The Miracle Pill

by Peter Walker

  The picture gets notably worse when it comes to children. They should aim for an hour of moderate-to-vigorous activity every single day, with those aged under five active for at least three hours daily. In fact, the UK guidance for the latter age group says children so young should never be immobile for long periods, apart from when they’re asleep. But in the UK, only 22 per cent of those aged five to fifteen are reaching the minimum, a figure that declines below 15 per cent in adolescence. Even worse are the statistics for the youngest children, aged two to four, whose mandated three hours a day of movement is vital to lay down bone density and build muscles, as well as acquire the motor skills needed for life. Just 9 per cent manage this.13

  The UK is no outlier. In fact, in global terms it is broadly typical. Just over a week before the opening of the 2012 London Olympics, revered medical journal The Lancet devoted an issue to what it described as the worldwide ‘pandemic of physical inactivity’. While the edition was timed to coincide with a sporting event, the stress was very much on everyday activity. ‘It is not about running on a treadmill, whilst staring at a mirror and listening to your iPod,’ the Lancet editors wrote in an introduction. ‘It is about using the body that we have in the way it was designed, which is to walk often, run sometimes, and move in ways where we physically exert ourselves regularly, whether that is at work, at home, in transport to and from places, or during leisure time in our daily lives.’14

  Among the papers was a study by a team of academics seeking to quantify for the first time the global extent of inactive lifestyles. Led by Pedro Hallal, a Brazilian epidemiologist, it took data from just under 90 per cent of the world’s population, using a recently agreed standardised international physical activity questionnaire, allowing for the first time robust comparisons between countries and regions.

  The headline figure was that 31.1 per cent of people aged fifteen or older were insufficiently active. For those aged thirteen to fifteen, four in five across the world were not meeting the targets.

  The study also uncovered the sheer variation across regions, countries, genders and ages. While 43 per cent of adults were inactive in the Americas, this fell to 17 per cent in southeast Asia. Between individual nations the difference was more extreme still, going from fewer than 5 per cent of people not meeting activity guidelines in Bangladesh to very nearly 80 per cent in Malta, the Mediterranean island which despite its idyllic holiday destinations is dominated by car travel. Globally, women were less active than men – 34 per cent were too immobile against 28 per cent – and older people tended to perform less well.15

  Another huge international project has sought to specifically chart the activity levels of children and teenagers. The somewhat ponderously named Global Matrix 3.0 Physical Activity Report Card covers forty-nine countries, and is regularly updated. Fittingly for a study involving young people, each country’s results are given in a school report–style grading system of A to F. To extend the parallel a little further, it’s fair to say that if many nations were handed such a report at school, they’d probably try to lose it on the way home, or quietly feed it to the dog.

  Countries are rated both for overall youth activity levels, and for specifics such as organised school sport, active travel and input from government. The column for overall grades is a pretty sorry one, featuring a handful of Fs – hang your heads in shame, China, Belgium, Scotland and South Korea – and a mass of Ds, with the USA and Australia both awarded a D-minus. England scrapes a C-minus, with poor scores for active travel and sitting time redeemed in part by school sports.

  The only country to gain above a C is Slovenia, topping the table with a highly respectable overall A-minus. The small and mountainous former Yugoslav state might be a geographical minnow – the world’s 150th biggest country by size, it has a population of just 2 million – but is keenly studied by those interested in population-wide physical activity, and we shall return to it later in the book.16

  Yet another international study has examined a series of countries to firstly assess how much worse inactivity levels have become in recent decades, and then extrapolate current trends to see what might be coming in future decades. It makes the assessment using a bespoke health metric which the US researchers titled, Sleep, Leisure, Occupation, Transportation, and Home-based Activities. This gives you the acronym SLOTH, something I can only imagine brought a self-satisfied chuckle to whoever first coined it.

  In the UK, the project found, overall activity levels had fallen 20 per cent in just over three decades, with the amount of exertion people undergo in their work dropping by almost half. By 2030, the researchers predicted, total activity for Britons will be 35 per cent lower than in the mid-1960s. In China, average activity is expected to fall notably more quickly, by a half between the early 1990s and 2030. It is, however, the US where the most astonishing figures lurked. The academics calculated that on current trends, by 2030 the average American will, over an average week, expend only about 15 per cent more total bodily energy than someone who spent the entire seven days in bed.17 If that sounds worrying, it should be.

  The myth of personal choice

  In the 2008 Pixar film WALL·E, while the eponymous solitary robot endlessly cleans up a rubbish-ruined Earth, the people of the twenty-ninth century are portrayed as space-dwelling, corpulent, jumpsuit-dressed adult-babies, who spend their lives on mobile reclining chairs, a screen permanently at hand. It can be difficult to read studies about the seemingly unstoppable decline in human movement without viewing the film as prophetic, as well as an indictment of humanity’s collective decision to slide towards a future of indolence, lethargy and pharmaceutically managed ill-health.

  But such a judgemental stance is a grave mistake. The decline in physical activity has had many drivers, but a sudden, global outbreak of idleness is not one of them. This is a crucial point to stress. In fact, one of the reasons the crisis has advanced, largely unchecked, for so long is because governments have ducked responsibility by falsely portraying the issues as based on individual choice and willpower.

