1
Introduction
China has been transforming. Since the late 1970s, China's economy has increased many
fold, the proportion of Chinese living in urban areas has more than doubled, life
expectancy has increased by 10 years
1
and the country has transitioned from the “bicycle kingdom” to the world's largest
“auto market”.
2
As a result, China is now challenged by the “side effects” of economic development
at a much larger scale and a faster pace than any other country in history. These
problems include, but are not limited to, population aging, rising non-communicable
disease (NCDs), and environmental pollution.
Currently, people aged over 60 years account for more than 15% of the population and
the percentage is expected to grow due to improvements in life expectancy and reductions
in birth rates.
3
Major NCDs, such as cardiovascular disease, cancer, chronic obstructive pulmonary
disease, and diabetes, bear the largest disease burden in China
4
and NCDs account for 87% of total deaths overall.
5
Central to the dual problems of population aging and rising NCDs are lifestyle behaviors,
such as physical activity (PA). The evidence suggests a marked decrease in PA, particularly
in the domains of occupational and domestic activities.
6
Unfortunately, PA research is still in an early stage in China. Globally, China accounts
for around 20% of the pandemic of physical inactivity, but contributes to less than
3% of the research outputs on PA.
7
There is little research examining population trends in PA across different age groups,
the associations between PA and health outcomes, the correlates and determinants of
PA and the efficacy, effectiveness, and cost-effectiveness of interventions for promoting
PA.
To reverse the trend of the epidemic of physical inactivity, it is critical to step
up research to build evidence base in China. Special issues on PA, such as the current
one in the Journal of Sport and Health Science, are critical in catalyzing the process.
In this commentary, we discuss the areas of challenges and improvements in PA and
public health in China and provide suggestions for future research and practice.
2
Areas of improvements and suggestions for future research
2.1
PA across domains and the intensity continuum
In the past 2 decades, the field of PA and health has evolved from a central focus
on sports and exercise to more recently recognizing the benefits of PA from different
domains, of different levels of intensity, and in long or short bouts. This paradigm
change has led to growing global research on active travel, incidental (daily lifestyle)
PA, and prolonged sedentary behavior (sitting time). Currently, most research on PA
in China has focused on leisure-time physical activity (LTPA). Given that LTPA is
uncommon in China and only represents a small proportion of total PA,
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it is important to better understand other domains, such as transport-related activity,
where potential opportunities of promoting population-level PA exist.
Another major breakthrough in the understanding of PA and health is the increasing
evidence on the health effects of light-intensity PA9, 10 and sedentary behavior,
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which are particularly relevant to seniors due to the overall lower PA levels and
physical function. Some proposed that PA should be considered as a continuum where
various intensities offer unique health benefits. To date, most studies on PA in China
focused on moderate-to-vigorous intensity PA, which accounts for only a small fraction
of the total daily energy expenditure. More research on light-intensity PA and sedentary
behavior across different domains and demographic subgroups could shed light on the
overall patterns and distributions of PA in China, and its relationship to obesity.
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2.2
PA in a broader context of prevention
PA is not just about energy expenditure and obesity prevention. More research in China
should explore the comprehensive outcomes of PA with a particular focus on the areas
where evidence is still accumulating, such as mental health
13
and cognitive function.
14
Furthermore, beyond disease prevention, PA could promote positive mood, well-being,
quality of life, and have positive social and environmental implications.
It is important to note that the benefits of PA not only apply to primary prevention,
but also lie in secondary prevention/disease management. For example, PA is an important
component of diabetes management
15
and cardiac rehabilitation.
16
Despite the high prevalence of diabetes and rising cardiovascular disease, lifestyle-based
secondary prevention is still an under-developed area in China. This is an adjunct
to clinical therapy, and the co-benefits of PA in people with established chronic
disease could save substantial healthcare costs.
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2.3
Interdisciplinary and cross-sectoral collaboration
Redefining PA is essential to making a population-wide difference. It is not only
relevant to sports scientists, but also to a range of health professionals, gerontologists,
social scientists, urban planners, psychologists, educators, transportation engineers'
and others. Promoting PA requires interdisciplinary and cross-sectoral collaboration
that makes active choices the accessible, cheap, and easy choices. Currently, this
collaborative approach to PA is rarely reflected in research in China. In fact, this
is a larger issue that is commonly documented in health behavior research in China.
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The current research gaps in China present great opportunities for exploring the frontiers
of PA and public health using collaborative approaches. For example, the relationship
between aspects of urban environments, transportation systems and PA has not been
well explored; there is a dearth of research on community-based interventions to promote
PA among seniors; PA-related myths and misunderstandings are widely held (e.g., vigorous
PA is sometimes considered harmful to health), particularly among seniors, but are
seldom documented by research, health professionals have rarely been utilized as the
“agent of change” for PA promotion; and economic evaluations have not been widely
applied to PA interventions. Meanwhile, many unique types of PA and their cultural
perspectives should be explored to encourage participation in culturally appropriate
and socially reinforcing activities. For example, dancing at public places has grown
“organically” throughout the country as one of the most popular forms of exercise
among senior women in urban areas.
2.4
Opportunistic evaluation of policies, programs, and environmental changes
China is changing at a rapid pace. Change presents opportunities for evaluation. Many
programs implemented at a local or national level may have implications for PA and
overall lifestyle behaviors in China, such as “Healthy Lifestyle Action for All”,
co-sponsored by the Disease Prevention and Control Bureau of the Ministry of Health
of China, the National Patriotic Public Health Office, and the Chinese Center for
Disease Control and Prevention. Other changes to the built, social, and policy environments
may indirectly affect PA, such as restrictions on car ownership, development of new
neighborhoods, and construction of public recreational spaces. It is important to
opportunistically capture these ever-present changes and evaluate their impacts on
PA and health, using pragmatic yet robust methodologies. This does not imply the need
for randomized trials, which, in reality, are less feasible at the community level.
Instead, innovative PA programs in schools, districts, or community centers can be
compared with their counterparts that have not yet implemented these programs, to
assess the effectiveness of these programs in the real world. If demonstrated to be
effective, China has excellent capacity to scale up specific interventions and deliver
them across many communities. This provides research opportunities to assess the implementation
and reach of these “scaled up” programs.
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Conclusion
Economic development has brought prosperity to China, but has also created problems.
To counter rising NCDs, it is important to promote a healthy and physically active
lifestyle. The field of PA and public health is growing in China, but is still disproportionate
to the size of the epidemic of physical inactivity. Gaps and limitations exist but
also present opportunities for future research and practice. The current special issue
on PA, aging, and health in China is a promising step toward more comprehensive, cross-disciplinary,
and culturally relevant research in China. Through this special issue, we urgently
advocate for stepping up research on PA in China. In this commentary, we provided
specific suggestions as a potential “roadmap” for this endeavor.
Authors' contributions
DD and AEB conceptualized this paper; DD drafted the first version of this paper;
and FH and AEB provided critical feedback. All authors have read and approved the
final version of this paper, and agree with the order of presentation of the authors.
Competing interests
None of the authors declare competing financial interests.