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Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants

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Open Access Published:September 04, 2018 DOI:https://doi.org/10.1016/S2214-109X(18)30357-7
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    Summary

    Background

    Insufficient physical activity is a leading risk factor for non-communicable diseases, and has a negative effect on mental health and quality of life. We describe levels of insufficient physical activity across countries, and estimate global and regional trends.

    Methods

    We pooled data from population-based surveys reporting the prevalence of insufficient physical activity, which included physical activity at work, at home, for transport, and during leisure time (ie, not doing at least 150 min of moderate-intensity, or 75 min of vigorous-intensity physical activity per week, or any equivalent combination of the two). We used regression models to adjust survey data to a standard definition and age groups. We estimated time trends using multilevel mixed-effects modelling.

    Findings

    We included data from 358 surveys across 168 countries, including 1·9 million participants. Global age-standardised prevalence of insufficient physical activity was 27·5% (95% uncertainty interval 25·0–32·2) in 2016, with a difference between sexes of more than 8 percentage points (23·4%, 21·1–30·7, in men vs 31·7%, 28·6–39·0, in women). Between 2001, and 2016, levels of insufficient activity were stable (28·5%, 23·9–33·9, in 2001; change not significant). The highest levels in 2016, were in women in Latin America and the Caribbean (43·7%, 42·9–46·5), south Asia (43·0%, 29·6–74·9), and high-income Western countries (42·3%, 39·1–45·4), whereas the lowest levels were in men from Oceania (12·3%, 11·2–17·7), east and southeast Asia (17·6%, 15·7–23·9), and sub-Saharan Africa (17·9%, 15·1–20·5). Prevalence in 2016 was more than twice as high in high-income countries (36·8%, 35·0–38·0) as in low-income countries (16·2%, 14·2–17·9), and insufficient activity has increased in high-income countries over time (31·6%, 27·1–37·2, in 2001).

    Interpretation

    If current trends continue, the 2025 global physical activity target (a 10% relative reduction in insufficient physical activity) will not be met. Policies to increase population levels of physical activity need to be prioritised and scaled up urgently.

    Funding

    None.

    Introduction

    The health benefits of physical activity are well established and include a lower risk of cardiovascular disease, hypertension, diabetes, and breast and colon cancer. Additionally, physical activity has positive effects on mental health, delays the onset of dementia, and can help the maintenance of a healthy weight.
      Physical Activity Guidelines Advisory Committee report, 2008. To the Secretary of Health and Human Services. Part A: executive summary. Nutr Rev. 2009; 67: 114-120
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          In recognition of this strong link between physical activity and major non-communicable diseases, member states of WHO agreed to a 10% relative reduction in the prevalence of insufficient physical activity by 2025, as one of the nine global targets to improve the prevention and treatment of non-communicable diseases.
            WHO. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. World Health Organization, Geneva; 2013
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            Monitoring current levels and trends of insufficient physical activity is essential to track progress towards this global physical activity target, but also to identify high-risk populations, to assess the effectiveness of policy, and guide future policy and programme planning.
            The first compilation of country data to produce global and regional estimates of insufficient physical activity was undertaken in the early 2000s, as part of the Global Burden of Disease study.
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            Bull and colleagues
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            included data for physical activity from 34 mainly high-income countries, mostly focusing on leisure time physical activity. Activity performed in other domains (activity at work, in the household, and for transport) had to be estimated for most countries, in order to get comprehensive and comparable results. Subsequently, two questionnaires including all activity domains were developed: the International Physical Activity Questionnaire
              International Physical Activity Questionnaire. Guidelines for Data Processing and Analysis of the International Physical Activity Questionnaire (IPAQ).
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              and the Global Physical Activity Questionnaire.
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              Both questionnaires have since been used in many surveys, including several large, international surveys such as the World Health Survey, the Eurobarometer surveys, and the WHO Stepwise Approach to NCD Risk Factor Surveillance.
              • Riley L
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              The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: methods, challenges, and opportunities. Am J Public Health. 2016; 106: 74-78
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              Mainly based on data from these questionnaires, WHO produced comparable estimates of insufficient physical activity in 122 countries in 2008, and updated them for 2010 for 146 countries. Both sets of estimates were published in The Lancet Physical Activity Series
              Black Laina Boots Women’s Biker Noir Les Tropéziennes wXqFn6Zqxf
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              Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet. 2012; 380: 247-257
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              and used to calculate the effect of insufficient physical activity on non-communicable diseases.
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              Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012; 380: 219-229
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              However, in The Lancet Physical Activity 2016 Series, Sallis and colleagues
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              Progress in physical activity over the Olympic quadrennium. Lancet. 2016; 388: loho loho Kendra Kendra UK9 Brown 1325-1336
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              noted that consistent data for trends in adult physical activity are still scarce. As a consequence, no article has reported regional and global trends of insufficient physical activity. We updated previously published
              • Hallal PC
              • Andersen LB
              • Bull FC
              • et al.
              Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet. 2012; 380: 247-257
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                WHO. Global Health Observatory (GHO) data. Prevalence of insufficient physical activity.
                Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                country, regional, and global estimates of adult prevalence of insufficient physical activity with new data and new methods, and estimated, for the first time, global and regional trends from 2001 to 2016.