  This is a complex area, and worth exploring properly. To begin with, it is true that most people, if prompted, probably have at least a basic idea that moving more and sitting less is, on balance, likely to be better for their health. A lot will have heard about the 150-minutes-a-week activity target. Even more will most likely know another much-pushed goal, that of walking 10,000 steps a day. So why do so few people manage it?

  One idea that often gets mentioned is insufficient time. It is true that for all the predictions of automation ushering in a life of leisure, many people work just as many hours, or more, than their parents did a few decades earlier. This theory, however, comes with a fairly big caveat. In the words of William Haskell, a now-retired Stanford University professor who is one of the founding figures of the modern physical activity world: ‘Surveys show that the most frequent given reason for not being more physically active is lack of time, but this is in a population that reports at least several hours of TV-watching each day.’18

  Haskell is being a touch mischievous. Watching television is a leisure pursuit, often done in the evening alongside family or other loved ones. It can take significant gumption to wave away the proffered glass of wine, peel yourself from the sofa and head out for a run, or to the gym. This is what public health experts like to call ‘discretionary time’. Carving out chunks from it can be a big ask.

  This is the central point: if you really want physical movement to embed in someone’s life, it has to be in the form of another beloved public health term – ‘incidental activity’. This is, at its simplest, activity which takes place almost as an afterthought, because it forms part of your regular day. It is what happened in the past when people did farm chores, or carried in wood for the fire, or walked to school. This was just life. In contrast, sport and exercise generally happen in discretionary time, which is one of the main reasons they are so unsuited to replacing regular exertion as a population-wide driver of bet
ter health.

  The distinction between these two very different things is often missed, not least by governments. In the broadest terms, physical activity is every single piece of movement you make during the day, from brushing your teeth in the morning, to walking up a flight of stairs to your office, or sprinting to catch a train. Exercise is just a subset of physical activity. It is activity which, to use one formal, academic definition, is ‘planned, structured, repetitive, and purposive in the sense that improvement or maintenance of one or more components of physical fitness is an objective’.19

  If that isn’t completely clear, take an example from my own life. I’m currently writing this book in an empty flat about three miles from where I live in south London, borrowed as a short-term writing base. This morning, like more or less every time I have made the trip, I cycled. This was very much physical activity, but not exercise – I did it primarily because it was by far the quickest and most convenient way to travel. Yes, according to a wrist-worn fitness monitor I have borrowed for self-experiment purposes while writing the book, I expended around 170 calories and pushed my heart rate to a peak of 151 beats per minute. But the exertion came about as a side effect, not a primary intention, even if the health benefits were, for me, both known and welcome. Instead, if I had decided to take a day off from the laptop, put on some bike clothes and ridden a few miles further south into the green belt countryside before returning home, this would also have been activity, but exercise as well.

  My example highlights something else. The route is almost all on roads without any protected bike lanes. So, in deciding to cycle, I had to make the conscious choice for my unprotected body to directly share road space with two-tonne slabs of metal, gliding closely past me, even at relatively low speeds of around 30mph. I’m okay with doing this because I’ve cycled alongside cars for years, and I more or less know what to expect. I’m also male and in middle age, one of the demographics more likely to brave urban streets on a bike. But many other people would not be so bullish. And so travelling by bike, the method through which I gain a significant proportion of my weekly physical activity, would be entirely closed off to them.

  This is a vital point to consider in our story of vanishing everyday movement – it is a far broader issue than slightly trite discussions about personal responsibility. As soon as you start examining the world from the perspective of adding activity into your routine, you quickly see how thoroughly, how carefully, and at times how cunningly the built environment that surrounds us has been redesigned over the past seventy or so years to make regular exertion an increasingly difficult, at times almost impossible, choice.

  To take another example, think about the last time you walked into an office block or large hotel. Almost certainly, the lifts would have been in direct view. But the stairs? If you wanted to climb even a single flight you would probably have had to hunt along a corridor for the recessed fire door, made sure you didn’t set off an alarm in opening it, and then trekked up a generally blank, narrow, windowless stairwell in the hope you could open the door at your destination. It’s not exactly intuitive.

  The disincentives to movement exist in just about every environment in which we live our lives, and come in many forms. If you have a desk-based job, then if email reduced the number of times you walked twenty yards down the office to talk to a colleague, then the recent plethora of text-based chat apps might have stopped this altogether. Meanwhile, the rise of online retailers has played a significant role in the ebbing away of that most basic of leisure-time physical actions, walking round the shops. As soon as you start thinking in this way, the examples crop up in virtually every part of life.

  I discussed all this with Xand van Tulleken, a British doctor who has a master’s degree in public health but is primarily known as a TV presenter on medical and health matters, often alongside his identical twin and fellow doctor, Chris.

  One of the main parts of van Tulleken’s job is to explain often complex health ideas to mass audiences, and he is very eloquent on why people’s choices in areas such as being active are nowhere near as straightforward as they might seem. ‘One of the things I often end up saying to people is that the only person who can really affect your health is you,’ he tells me. ‘And that is true as individuals. We are just making all the choices that determine our life expectancy. But we’re making them in an environment where we are unbelievably constrained.’

