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Physical inactivity is an important public health issue also because of its economic impact on the healthcare system. There are direct and indirect costs associated with physical inactivity. Direct costs are the direct medical healthcare costs and include, for example, the number of hospitalisations, doctor visits, drugs, etc., to treat specific diseases associated with physical inactivity (e.g., cardiovascular diseases, diet and obesity-related chronic diseases). Indirect costs include the economic loss due to illness, injury-related work disability, or premature death (Popkin, Kim, Rusev, Du, & Zizza, 2006).

2.3.2.1 Direct medical costs

In developed countries, it is estimated that the direct healthcare costs due to physical activity range from 1.5% to 3.0% of total healthcare costs and this affects public and private healthcare systems (Oldridge, 2008). For example, in the United States, a cross- sectional stratified analysis of the 1987 U.S. National Medical Expenditure Survey (Pratt, Macera, & Wang, 2000) revealed that physically active people, aged 15 and older, without physical impairments, had on average lower medical costs as opposed to people who were inactive. In fact, the average annual direct medical cost of active people was $1,019 and $1,349 for those who reported not being active (Pratt et al., 2000). Moreover, medical costs were lower among those who were physically active and did not smoke ($953 per year). Brownson, Boehmer and Luke (2005) reported that the total impact on medical costs due to inactivity and its consequences was $76 billion in 2000 (Brownson et al., 2005, p. 421).

Garrett et al. (2004), studied a population living in the state of Minnesota, USA, and subscribed to a large health plan (Blue Cross Blue Shield), reported that the total medical expenditures due to physical inactivity were $83.6 million (Garrett, Brasure, Schmitz, Schultz, & Huber, 2004). In another study, which combined the results of two national surveys (the 1996 Medical Expenditure Panel Survey and the 1995 National Health Interview Survey), Wang and colleagues (2004) found that in 1996 that physical

inactivity accounted for 13.1% ($5.4 billion) of the total medical expenditure of people diagnosed with cardiovascular diseases. Projecting these percentages to the total health and economic burden of cardiovascular diseases in 2001, the direct medical expenditure reached $23.7 billion, associated to 9.2 million cases (Wang, Pratt, Macera, Zheng, & Heath, 2004). Similar estimates were produced by Colditz (1999) who reported that physical inactivity alone cost approximately $24 billion to the healthcare system, corresponding to the 2.4% of the total U.S. healthcare expenditures in 1999.

In Canada, the direct healthcare costs of physical inactivity in 1999 were estimated to be about $2.1 billion, or 2.5% of the total direct healthcare costs (Katzmarzyk, Gledhill, & Shephard, 2000). However, only two years later, the economic burden of physical inactivity rose to an estimated $5.3 billion ($1.6 billion in direct costs and $3.7 billion in indirect costs). The total economic costs of physical inactivity and obesity represented 2.6% and 2.2%, respectively, of the total healthcare costs in Canada in 2001 (Katzmarzyk & Janssen, 2004). A study with a Chinese population estimated that the costs for the direct dietary and physical activity effects were more than $4.7 billion in 2000, and were projected to remain stable until 2050, when it is estimated that they will be about $4.3 billion (Popkin et al., 2006).

In Australia, a recent report by the Australian health insurance company Medibank estimated that in 2007 the total gross cost of physical inactivity was $1.5 billion a year in terms of healthcare expenditures for the prevention, diagnosis and treatment of medical conditions (Medibank, 2007). Of the total direct cost, $468.7 million were costs related to falls, and $371.5 million to Coronary Heart Disease due to physical inactivity (Medibank, 2007, p. 5). In 2008, the estimated total gross cost was $1.6 billion (Medibank, 2008, p. 6). Moreover, regarding the costs projected on the whole economy, Medibank and KPMG-Econtech estimated that inactivity caused a loss of $9.3 billion in GDP.