                Methods

                Study design

                We estimated the prevalence of insufficient physical activity in adults aged 18 years and older, in 168 countries, for three World Bank income groups, nine regions ( Round K Chiffon Neck Fashion Gray Light Lady Black Panel Allegra Casual Dress EfdOqf),
                  NCD Risk Factor Collaboration. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017; 390: 2627-2642
                  Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
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                  NCD Risk Factor Collaboration. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet. 2017; 389: 37-55
                  Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                  and globally for 2001–16. Insufficient physical activity was defined as adults not meeting the WHO recommendations
                    WHO. Global recommendations on physical activity for health. World Health Organization, Geneva; 2010
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                    on physical activity for health—ie, at least 150 min of moderate-intensity, or 75 min of vigorous-intensity physical activity per week, or any equivalent combination of the two.

                    Data sources

                    We included data that fulfilled the following criteria: (1) the survey questionnaire explicitly included physical activity across four key domains—ie, for work, in the household (paid or unpaid), for transport to get to and from places (ie, walking and cycling), and during leisure time (ie, sports and active recreation); (2) data were collected through random sampling with a sample size of at least 200, and were representative of a national or defined subnational population; (3) prevalence of insufficient physical activity was reported by age and sex, according to current WHO,
                      WHO. Global recommendations on physical activity for health. World Health Organization, Geneva; 2010
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                      or former physical activity recommendations.
                      • Pate RR
                      • Pratt M
                      • Blair SN
                      • et al.
                      Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995; 273Negro Boots Women’s Schwarz Cass Black Tatoosh Noir 6qYpZwnA: 402-407
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                      These former guidelines recommended for adults to spread out their activity during the week in doing at least 30 min of moderate activity on at least 5 days, or equivalent. They were in place until an update of evidence in 2008,
                        Physical Activity Guidelines Advisory Committee report, 2008. To the Secretary of Health and Human Services. Part A: executive summary. Nutr Rev. 2009; 67: 114-120
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                        when this requirement was removed.
                        Physical activity data collected using wearable devices, such as accelerometers or pedometers, were not included because of the limited comparability with self-reported data. Where available, we used individual-level data to calculate the prevalence of insufficient physical activity, taking the sampling designs into account. Where raw data were not available, we used aggregated data as reported. We included all data that met the inclusion criteria and that were provided before the end of September, 2017.
                        We obtained data from WHO and other international surveys.
                        • Riley L
                        • Guthold R
                        • Cowan M
                        • et al.
                        The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: methods, challenges, and opportunities. Am J Public Health. 2016; 106: 74-78
                        Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                        We also did a systematic literature search of PubMed, up to October, 2015, for articles published in English, Portuguese, German, Spanish, Chinese, and Italian, including the International Physical Activity Questionnaire and the Global Physical Activity Questionnaire as search terms. To identify additional data sources, we also analysed and verified results of the 2017 WHO NCD Country Capacity Survey,
                          WHO. Assessing national capacity for the prevention and control of NCDs.
                          Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                          in which each WHO member state answered a question on the inclusion of physical activity in national risk factor surveys. We also had personal communications with WHO regional focal points, personal networks, and directly with researchers, including inquiries about additional data from authors of published studies. Finally, we had a 6-week consultation with all WHO member states in which countries commented on the first draft of estimates and submitted any additional data. After the consultation, the estimates were updated during October, 2017, with new data that were submitted. In total, 358 surveys from 168 countries were included in the analysis ( appendix pp 2–15).