  Van Tulleken notes that living, as he does, in a relatively privileged stratum of society where virtually no one smokes or drinks to excess and most exercise regularly can bring a temptation to feel, as he puts it, ‘slightly smug’. He warns against such feelings: ‘Really, that’s bollocks. You would have to go a long way in the UK to find someone who sincerely didn’t know that beer was bad, fags were bad, or exercise was good. But for some people it’s made enormously difficult.

  ‘I am not an exemplar of a healthy life by any means. But if I had two jobs, was a single parent trying to support kids with special needs, with an uncertain future myself, I would find it very, very much harder not to eat terrible food and seek joy in unhealthy things. If I think about how hard it is for me to make a good choice, and then imagine stripping away my safety nets, my parachutes, I think it would be so difficult.’20

  Sport won’t change things

  Van Tulleken describes this prevailing narrative about physical activity as ‘the cult of individual responsibility’. This illusion is sustained in no small part by the parallel commodification of exercise, represented as something theoretically available to all but, in practice, often impossible for those poor in money or time, or otherwise challenged. It is illuminating to consider how the decades-long drift away from everyday movement has been so closely tracked by the gradual evolution of sport and gym-going into a value-laden semi-religion, with bodily health viewed not as a routine occurrence but a personal project, one closely attached to appearance, status and wealth.

  While the idea of gymnasiums comes from the Ancient Greeks, the arrival of their modern equivalents coincided, both chronologically and geographically, with the initial peaks of industrialisation and urbanisation, just as centuries of everyday movement started to gradually ebb away. The first modern gyms were associated with the curious and relatively short-lived phenomenon of Muscular Christianity, a movement based on faith-based masculine athleticism which grew out of the English public school system in the 1850s. It later took root in the US and the associated movement of the YMCA, where it was responsible for the invention of basketball and volleyball.

  As the decades progressed, the modern cult of exercise began to emerge. In a fascinating book about the fitness industry,21 Jennifer Smith Maguire, a British-based academic who specialises in the sociology of consumer culture, points out that celebrity personal trainers are by no means a new phenomenon. In the 1920s, Artie McGovern, a former flyweight boxer who ran a New York gym, became the must-have physical guru for Broadway stars and Wall Street financiers alike, after helping the overweight and overindulging Babe Ruth recover from a trough in his baseball career. It was around the same time that Angelo Siciliano, a somewhat scrawny Italian immigrant to the US, but now beefed up, rebranded himself as Charles Atlas, making a fortune selling exercise regimes based around newspaper adverts in which bullies kicked sand into the face of young weaklings.

  The growth of the modern gym-as-personal-temple is more recent, with Smith Maguire identifying the turning point as 1975, when the New York City Yellow Pages replaced its listings for ‘gymnasiums’ with the new category of ‘health clubs’. The boom since then has been staggering. It can be difficult to quantify, but various estimates put the worldwide annual revenues of the health club and fitness industry at about £65 billion, significantly more than the GDP of countries like Bulgaria and Croatia.22

  We now have a glaring divide of physicality. On the one side are the minority of adherents to the exercise industry, where running shoes can cost £200 and yoga mats even more, and where new
fads arrive with tech industry–like rapidity. Consider Peloton, a US start-up offering spin classes streamed to your home, using a £2,000 stationary bike. It was launched in 2013 with a few hundred thousand pounds gathered from a crowdfunding website. Six years later, an initial share offering valued the company at £6.5 billion.23

  Another phenomenon is the tendency of some people towards ever-greater levels of exertion. Ultrarunning is any event where the route is longer than the 26-and-a-bit miles of a marathon, although they often span 50 or 100 miles, or greater. These are far from new, but until the past few years they tended to be rare and extremely niche events. Not anymore. In the UK alone, there are now about 500 such events a year, a ten-fold increase in just a decade.24

  Even as overall activity levels stagnate, the UK now has an estimated 10 million people who are members of a gym, a 25 per cent increase in the past five years.25 Modern gyms in particular epitomise this increasingly elitist approach to exertion. ‘It’s not just about exercise, or about how muscles are looking a certain way,’ Smith Maguire tells me. ‘There’s a whole moral economy around how you approach yourself as a site of work, as a site of display for others, as a place for working out your identity.’26

  A couple of years ago, when the high-end US gym chain Equinox opened a new £350-a-month outlet in St James’s, one of central London’s most expensive mini-enclaves, Harvey Spevak, the company’s executive chairman, gave an interview to the Financial Times27 which could have been explicitly designed to illustrate Smith Maguire’s points. Equinox gyms’ patrons, Spevak said, were not the sort to be satisfied with two visits a week – more like two classes every day. ‘They want it all,’ Spevak told the interviewer with almost paternal pride. ‘They want to figure out a way they can feel good, look good, be active, and be with like-minded individuals as well as thrive in whatever their personal objectives are.’ Equinox also has a parallel chain of five-star hotels, intended for what Spevak called, somewhat intimidatingly, the ‘high-performance traveller’.