9.0) |
| Chad | 17.5(13.6–21.3) | 23.3(19.1–27.5) |
| China | 9.3(6.0–12.7) | 11.8(7.2–16.4) |
| Comoros | 1.6(0.5–2.7) | 3.8(1.7–5.9) |
| Congo | 23.5(16.5–30.5) | 30.2(21.8–38.5) |
| Côte d'Ivoire | 10.3(8.1–12.5) | 18.8(14.8–22.8) |
| Croatia | 10.2(6.9–13.6) | 8.5(5.5–11.4) |
| Czech Republic | 10.9(5.1–16.7) | 7.5(3.8–11.2) |
| Dominican Republic | 37.8(34.5–41.1) | 43.8(40.3–47.4) |
| Ecuador | 18.0(13.1–22.8) | 27.3(22.9–31.7) |
| Estonia | 4.3(2.3–6.3) | 5.0(1.6–8.5) |
| Ethiopia | 9.4(7.1–11.8) | 16.0(13.9–18.2) |
| Georgia | 7.4(4.1–10.7) | 8.7(6.6–10.8) |
| Ghana | 7.9(5.9–9.8) | 15.1(12.7–17.5) |
| Guatemala | 3.6(2.7–4.6) | 4.2(3.4–5.0) |
| Hungary | 9.5(5.7–13.2) | 8.0(5.5–10.6) |
| India | 9.3(6.6–12.0) | 15.2(12.1–18.3) |
| Kazakhstan | 13.2(7.8–18.7) | 12.0(8.4–15.5) |
| Kenya | 7.9(3.6–12.3) | 11.6(8.4–14.8) |
| Laos | 9.7(8.1–11.4) | 14.4(12.6–16.2) |
| Malawi | 8.3(5.5–11.0) | 14.3(12.2–16.4) |
| Malaysia | 16.0(14.2–17.8) | 23.2(21.3–25.1) |
| Mali | 11.5(8.5–14.5) | 19.1(15.0–23.2) |
| Mauritania | 51.7(45.8–57.7) | 71.2(67.1–75.3) |
| Mauritius | 16.9(13.1–20.6) | 17.7(13.5–21.8) |
| Mexico | 16.2(15.0–17.3) | 17.5(16.3–18.7) |
| Myanmar | 6.5(4.1–8.8) | 14.2(11.0–17.3) |
| Namibia | 30.8(27.2–34.4) | 47.5(43.9–51.1) |
| Nepal | 6.7(5.6–7.7) | 9.7(8.7–10.8) |
| Pakistan | 12.8(10.2–15.3) | 27.3(24.8–29.9) |
| Paraguay | 19.7(17.5–22.0) | 20.9(18.8–23.0) |
| Philippines | 5.8(4.7–6.8) | 9.3(7.6–11.0) |
| Russian Federation | 7.2(3.9–10.5) | 5.2(3.9–6.6) |
| Senegal | 15.2(11.9–18.5) | 22.6(18.8–26.5) |
| Slovakia | 15.7(4.4–27.1) | 6.6(2.4–10.8) |
| Slovenia | 10.4(6.5–14.4) | 13.7(9.5–17.9) |
| South Africa | 43.0(37.4–48.6) | 46.6(41.4–51.9) |
| Spain | 27.4(24.6–30.1) | 33.1(30.7–35.5) |
| Sri Lanka | 7.3(5.4–9.1) | 13.8(10.8–16.8) |
| Swaziland | 47.9(41.7–54) | 55.4(50.6–60.2) |
| Tunisia | 11.0(9.2–12.8) | 18.2(15.5–21.0) |
| Turkey | 28.1(25.8–30.4) | 42.4(40.0–44.8) |
| Ukraine | 5.4(3.1–7.8) | 3.9(2.0–5.8) |
| United Arab Emirates | 37.9(29.8–46.1) | 56.7(51.1–62.3) |
| Uruguay | 24.2(19.3–29.2) | 29.0(23.5–34.5) |
| Vietnam | 7.7(4.7–10.6) | 8.8(5.6–12.0) |
| Zambia | 7.8(6.1–9.5) | 12.3(10.1–14.5) |
| Zimbabwe | 14.1(11.6–16.6) | 22.0(19.6–24.5) |
Prevalence for Different Age Groups and Settings
Overall, 17.7% of the pooled sample were considered inactive (15.2% of men and 19.8% of women). For men and women, groups aged 18–29, 30–39, and 40–49 showed a relatively similar prevalence of physical inactivity, whereas with older age groups, physical inactivity increased with increasing age (Figure 3). When individual country results were examined by age (data not shown, but available at the InfoBase website),5 this pattern of older people's being more likely to be inactive is apparent in almost all countries, with the exception of men in eight countries (Côte d'Ivoire, Spain, the Czech Republic, Georgia, the Russian Federation, China, the Philippines, and Namibia) and women in six countries (Côte d'Ivoire, Guatemala, Slovakia, Slovenia, the Republic of the Congo, and China).