                          Statistical analysis

                          Survey data were sometimes not comparable because of differences in study design. We applied four key adjustments to survey data using linear regression modelling to improve comparability ( appendix pp 17–27). First, we converted definitions. For surveys in which data were reported only for the former recommendation on physical activity for health,
                          • Pate RR
                          • Pratt M
                          • Blair SN
                          • et al.
                          Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995; 273: 402-407
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                          and not for the current recommendation,
                            WHO. Global recommendations on physical activity for health. World Health Organization, Geneva; 2010
                            Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                            we converted data to the current recommendation, our target indicator.
                            Second, we adjusted for over-reporting in the International Physical Activity Questionnaire. This questionnaire over-reports physical activity, leading to an underestimation of the prevalence of insufficient activity.
                            • Rzewnicki R
                            • Vanden Auweele Y
                            • De Bourdeaudhuij I
                            Addressing overreporting on the International Physical Activity Questionnaire (IPAQ) telephone survey with a population sample. Public Health Nutr. 2003; 6: 299-305
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                            • Brown Kendra loho Kendra loho UK9 Hallal PC
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                            • et al.
                            Lessons learned after 10 years of IPAQ use in Brazil and Colombia. J Phys Act Health. 2010; 7: S259-S264
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                            • Ekelund U
                            • Sepp H
                            • Brage S
                            • et al.
                            Criterion-related validity of the last 7-day, short form of the International Physical Activity Questionnaire in Swedish adults. Public Health Nutr. 2006; 9: 258-265
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                            • Ainsworth BE
                            • Macera CA
                            • Jones DA
                            • et al.
                            Comparison of the 2001 BRFSS and the IPAQ Physical Activity Questionnaires. Med Sci Sports Exerc. 2006; 38: 1584-1592
                            Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                            To correct for this over-reporting, we applied an adjustment factor to surveys that used the International Physical Activity Questionnaire. This adjustment factor was determined by exploring differences in prevalence between the International Physical Activity Questionnaire and other, similar survey questionnaires, such as the Global Physical Activity Questionnaire, in countries that have used both.
                            Third, we adjusted data from surveys that had only urban samples. Of the 358 surveys used, 27 reported data for urban populations only. For these surveys, we estimated the prevalence in rural areas using information from surveys reporting both urban and rural prevalence. We calculated a national estimate combining the two by applying estimates of population by area of residence for the respective survey year.
                              United Nations. Department of Economic and Social Affairs. Population Division. World Urbanization Prospects, the 2014 revision.
                              https://esa.un.org/unpd/wup/
                              Date accessed: October 13, 2017
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                              Fourth, for surveys that did not report data for all ages older than 18 years, we estimated the data for the missing age groups using information from surveys that reported age-specific values for the entire age range.
                              The methods used to generate final estimates of insufficient physical activity prevalence by country, year, sex, and age differed depending on the availability of data on trends over time.
                              Of the 168 countries included, 65 had done at least two comparable surveys from different years using the same questionnaire ( appendix p 16). For these countries, we estimated the prevalence of insufficient physical activity for each year from 2001, to 2016, using a multilevel mixed-effects linear regression model. To allow estimates to be informed by data from the same country, from other countries in the region, and other variables, this model included a random slope on year, a random intercept for each country, and fixed effects for country urbanisation, education, and location within nine previously defined regions that have been used in similar analysis for other non-communicable disease risk factors.
                                NCD Risk Factor Collaboration. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017; 390: 2627-2642
                                Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                  NCD Risk Factor Collaboration. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet. 2017; 389: 37-55
                                  Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                  For 76 countries, only one survey was available. We assumed no change over time in these countries, based on the fact that the average change in prevalence per year across the 65 countries with at least two comparable surveys was less than 0·01%.
                                  27 countries had done several surveys with different survey coverage, or with different questionnaires, limiting comparability of these survey data. Although we adjusted for over-reporting in the International Physical Activity Questionnaire, we considered the comparison of adjusted data from the International Physical Activity Questionnaire to data from other questionnaires to be insufficient to inform country trends. Therefore, for these 27 countries, we also assumed a flat trend, whereby the trend line was based on the average prevalences across surveys for each country.
                                  To derive final estimates for the entire age range, we age-standardised resulting sex-specific and age-specific prevalence estimates using the WHO Standard Population.
                                  • Ahmad O
                                  • Boschi-Pinto C
                                  • Lopez AD
                                  • Murray CJL
                                  • Lozano R
                                  • Inoue M
                                  Age standardization of rates: a new WHO standard. World Health Organization, Geneva; 2001
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                                  To produce global and regional estimates, and estimates for World Bank income groups, we created population-weighted sex-specific and age-specific estimates for each subgroup and year,
                                    United Nations. Department of Economic and Social Affairs. Population Division. Monitoring Global Population Trends.
                                    http://www.un.org/en/development/desa/population/publications/index.shtml
                                    Brown Kendra loho UK9 loho Kendra Date accessed:October 13, 2017
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                                    and then age-standardised these estimates.
                                    • Ahmad O
                                    • Boschi-Pinto C
                                    • Lopez AD
                                    • Murray CJL
                                    • Lozano R
                                    • Inoue M
                                    Age standardization of rates: a new WHO standard. World Health Organization, Geneva; 2001
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                                    Using the bootstrap method, we drew 1000 samples, each containing 80% of all survey data, to produce uncertainty intervals [UI] for these estimates, representing the 2·5th and 97·5th percentile of the 1000 draws. We calculated trends as the difference in prevalence between 2001, and 2016, and considered a change in prevalence over time to be statistically significant if fewer than 2·5% of draws showed changing trend ( appendix pp 17–27).
                                    • Stevens GA
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                                    Role of the funding source

                                    There was no funding source for this study. The corresponding author had full access to all the data and had final responsibility for the decision to submit for publication.

