Physical activity: the way ahead for a healthier India

To the Editor, Physical inactivity is a global health problem with considerable healthcare and economic burden. Various studies show a strong association between physical inactivity and the development of non-communicable diseases (NCDs) [1–5]. Physical inactivity has a negative effect on mental health and quality of life as well. Globally, the NCDs have replaced communicable diseases (CDs) as a cause for mortality [6]. NCD-related deaths have increased exponentially; WHO estimates that over 80% of them occur in lowand middle-income countries (LMICs) [4]. The published literature to date suggests an epidemic of physical inactivity and NCDs in India [7– 11]. India is almost contributing two thirds of the mortality due to NCDs in the South-East Asia Region [6, 10]. The additional worrying fact is that NCDs are developing a decade earlier in the Indian population than individuals in the developed nations [12]. There are multifactorial reasons for such a rise, though physical inactivity is considered the most crucial factor for this NCDs epidemic [2]. Indeed, this global burden of NCDs is caused due to physical inactivity, and we suggest that focus on physical activity (PA) is the way ahead. We must discuss in what ways we can move forward and promote PA to impact the public health.

Physical activity: the way ahead for a healthier India

Ammar Suhail
To the Editor, Physical inactivity is a global health problem with considerable healthcare and economic burden. Various studies show a strong association between physical inactivity and the development of non-communicable diseases (NCDs) [1][2][3][4][5]. Physical inactivity has a negative effect on mental health and quality of life as well. Globally, the NCDs have replaced communicable diseases (CDs) as a cause for mortality [6]. NCD-related deaths have increased exponentially; WHO estimates that over 80% of them occur in low-and middle-income countries (LMICs) [4]. The published literature to date suggests an epidemic of physical inactivity and NCDs in India [7][8][9][10][11]. India is almost contributing two thirds of the mortality due to NCDs in the South-East Asia Region [6,10]. The additional worrying fact is that NCDs are developing a decade earlier in the Indian population than individuals in the developed nations [12]. There are multifactorial reasons for such a rise, though physical inactivity is considered the most crucial factor for this NCDs epidemic [2].
Indeed, this global burden of NCDs is caused due to physical inactivity, and we suggest that focus on physical activity (PA) is the way ahead. We must discuss in what ways we can move forward and promote PA to impact the public health.

The way ahead
PA has already been proven to help prevent and manage different NCDs [13]. PA has also shown evidence in the reduction of NCDs associated with premature deaths [14]. The best way forward is to promote PA at a population level. According to the literature, PA is emphasized as the most robust intervention to decrease risks associated with NCDs' development. Despite the fact, there is a decrease in the number of physically active individuals. The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study reports a large percentage of people in India are inactive, with fewer than 10% engaging in recreational physical activity [2]. The increasing economic development, improvement in transportation methods, and other technological advancements further increase the level of physical inactivity [13].
The NCD interventions can be addressed at two levels: population-based interventions and individual-based interventions. Population-based interventions focus on reducing NCD risk factors, and individual-based interventions focus on NCDs in primary care settings [9]. The integration of both approaches is needed to tackle the widespread increase of NCDs [15,16]. Improving physical activity at the population level may bring a 6 to 10% downfall in major NCDs [3]. In the Indian context, the lack of people participating in physical activity can be attributed to various reasons. The way forward should be addressing all these reasons to achieve the desired levels of PA. National health portal in response to the new Global Action Plan on Physical Activity (GAPPA) 2018-2030 suggest reductions in physical inactivity by 25% by 2025 [17].
Increasing physical activity requires a systems-based approach-it cannot be a single policy solution [13]. In a country like India which has the greatest diversity, this must be done at various levels. The increased level of PA in a society can be achieved through three methods; one of them should be promoting PA at the national level, aided by a national policy targeted at such interventions. There is a need to formulate a national physical activity program to appropriately promote physical activity at the population level so that lacunae could be bridged [9]. Secondly, by incorporating PA and its benefits in our education system, to imbibe PA in the social and cultural norms of the society. A recent study proposed incorporating NCD risk reduction strategies and practical sessions on health promotion and behavior change activities in the health professional education system. The research also suggests that our curriculum lacks focus on healthcare promotion and long-term physical activity [7].
Thirdly, there is a need to understand our environments, as they will play a role in facilitating PA [11]. WHO suggests that creating active environments must achieve a 15% reduction in physical inactivity by 2025. This reduction is a crucial step to curb the rise of NCDs. The strategy of building physical activity facilitating environments will replicate in terms of active people and active societies. Better environments can be created by strengthening road safety, improving access to public open spaces, improving walking and cycling networks, and implementing proactive building policies [11,13]. These strategies of building physical activity enabling environments will replicate in terms of active people and active societies.
The other factors that need to be addressed are barriers, beliefs, and myths associated with PA and NCDs to ensure better PA participation. The studies exploring PA barriers in the Indian context highlight social and cultural norms such as females face social censuring for participating in PA [18]. The majority of people believe that routine household activities are the same as PA [19]. These beliefs and myths must be addressed at the community level. The barriers differ among age groups, and this should be considered while designing policies for different age groups. In adolescence, physical inactivity is associated with electronic gadgets and lethargy, while in middle-aged females, it is related to lack of time, motivation, and interest [19]. Considering this system-based approach of addressing all the factors is the right way ahead. PA can be used as a preventive tool to curb the epidemic rise of NCDs.
In every health care system, preventive measures reduce chances of further damage, improve quality of life, and yet remain cost-effective. Physical activity can be deemed an easy, efficient, and most affordable method for the population.

Abbreviations
NCDs: Non-communicable diseases; CDs: Communicable diseases; LMICs: Lower middle-income countries; PA: Physical activity; GAPPA: Global Action Plan on Physical Activity