Will increasing fiscal resources promote physical fitness?

There is increasing evidence that people who exercise are more healthy, live longer and enjoy a better quality of life than those who do not exercise.1 How much healthier, how much longer and how much better the quality remain to be determined. Assigning a dollar amount to those increases could provide support for a change in public policy on government funding for physical activity programs. Decision makers such as government officials, executives whose companies have extensive employee health benefits, and insurers must determine whether support for fitness programs is not only a sound physical investment but also a sound fiscal investment. Peter Katzmarzyk and colleagues2 (see page 1435) provide evidence that physical inactivity is costly to society and that cost is measurable in dollar amounts, but is this the evidence the decision makers are looking for? The good news is that it might be. The bad news is that it might not matter.

First, the good news: Katzmarzyk and colleagues conducted a systematic review of the literature and calculated relative risk estimates of the effects of physical inactivity on 7 serious and prevalent illnesses. They then determined the direct health care costs associated with these illnesses and estimated the proportion of those costs directly attributable to physical inactivity.

Certainly, epidemiologists and biostatisticians will approve of the analytical approach that the authors took to calculate the $150 million annual cost of physical inactivity to Canadians. There are limitations to their analysis, however, both acknowledged and unacknowledged, that may affect the validity of their conclusions. For example, the authors admit that much of their data on the costs of illness were obtained from the Economic Burden of Illness in Canada, 1993,3 and that expenditures for colon cancer, breast cancer, type 2 diabetes and hypertension had to be estimated from prevalence and incidence data or from expenditure data from the United States. Additionally, as the authors state, physical activity itself is difficult to measure accurately. The authors do not acknowledge that using several meta-analyses to pool data is a method that I believe may itself be flawed. Despite the limitations inherent in this type of analysis, Katzmarzyk and colleagues maintain, and I agree, that their estimates are conservative. Their logic is persuasive, and their conclusions are not so overwhelming as to be unbelievable.

However, all of the news is not good. No matter how compelling the data and how dire the consequences of noncompliance, the “field of dreams” philosophy regarding physical activity has not proved effective. Even if the government and corporate decision makers are convinced that an investment to support physical activity will provide a return on their investment and funds are committed ... if they “build it,” will they come? The answer is unclear; the fear of ill health and an early death or a poorer quality of life has not resulted in an increase in physical activity,4 nor have previous descriptions of the economic cost of inactivity.5 The fiscal logic notwithstanding, the economic burden of physical inactivity has been no more compelling an argument than other attempts to motivate people to exercise. It just might not matter.

It is possible that government investment in promoting physical activity may only be effective if it approaches the hundreds of millions of dollars lost because of physical inactivity. And then, what have we gained? Or, as argued by many corporate benefits actuarials, physically inactive people who have other high health risk behaviours tend to die young, and although they may be an initial burden on the health care system, their early death is actually good for high-cost pension plans.

Despite the uncertainty of the impact this article and others with the same message may or may not have on activity levels, we must continue to build a scientific and economic rationale to encourage physical activity. At the same time, we must explore new ways to motivate people to exercise. It is not enough for us to “know” that it is good for us to exercise. Governments should indeed provide resources to support fitness facilities and organized exercise programs, but some of the funds must be set aside for marketing and promotion as well. Without ease of access and incentives for participation, the desired end result will not be realized. Even if we can't precisely quantify the economic gains of increasing physical activity, we should continue to provide the best rationale and incentives to encourage participation in the best fitness programs we can. Physical activity improves health; it reduces health care costs, and it makes us look good and feel good longer.