                                    Results

                                    Our analysis included 358 population-based surveys done between 2001 and 2016, with 1·9 million participants from 168 countries ( Round K Chiffon Neck Fashion Gray Light Lady Black Panel Allegra Casual Dress EfdOqf), representing 96% of the world's population. The availability of data across income groups and regions was spread fairly evenly, with the exception of Latin American and Caribbean countries where just more than half of countries had data ( table 1). Of the 358 surveys included, 301 were nationally representative, and 150 of 168 countries had at least one national survey ( appendix pp 2–15).
                                    Table 1 Distribution of data across income groups and regions
                                    All countries (n=231) Region Income group
                                    Central Asia, Middle East, north Africa (n=28) Central and eastern Europe (n=20) East and southeast Asia (n=16) High-income Asia Pacific (n=3) High-income Western countries (n=36) Latin American and Caribbean (n=47) Oceania (n=22) South Asia (n=6) Sub-Saharan Africa (n=53) Low-income (n=31) Middle-income (n=109) High-income (n=75)
                                    Countries with data (%) 168 (72·7%) 23 (82·1%) 17 (85·0%) 13 (81·3%) 3 (100·0%) 24 (66·7%) 25 (53·2%) 17 (77·3%) 5 (83·3%) 41 (77·4%) 24 (77·4%) 89 (81·7%) 54 (72·0%)
                                    Percentage of population covered with data 95·8% 90·4% 98·3% 97·3% 100·0% 99·0% 87·6% 94·3% 98·5% 89·6% 81·9% 96·9% 96·3%
                                    Number with trend data
                                    Defined as having used the same instrument and coverage at more than one point in time.
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                                    (%)
                                    65 (28·1%) 8 (28·6%) 11 (55·0%) 7 (43·8%) 2 (66·7%) 20 (55·6%) 5 (10·6%) 7 (31·8%) 1 (16·7%) 4 (7·5%) 1 (3·2%) 27 (24·8%) 36 (48·0%)
                                    * Defined as having used the same instrument and coverage at more than one point in time.
                                    65 of 168 countries had at least two surveys using the same questionnaire and survey coverage ( table 1, appendix p 16). Availability of data meeting these two criteria was skewed towards higher-income countries, with only 3·2% of low-income countries and 48·0% of high-income countries having trend data ( table 1).
                                    Globally, more than a quarter of adults (27·5%, 95% UI 25·0–32·2) were insufficiently physically active in 2016 ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6). Between 2001 and 2016, levels of insufficient physical activity have decreased only marginally and insignificantly, with a global prevalence of 28·5% (23·9–33·9) in 2001. Women were less active than men, with a prevalence difference of 6 percentage points between sexes in 2001 (25·5%, 95% UI 23·1–33·0 for men, and 31·5%, 95% UI 27·9–37·8 for women), and of more than 8 percentage points in 2016 (23·4%, 21·1–30·7, for men, and 31·7%, 28·6–39·0, for women; Figure 1, Figure 2).
                                    Table 2 Prevalence of insufficient physical activity in 2016
                                    Overall percentage of insufficient physical activity (95% UI) Percentage of men with insufficient physical activity (95% UI) Percentage of women with insufficient physical activity (95% UI) Country with the minimum prevalence Country with the maximum prevalence
                                    Country Prevalence (95% CI) Country Prevalence (95% CI)
                                    All countries 27·5% (25·0–32·2) 23·4% (21·1–30·7) 31·7% (28·6–39·0) Uganda 5·5% (4·0–7·6) Kuwait 67·0% (58·6–74·3)
                                    Central Asia, Middle East, and north Africa 32·8% (31·0–35·2) 25·9% (23·7–28·7) 39·9% (37·9–42·7) Jordan 11·9% (8·4–16·4) Kuwait 67·0% (58·6–74·3)
                                    Central and eastern Europe 23·4% (20·9–28·0) 22·0% (18·6–28·8) 24·7% (21·7–33·9) Moldova 11·5% (8·1–16·0) Serbia 39·5% (30·8–48·8)
                                    East and southeast Asia 17·3% (15·8–22·1) 17·6% (15·7–23·9) 16·9% (14·9–25·7) Cambodia 10·5% (6·9–15·7) Philippines 39·7% (31·3–48·6)
                                    High-income Asia Pacific 35·7% (34·4–37·0) 33·0% (29·4–33·6) 38·3% (37·4–42·6) South Korea 35·4% (20·9–52·9) Singapore 36·5% (21·7–54·3)
                                    High-income Western countries 36·8% (34·6–38·4) 31·2% (28·5–32·6) 42·3% (39·1–45·4) Finland 16·6% (12·9–21·0) Cyprus 44·4% (36·8–52·1)
                                    Latin America and Caribbean 39·1% (37·8–40·6) 34·3% (32·5–35·5) 43·7% (42·9–46·5) Dominica 21·6% (16·3–28·0) Brazil 47·0% (38·9–55·3)
                                    Oceania 16·3% (14·3–20·7) 12·3% (11·2–17·7) 20·3% (18·8–28·7) Niue 6·9% (4·8–9·9) American Samoa 53·4% (41·4–65·0)