In Europe, physical inactivity was associated with high financial costs in various countries across the region, according to the 2006 WHO report on Physical activity in

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€150 – €3001 _{per European citizen per year (Cavill et al., 2006). For example, in}

Switzerland, a country with a private-based healthcare system, a study by Martin and colleagues (2001) showed that physical inactivity accounted for 1.6 billion Swiss francs per year.

In England, the Department of Culture, Media and Sports (DCMS) estimated that physical activity accounted for at least £2 billion a year (DCMS, 2002). Allender, Foster, Scarborough and Rayner (2007) estimated that in 2002, physical inactivity impacted on the NHS costs of £1.06 billion2_{. In 2006, Cavill and colleagues (2006) estimated that the}

annual costs (including direct and indirect costs) to the National Health Service (NHS) ranged between €3 and €12 billion (Cavill et al., 2006, p. 7). It was also underlined that this estimated costs “excludes the contribution of physical inactivity to overweight and obesity, whose overall cost might run to €9.6-10.8 billion per year” (Cavill et al., 2006, p. 7). More up-to-date estimates, published in the Be active, be healthy: a plan for

getting the nation moving of the Department of Health, showed that the annual costs to

NHS due to physical inactivity ranged between £1 and £1.8 billion (DH, 2009, p. 14).

2.3.2.2 Indirect costs of physical activity

In 2011, the World Health Organization (WHO) estimated that the indirect costs of physical inactivity consisted of about 3.2 million deaths per year globally (WHO, 2011a, p. 1, 2011b, para. 2). In the 2001 WHO World Health Report it was estimated that the indirect costs of physical inactivity were “1.9 million deaths and 19 million Disability Adjusted Life Years (DALYs) globally (WHO, 2002, p. 61). DALYs include the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.

1 _{This range corresponds to approximately $190.74 – $381.48 (1 EUR = 1.27160 USD; 1 USD =}

0.786410 EUR) and to CHF 182.17 - 364.35 (1 EUR = 1.21451 CHF; 1 CHF = 0.823380 EUR), according to mid-market rates for: 7/1/2012.

2 _{This translates in approximately $1.63 billion (1 GBP = 1.54251 USD; 1 USD = 0.648294 GBP) or}

CHF 1.56 billion (1 GBP = 1.47325 CHF; 1 CHF = 0.678771 GBP), according to mid-market rates for: 7/1/2012.

In the United States, Brownson and colleagues (2005) estimated that the annual indirect cost ranged from 200,000 to 300,000 healthy lives in 2000. In Canada, Katzmarzyk and colleagues (2000) estimated that in 1995, 21,000 lives were lost due to physical inactivity. Within the European region, the UK Department of Culture, Media and Sports (DCMS) estimated that 54,000 lives a year were lost prematurely due to physical inactivity (DCMS, 2002). Allender, Foster, Scarborough and Rayner (2007) estimated that in 2002, physical inactivity was directly responsible for the loss of 3% of DALYs in the UK. The cost for the whole economy in terms of productivity is estimated to be about £5.5 billion (due to sickness absence) and £1 billion from premature death of people of working age. In total, these costs reach approximately £8.3 billion every year (DH, 2009, p. 15). For example, in Switzerland, physical inactivity accounted for 1.4 million disease cases, almost 2,000 deaths, and indirect costs of .8 billion Swiss francs (Martin et al., 2001).

All these data suggest that promoting and encouraging physical activity is important also for reducing health-related costs. If people became more physically active, the direct and indirect costs could be significantly reduced. For example, Powell and Blair (1994) estimated that mortality due to sedentary living associated with coronary heart diseases, colon cancer and diabetes, could be reduced by 5-6% per year (30,000-35,000 deaths), if people become moderately active (Powell & Blair, 1994). In economic terms, a 10% of reduction in the prevalence of physical inactivity could result in savings of about $150 million per year in direct health care expenditures (Katzmarzyk et al., 2000, p. 1438).

58 BACKGROUND AND RATIONALE