Privileging the privileged: the public health focus on leisure time physical activity has contributed to widening socioeconomic inequalities in health

To examine temporal trends in participation in sport and exercise activities in England between 1997 and 2006 while taking into account wider societal changes. A series of annual cross-sectional surveys. Nationally representative samples of men (n = 27 217) and women (n = 33 721) aged >or=16 years. Any (more than once every 4 weeks) and regular (more than once a week) participation in overall sport and exercise and a number of sport and exercise groupings (eg cycling, swimming, gym and fitness club-based activities (G/FC), racquet sports). Time point (1997/98, 2003/04, 2006) was the main dependent variable. Age-standardised overall regular participation changed from 40.8% in 1997/98 to 41.2% in 2006 for men (multivariable-adjusted participation OR = 1.11 in 2006, 95% CI 1.03 to 1.19, p or=45 years) (1.25, 1.16 to 1.35, p<0.001). Young men (16-29 years) had reduced ORs for cycling (0.72, 0.58 to 0.88, p = 0.008), dancing (0.60, 0.45 to 0.82, p = 0.001), running (0.78, 0.64 to 0.94, p<0.001) and racquet sports (0.60, 0.42 to 0.86, p = 0.003). In men, increases were pronounced only among men from non-manual social classes, higher income households and white ethnic backgrounds. Sports and exercise participation in England has changed between 1997 and 2006 as the result of increases among middle-aged and older adults and decreases among young men. There are no signs that the participation gap between less and more advantaged population groups is narrowing.

Since Hippocrates first advised us more than 2000 years ago that exercise-though not too much of it--was good for health, the epidemiology of physical activity has developed apace with the epidemiological method itself. It was only in the mid-20th century that Professor Jeremy N Morris and his associates used quantitative analyses, which dealt with possible selection and confounding biases, to show that vigorous exercise protects against coronary heart disease (CHD). They began by demonstrating an apparent protection against CHD enjoyed by active conductors compared with sedentary drivers of London double-decker buses. In addition, postmen seemed to be protected against CHD like conductors, as opposed to less active government workers. The Morris group pursued the matter further, adapting classical infectious disease epidemiology to the new problems of chronic, non-communicable diseases. Realizing that if physical exercise were to be shown to contribute to the prevention of CHD, it would have to be accomplished through study of leisure-time activities, presumably because of a lack of variability in intensities of physical work. Accordingly, they chose typical sedentary middle-management grade men for study, obtained 5-minute logs of their activities over a 2-day period, and followed them for non-fatal and fatal diseases. In a subsequent study, Morris et al. queried such executive-grade civil servants by detailed mail-back questionnaires on their health habits and health status. They then followed these men for chronic disease occurrence, as in the earlier survey. By 1973 they had distinguished between 'moderately vigorous' and 'vigorous' exercise. In both of these civil service surveys, they demonstrated strong associations between moderately vigorous or vigorous exercise and CHD occurrence, independent of other associations, in age classes 35-64 years. In the last 30 years, with modern-day computers, a large number of epidemiological studies have been conducted in both sexes, in different ethnic groups, in broad age classes, in a variety of social groups, and on most continents of the world. These studies have extended and amplified those of the Morris group, thereby helping to solidify the cause-and-effect evidence that exercise protects against heart disease and averts premature mortality.