                                    South Asia 33·0% (23·0–51·7) 23·5% (14·4–54·3) 43·0% (29·6–74·9) Nepal 13·4% (11·2–15·6) India 34·0% (22·3–47·7)
                                    Sub-Saharan Africa 21·4% (19·1–23·3) 17·9% (15·1–20·5) 24·8% (21·8–27·2) Uganda 5·5% (4·0–7·6) Mauritania 41·3% (33·4–49·2)
                                    Low-income 16·2% (14·2–17·9) 13·4% (11·3–15·6) 18·8% (15·9–21·4) Uganda 5·5% (4·0–7·6) Mali 40·4% (33·6–47·3)
                                    Middle-income 26·0% (22·6–31·8) 21·9% (18·9–31·3) 30·1% (26·0–39·5) Lesotho 6·3% (4·5–8·6) American Samoa 53·4% (41·4–65·0)
                                    High-income 36·8% (35·0–38·0) 32·0% (29·8–33·1) 41·6% (39·1–43·9) Finland 16·6% (12·9–21·0) Kuwait 67·0% (58·6–74·3)
                                    Figure 1 Trends in insufficient physical activity in men from 2001 to 2016
                                    Figure 2 Trends in insufficient physical activity in women from 2001 to 2016
                                    Prevalence of insufficient physical activity ranged from 16·3% (95% UI 14·3–20·7) in Oceania to 39·1% (37·8–40·6) in Latin America and the Caribbean in 2016 ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6). Between 2001 and 2016, the prevalence of physical inactivity increased by more than 5 percentage points in high-income Western countries (from 30·9%, 26·4–38·1 in 2001, to 36·8%, 34·6–38·4, in 2016) and in Latin America and Caribbean (from 33·4%, 29·1–38·6, in 2001, to 39·1%, 37·8–40·6, in 2016), whereas east and southeast Asia had a decrease of more than 5 percentage points (from 25·7%, 20·6–29·4, in 2001, to 17·3%, 15·8–22·1, in 2016).
                                    Across all regions, with the exception of east and southeast Asia, women were less active than men in 2016 ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6). There was a difference between sexes of more than 10 percentage points in central Asia, Middle East and north Africa; high-income Western countries; and south Asia ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6). The highest levels of insufficient activity (>40%) among women in 2016 were in Latin America and the Caribbean, south Asia, and high-income Western countries ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6). The lowest levels of physical activity in men (<20%) in 2016 were in Oceania, east and southeast Asia, and sub-Saharan Africa ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6).
                                    The prevalence of insufficient physical activity in high-income countries was more than double the prevalence in low-income countries in 2016 ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6). The prevalence increased over time in high-income countries, from 31·6% (27·1–37·2) in 2001, to 36·8% (35·0–38·0) in 2016, whereas it was stable in low-income countries, at 16·0% (12·0–19·6) in 2001, and 16·2% (14·2–17·9) in 2016 ( Women’s Colours Berry Sandals Gladiator Various Blueberry 3 Black Leopard S Kisumu Blueberry MBT 6SqUdw6, figure 3).
                                    Figure 3 Trends in insufficient physical activity for three income groups from 2001 to 2016
                                    Country-specific, age-standardised prevalence of insufficient physical activity in 2016 ranged from 5·5% (4·0–7·6) in Uganda to 67·0% (58·6–74·3) in Kuwait ( appendix pp 28–31). In four countries, the prevalence of insufficient physical activity was more than 50% (Kuwait, American Samoa, Saudi Arabia, and Iraq), whereas the prevalence was lower than 10% in seven countries (Uganda, Mozambique, Lesotho, Tanzania, Niue, Vanuatu, and Togo). In 55 (32·7%) of 168 countries, more than a third of the population was insufficiently physically active.
                                    In 159 of 168 countries, prevalence of insufficient physical activity was lower in men than in women, with a difference of at least 10 percentage points in 65 countries, and a difference of more than 20 percentage points in nine countries: Barbados, Bahamas, Saint Lucia, Palau, Iraq, Bangladesh, Trinidad and Tobago, Iran, and Saudi Arabia. Figure 4, Figure 5 show country prevalence for men and women.
                                    Figure 4 Country prevalence of insufficient physical activity in men in 2016
                                    Figure 5 Country prevalence of insufficient physical activity in women in 2016
                                    Of the 65 countries with data for trends over time, 28 had decreasing levels of insufficient activity, whereas levels were increasing in 37 countries. The largest decreases (>15%) have occurred in Cook Islands, Jordan, Tokelau, Samoa, Myanmar, Solomon Islands, and Tonga, while the largest increases (>15%) occurred in Brazil, Bulgaria, Germany, Philippines, and Singapore. The average change across all of 65 countries was less than 0·01%.