Figure 3.
Prevalence of inactivity for the pooled sample of 51 countries, by age group and urbanity for men and women, World Health Survey, 2002–2003. Age-adjusted to the WHO standard population for the urban and rural subgroups.
Both men and women living in urban areas were more likely to be inactive compared to those living in rural areas. The difference was more obvious for men (Figure 3). This finding was also true for most of the individual countries (results not shown, but available at InfoBase Home Page),5 except for men in 12 countries and women in 16 countries.
Discussion
This study showed that 17.7% (15.2% of men and 19.8% of women) of a pooled sample of 212,021 individuals from 51 mainly low- and middle-income countries were physically inactive. These numbers are relatively low compared to those in other studies that used similar definitions of physical inactivity and were undertaken during the same years in high-income countries. According to results for 2003 from the Behavioral Risk Factor Surveillance System (BRFSS), 52.8% of U.S. citizens were inactive (50.2% of men, 55.4% of women).19 The Health Survey for England reported a prevalence of inactivity of 63% for men and 76% for women.20 Pooled prevalence of sedentarity for 15 European countries from the Eurobarometer Wave 58.2 was 31.0% for both genders combined.10 These figures indicate that inactivity may be more prevalent in wealthier countries. However, given rapid urbanization, economic growth, and technologic changes in the developing world—and therefore the likelihood of increased physical inactivity in these countries21—urgent action should be taken now to set up interventions aimed at increasing physical activity levels in these settings.
The comparison of results from this study to those from others, however, must be undertaken with caution, and the examples above are meant only to give a rough idea for putting the results into context. Factors that limit the comparison of results from this study to those of the BRFSS or the Health Survey for England include the use of different questionnaires as well as the inclusion of different age groups (people aged 18 and older in the BRFSS, aged 16 and older in the Health Survey of England).19, 20 As many surveys show, physical inactivity is more prevalent in older age groups,19, 22, 23, 24 and an increase in overall prevalence of physical inactivity is likely when these groups are included in any results. In addition, the BRFSS used a different question order (moderate before vigorous); direct comparison of BRFSS and IPAQ results is not recommended.25 For the Health Survey for England, analysis was slightly different, as bouts of activity that lasted less than 30 minutes were not recorded.20
In contrast, the Eurobarometer Wave 58.2 used the IPAQ as well, and analysis has been undertaken in the same way.10 Spain was the only country for which IPAQ data from both the Eurobarometer Wave 58.2 and the World Health Survey were available; prevalence of inactivity in that country was 27.3% for men and 34.9% for women in the Eurobarometer study as compared to 27.4% and 33.1% in this study, which indicates that IPAQ produces consistent results. Overall, for 27 of the 51 countries presented in this paper, adult physical activity data have been previously reported,5 but IPAQ was, other than in Spain, used in only three subnational studies in Brazil.26, 27, 28 Results from these studies are not comparable to the present results, as different cut-points were reported.
For one of the countries included in this study, Côte d'Ivoire, data derived from the Global Physical Activity Questionnaire (GPAQ) were available.29 GPAQ has also been developed for international assessment of overall physical activity and applies the same cut-points as IPAQ.30, 31 The difference between the questionnaires is that GPAQ assesses physical activity behavior separately for each of the work, transport, and leisure-time domains,30 while IPAQ does not ask about domain specifically. This different approach may have led to differences in results: GPAQ data showed a prevalence of physical inactivity of 86.3% for men and 89.4% for women compared to 10.5% and 18.8%, respectively, in this study. Unfortunately, to date there is no other country for which both IPAQ and GPAQ data have been published. Future research should investigate these discrepancies further. However, differences in results between the two studies could also be due either to different regional coverage, as both studies are subnational, or to data collection in different seasons. The data for Côte d'Ivoire presented in this study were collected from March to June 2003, whereas GPAQ data were collected from September to October 2005. It is well known that physical activity behavior depends on seasons and climate, which complicates the comparison of results within and across countries.6, 32, 33 The time of data collection for all countries in this study is available at the InfoBase Home Page.5
In summary, comparisons of studies confirm the previously reported overestimation of physical activity of the IPAQ,25, 34, 35 as differences between study results are too big to be explained simply by limitations of comparability (e.g., Eurobarometer results compared to results from other studies in high-income countries, or IPAQ results compared to GPAQ results for Côte d'Ivoire). The problem of physical inactivity is therefore likely to be underestimated by the IPAQ. The comparison of IPAQ results from different studies undertaken in the same country (Spain), however, indicates that IPAQ produces consistent results. Likewise, for country results within WHO regions, the order was found to be consistent for men and women. Countries that had an outstandingly high prevalence of physical inactivity within their region for both men and women were Mauritania, Swaziland, South Africa, the Dominican Republic, the United Arab Emirates, Turkey, Spain, and Malaysia. Except for the Dominican Republic, Spain, and Malaysia, in all these countries the prevalence of overweight and obesity was also estimated as being relatively high compared to other countries in the region.36 This indicates a serious public health problem with regard to chronic diseases that should be addressed accordingly.