                                    Discussion

                                    Our analysis, including data from nearly 2 million participants (representing 96% of the global population), shows that globally, in 2016, more than a quarter of all adults was not getting enough physical activity. This puts more than 1·4 billion adults at risk of developing or exacerbating diseases linked to inactivity, and needs to be urgently addressed. Previous estimates showed a global prevalence of insufficient physical activity of 23·3% in 2010. This difference from our results is due to our inclusion of nearly twice as many surveys (358 vs 195), and our ability to produce estimates for an additional 22 countries. Our estimates will be made available in the WHO Global Health Observatory,
                                      WHO. Global Health Observatory (GHO) data. Prevalence of insufficient physical activity.
                                      Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                      where they can be downloaded for use in projects such as burden of disease calculations.
                                      • 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: 219-229
                                      Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                      Prevalence of insufficient physical activity varied greatly across regions and income groups in 2016. We found the highest levels in Latin America and the Caribbean, high-income Western countries, and high-income Asia Pacific, and prevalence was more than double in high-income countries than in low-income countries in 2016. In wealthier countries, the transition towards more sedentary occupations and personal motorised transportation probably explains the higher levels of inactivity. Conversely, in lower-income countries, more activity is undertaken at work and for transport; however, these behaviours are changing rapidly.
                                      • Ng SW
                                      • Popkin BM
                                      Time use and physical activity: a shift away from movement across the globe. Obes Rev. 2012; 13: 659-680
                                      Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                      National policy needs to be implemented to encourage non-motorised modes of transportation, such as walking and cycling, and to promote participation in active recreation and sports in leisure time. Such policies are particularly important in countries with rapid urbanisation, such as Argentina, Brazil, and Colombia,
                                        United Nations. Department of Economic and Social Affairs. Population Division. World Urbanization Prospects, the 2014 revision.
                                        https://esa.un.org/unpd/wup/
                                        Date accessed: October 13, 2017
                                        Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                        which contribute to the high levels of insufficient activity in Latin America and the Caribbean. Effective policies include improved provision of cycling and walking infrastructure, improving road safety, and creating more opportunities for physical activity in public open spaces and parks, in workplaces, and in other local community settings.
                                          ISPAH International Society for Physical Activity and Health. The Bangkok Declaration on Physical Activity for Global Health and Sustainable Development. Br J Sports Med. 2017; 51: 1389-1391
                                          Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                            WHO. Global action plan on physical activity 2018–2030. More active people for a healthier world. World Health Organization, Geneva; 2018
                                            Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                            • Stevenson M
                                            • Thompson J
                                            • de Sá TH
                                            • et al.
                                            Land use, transport, and population health: estimating the health benefits of compact cities. Lancet. 2016; 388: 2925-2935
                                            Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                            We also found a wide variation in country prevalence of insufficient activity both across and within regions. The prevalence of insufficient activity was lower than 10% in a few countries, and more than 50% in others. This inequality has also been confirmed by Althoff and colleagues,
                                            • Althoff T
                                            • Sosič R
                                            • Hicks JL
                                            • King AC
                                            • Delp SL
                                            • Leskovec J
                                            Large-scale physical activity data reveal worldwide activity inequality. Nature. 2017; 547: 336-339
                                            Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                            who used movement sensors built into smartphones to assess physical activity. Despite the difference in measurement method (we used self-reported physical activity), and differences in sampling, the resulting patterns of activity are similar, with some of the least active countries located in central and south America and north Africa and the Middle East, and some of the most active countries in east Asia and eastern Europe. The fact that activity varies greatly across countries, even within regions, suggests that the factors that influence inactivity lie mostly at the national, subnational, or community level, which is where policies are needed to increase physical activity.
                                              WHO. Global action plan on physical activity 2018–2030. More active people for a healthier world. World Health Organization, Geneva; 2018
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              Our study confirms findings
                                              • Althoff T
                                              • Sosič R
                                              • Hicks JL
                                              • King AC
                                              • Delp SL
                                              • Leskovec J
                                              Large-scale physical activity data reveal worldwide activity inequality. Nature. 2017; 547: 336-339
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              • Ranasinghe CD
                                              • Ranasinghe P
                                              • Jayawardena R
                                              • Misra A
                                              Physical activity patterns among south-Asian adults: a systematic review. Int J Behav Nutr Phys Act. 2013; 10: 116
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              • Koohpayehzadeh J
                                              • Etemad K
                                              • Abbasi M
                                              • et al.
                                              Gender-specific changes in physical activity pattern in Iran: national surveillance of risk factors of non-communicable diseases (2007–2011). Int J Public Health. 2014; 59: 231-241
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              of lower activity in women than in men, with some of the biggest differences in south and central Asia and the Middle East and north Africa. One way to explain sex differences in activity is to assess male and female participation in different domains of activity (activity at work or in the household, for transport, and during leisure time), and at different intensities (moderate and vigorous). Previous research
                                              • Koohpayehzadeh J
                                              • Etemad K
                                              • Abbasi M
                                              • et al.
                                              Gender-specific changes in physical activity pattern in Iran: national surveillance of risk factors of non-communicable diseases (2007–2011). Int J Public Health. 2014; 59: 231-241
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              • Mielke GI
                                              • da Silva ICM
                                              • Kolbe-Alexander TL
                                              • Brown WJ
                                              Shifting the physical inactivity curve worldwide by closing the gender gap. Sports Med. 2018; 48: 481-489
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              • Guthold R
                                              • Louazani SA
                                              • Riley LM
                                              • et al.
                                              Physical activity in 22 African countries: results from the World Health Organization STEPwise approach to chronic disease risk factor surveillance. Am J Prev Med. 2011; 41: 52-60
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              indicates that women tend to do less leisure-time activity, and lower-intensity activity than do men. Offering more opportunities for safe and accessible leisure-time activity to women in order to increase their overall levels of activity would therefore help close the gender gap and achieve the 2025 global physical activity target.
                                              • Mielke GI
                                              • da Silva ICM
                                              • Kolbe-Alexander TL
                                              • Brown WJ
                                              Shifting the physical inactivity curve worldwide by closing the gender gap. Sports Med. 2018; 48Splendid Women’s Loafer Monk Black Strap Danele vvqrT: 481-489
                                              Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                              Furthermore, cultural norms, traditional roles, or lack of social and community support might lead to reduced participation in physical activity among girls and women. Understanding and addressing these barriers is needed to plan and deliver culturally sensitive actions to support behaviour change.
                                                WHO Regional Office for the Eastern Mediterranean. Promoting physical activity in the Eastern Mediterranean Region through a life-course approach. World Health Organization, Cairo; 2014
                                                Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                Our analysis was the first to assess trends in physical inactivity over time. The global prevalence of physical inactivity was stable between 2001 and 2016, suggesting no progress in reducing global levels to reach the 2025 global physical activity target.
                                                  WHO. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. World Health Organization, GenevaSandal Medium Ivanka Women's Patent Emalyn Pink Dress Trump wqq7IABxZT; 2013
                                                  Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                  However, we found a wide variation in trends in inactivity across regions, income groups, and countries. The largest increases in insufficient physical activity have occurred in high-income countries, whereas the largest decreases have occurred in east and southeast Asia. These decreases are largely explained by increased participation in physical activity in China, the most populous country in the region (data not shown). Leisure-time physical activity in China has increased,
                                                  • Tian Y
                                                  • Jiang C
                                                  • Wang M
                                                  • et al.
                                                  BMI, leisure-time physical activity, and physical fitness in adults in China: results from a series of national surveys, 2000–14. Lancet Diabetes Endocrinol. 2016; 4: 487-497
                                                  Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                  which might be explained by increased park use and physical activity among China's rapidly growing elderly population.
                                                  • Tu H
                                                  • Liao X
                                                  • Schuller K
                                                  • et al.
                                                  Insights from an observational assessment of park-based physical activity in Nanchang, China. Prev Med. 2015; 2: 930-934
                                                  Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                  The lack of progress in other regions might be explained by the fact that, although more than 70% of countries have an operational physical activity policy, the scale and reach of its implementation is yet to have a national impact.
                                                    WHO. Global action plan on physical activity 2018–2030. More active people for a healthier world. World Health Organization, Geneva; 2018
                                                    Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                    Our study is affected by several limitations. First, similar to all global analyses, data were not available for every country and year, and availability varied across countries and regions. Latin America and the Caribbean, high-income Western countries, Oceania, and sub-Saharan Africa had the lowest proportion of countries with data. However, within these regions, the most populous countries were more likely to have data, so that the proportion of the population with data in these regions was still high. Countries with a population of more than 10 million with no data were Bolivia, Haiti, and Peru in Latin America and the Caribbean; Angola, Burundi, Somalia, South Sudan, and Sudan in sub-Saharan Africa; Afghanistan in south Asia; Syria and Yemen in central Asia, Middle East, and North Africa; and North Korea in east and southeast Asia. Some of these countries are also classified as low-income countries, which had the lowest data availability of the income groups. The availability of data for trends in physical inactivity was clearly skewed towards high-income countries, with 48·0% of countries being covered, compared with 3·2% of low-income countries. In fact, our trend estimations for low-income countries were based on one country only, Benin, which limits the representativeness for other low-income countries. Data coverage for trends was low in sub-Saharan Africa, Latin American and the Caribbean, and south Asia, indicating that trend estimates for these regions should be interpreted with caution.
                                                    Second, data quality also varied across countries and over time. 131 (37%) of the 358 surveys included data that were collected through the WHO Stepwise Approach to NCD Risk Factor Surveillance, using the Global Physical Activity Questionnaire.
                                                    • Armstrong T
                                                    • Bull F
                                                    Development of the World Health Organization Global Physical Activity Questionnaire (GPAQ). J Public Health. 2006; 14: 66-70
                                                    Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                    • Riley L
                                                    • Guthold R
                                                    • Cowan M