The African region was the most heterogeneous. This was also the case for the prevalence of other chronic disease risk factors such as tobacco use, alcohol consumption, or low fruit-and-vegetable intake.5 The large diversity of countries in this region, many of which are undergoing rapid technologic transition, may be a potential explanation for this finding.
In the pooled sample of 212,021 individuals, the prevalence of physical inactivity was higher for women than for men, higher among older people, and higher among those living in urban areas. These results reflect findings for most individual countries of the sample,5 and are consistent with many other studies reporting the prevalence of physical inactivity by different age group22, 23, 24 or by urbanity.29, 37, 38 Migration to a city has been shown to increase sedentary behavior.39 These findings show that physical activity behavior is different in different population subgroups and settings, and programs and interventions should aim not only at increasing overall physical activity levels but also at reducing disparities among subgroups.
Limitations
First, the IPAQ shares the well-known shortcomings of physical activity questionnaires in general.6, 33, 40, 41 It potentially overestimates the prevalence of physical activity of populations.25, 34, 35 Its results for reliability and validity vary from poor to acceptable,42, 43, 44, 45 and its low scores in rural areas of developing countries raise concerns.42 These low coefficients might be due to the inappropriate wording of questions, or to different concepts of time in these settings. In general, it is very challenging to use the same questionnaire across different countries and cultural settings, given that it is difficult to control for factors such as the interpretation of questions, the understanding of the intensity of physical activity, or the climate.6
A second limitation stems from the fact that the quality of data is different for the compared countries in this study. For six of the 51 countries, samples were not nationally representative. Another seven countries had response rates lower than 50%, and hence the sample may not represent the physical activity behavior of the whole country.
Finally, fixed MET values, as used in this study, have been shown to overestimate true MET costs in sedentary middle-aged adults46 as well as in the elderly.33, 47 But although the fixed MET values may not be appropriate for all subgroups, they count among the only methods for estimating energy expenditure in large population studies, and the magnitude of the bias is likely to be similar in the compared populations.
Conclusion
This study reports, for the first time, the prevalence of physical inactivity for such a large diversity of countries. For many, physical inactivity data have never been previously reported. Results of this study are, with the exception of six countries, based on nationally representative samples from 51 countries, including 212,021 individuals.
The questionnaire used is one of the only questionnaires specifically designed for the international assessment of physical activity, and was tested for validity and reliability in developed as well as developing countries.42, 43, 44, 45 It assesses total energy expenditure, which is important for international comparability as, for example, assessing only leisure-time physical activity would ignore the large amount of physical activity performed at work in developing countries.33 Results of this study indicate that the physical activity estimates IPAQ produces are consistent, as a great similarity in results for country order for men and women was found; this similarity also occurred when results for Spain were compared to those produced by a different study that also used IPAQ.10
This study provides baseline information on the prevalence of physical inactivity for 51 countries around the world. It shows that physical inactivity varies greatly across different countries and settings, and that for some countries and population subgroups, particularly women aged 60–69, levels of physical inactivity are worrisome. This information should be used by countries and health policymakers when they establish interventions to increase physical activity levels to address the global chronic disease epidemic. The successful promotion of physical activity in countries such as Brazil to reduce rates of cardiovascular disease, stroke, and other diseases is promising, and suggests that similar benefits will emerge in other countries that implement the right interventions.48, 49 WHO encourages countries to implement the Global Strategy on Diet, Physical Activity, and Health.4 A guide for population-based approaches for increasing levels of physical activity has been developed that helps countries put the right interventions in place.50
Future research in the area of global surveillance of physical inactivity is greatly needed. It should focus both on gathering this kind of prevalence information for the countries that still lack it and on determining trends to allow the prediction of the future burden of chronic diseases due to physical inactivity.
The authors gratefully acknowledge the World Health Survey Consortium and the many study participants. The views expressed in this paper are the authors' and do not necessarily reflect those of the WHO.
No financial disclosures were reported by the authors of this paper.
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The full text of this article is available via AJPM Online at www.ajpm-online.net; 1 unit of Category-1 CME credit is also available, with details on the website.
PII: S0749-3797(08)00257-2
doi:10.1016/j.amepre.2008.02.013
© 2008 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Volume 34, Issue 6 , Pages 486-494, June 2008