                                                    • et al.
                                                    The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: methods, challenges, and opportunities. Am J Public Health. 2016; 106: 74-78
                                                    Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                    The WHO Stepwise Approach was started in 2001, and the earlier surveys tended to be less representative with sometimes only subnational coverage.
                                                    • Riley L
                                                    • Guthold R
                                                    • Cowan M
                                                    • et al.
                                                    The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: methods, challenges, and opportunities. Am J Public Health. 2016; 106: 74-78
                                                    Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                    Nonetheless, we included these data in our analysis because they help to provide global coverage for the earlier years.
                                                    Third, we had to rely on self-reported data in our analysis despite their limitations.
                                                    • Ara I
                                                    • Aparicio-Ugarriza R
                                                    • Morales-Barco D
                                                    • Nascimento de Souza W
                                                    • Mata E
                                                    • González-Gross M
                                                    Physical activity assessment in the general population; validated self-report methods. Nutr Hosp. 2015; 31: 211-218
                                                    Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                    Nationally representative data for physical activity that are collected objectively, using accelerometers, for example, are mostly only available for high-income countries, and results are not comparable across countries because of variations in data collection methods, data processing, and scoring.
                                                    • Wijndaele K
                                                    • Westgate K
                                                    • Stephens SK
                                                    • et al.
                                                    Utilization and harmonization of adult accelerometry data: review and expert consensus. Med Sci Sports Exerc. 2015; 47: 2129-2139
                                                    Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                    In the next few years we expect that more objective physical activity data will become available at a larger scale, and for the next update of our comparable estimates we will reconsider inclusion of these data in some way.
                                                    Finally, in some cases, our estimates are different to prevalence estimates produced by countries. There are several reasons for this difference. We adjusted our estimates for several factors when necessary. We also standardised our estimates to an artificial age structure, the WHO Standard Population.
                                                    • Ahmad O
                                                    • Boschi-Pinto C
                                                    • Lopez AD
                                                    • Murray CJL
                                                    • Lozano R
                                                    • Inoue M
                                                    Age standardization of rates: a new WHO standard. World Health Organization, Geneva; 2001
                                                    Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                    Furthermore, some countries tend to produce estimates for only leisure time physical activity, whereas we include four domains of physical activity. In these cases, national estimates of physical inactivity prevalence will be higher than our comparable estimates.
                                                    Our data show that progress towards the global target set by WHO member states to reduce physical inactivity by 10% by 2025 has been too slow and is not on track. Levels of insufficient physical activity are particularly high and still rising in high-income countries, and worldwide, women are less active than are men. A significant increase in national action is urgently needed in most countries to scale-up implementation of effective policies. The Global Action Plan on Physical Activity 2018–2030,
                                                      WHO. Global action plan on physical activity 2018–2030. More active people for a healthier world. World Health Organization, Geneva; 2018
                                                      Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                      is a new catalyst for global action, and provides a selection of 20 specific policies targeting different settings and populations that can be adapted and tailored to local contexts in all countries. However, implementation will require bold leadership and full engagement across sectors to change the current approach. Collaboration across sectors could generate significant returns, because policies that support increasing physical activity can provide other benefits to health, local economies, community wellbeing, and environmental sustainability, and contribute towards achieving many of the 2030 Sustainable Development Goals.
                                                        ISPAH International Society for Physical Activity and Health. The Bangkok Declaration on Physical Activity for Global Health and Sustainable Development. Br J Sports Med. 2017; 51: 1389-1391
                                                        Hollow Up Women's Cold Cruiize Classic Shoulder Dresses Bodycon Lace Black qFfZE
                                                        Contributors
                                                        RG analysed the data and wrote the first draft of the report. GAS and RG developed the methodological approach, with inputs from all other authors. All authors designed the study, and revised and approved the final report.
                                                        Declaration of interests
                                                        All authors are staff members of WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of WHO.
                                                        Acknowledgments
                                                        This study received no funding. See appendix (p 32) for further acknowledgments.

                                                        Supplementary Material

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                                                          Large-scale physical activity data reveal worldwide activity inequality.
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                                                          Figures

                                                          • Figure 1 Kendra loho loho Brown UK9 Kendra Trends in insufficient physical activity in men from 2001 to 2016
                                                          • Figure 2 Trends in insufficient physical activity in women from 2001 to 2016
                                                          • Figure 3 Trends in insufficient physical activity for three income groups from 2001 to 2016
                                                          • Figure 4 Country prevalence of insufficient physical activity in men in 2016
                                                          • Figure 5 Country prevalence of insufficient physical activity in women in 2016

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