Introduction
Most countries are falling behind on their commitments to the 2030 UN Sustainable Development Goal (SDG) 3.4 to reduce by a third the premature mortality from non-communicable diseases (NCDs), the leading cause of death and ill health globally.
Also of concern is the increasing global burden of mental health problems, exacerbated by the COVID-19 pandemic.
At this pace, countries are unlikely to achieve their 2030 SDG 3 commitments of ensuring healthy lives and promoting wellbeing for all at all ages.
Reducing the prevalence of modifiable risk factors, such as tobacco use, harmful use of alcohol, unhealthy diets, and physical inactivity, is a cost-effective strategy to reduce the burden of NCDs and mental health problems. Every US$1 invested in scaling up effective interventions to reduce risk factors and manage NCDs, for example, could generate a return of up to US$7 in low-income and middle-income countries (LMICs), where almost 85% of all premature deaths due to NCDs occur every year.
Yet, slow progress has been observed over the years, especially in those settings.
Physical inactivity is a major modifiable risk factor for NCDs and mental health conditions including stroke, hypertension, type 2 diabetes, coronary heart disease, several types of cancers, dementia, depression, and all-cause mortality; in particular, deaths due to cardiovascular diseases.
The global costs of physical inactivity to health-care systems, based on only five health outcomes (coronary heart disease, stroke, type 2 diabetes mellitus, breast cancer, and colon cancer), were estimated at INT$53·8 billion (2013), of which 58% was paid by the public sector.
To support countries’ responses, WHO identified 20 evidence-based policy recommendations, outlined in the WHO Global Action Plan on Physical Activity 2018–30, to guide national efforts to increase population levels of physical activity.
But global progress on reducing levels of physical inactivity has been slow.
Stronger advocacy is needed to establish the multisectoral action necessary to promote and enable more physical activity. This advocacy can be supported with an economic case for governments and non-governmental organisations to invest in physical activity.
Research in context
Evidence before this study
Physical inactivity increases the risk of death from non-communicable diseases (NCDs). Only one previous global study has estimated the direct health-care costs resulting from physical inactivity using a disease prevalence-based approach, reporting an economic cost to society of INT$53·8 billion (2013 prices), of which 58% was paid by the public sector. That study included five health outcomes for which estimates of the relative risks were available at the time. However, the study did not address the important questions of what would be the current and future potential preventable public health-care costs that could be averted if levels of physical inactivity were to be reduced or eliminated.
Added value of this study
This is the first global study to provide estimates of the number of new cases and associated public health-care costs that would occur from 2020 to 2030 that could be prevented if levels of physical inactivity were reduced or eliminated. This study provides new population-attributable fractions for seven health outcomes and mental health conditions (coronary heart disease, stroke, type 2 diabetes, cancers [breast, colon, bladder, endometrial, gastric, oesophageal, and renal], depression, and dementia) with strong evidence for the association with physical inactivity.
Implications of all the available evidence
This study combines the assessment of the health and economic impacts of NCDs and mental health conditions associated with physical inactivity, and provides policy makers with empirical data on the cost of not acting to reduce physical inactivity. These data will equip policy makers with evidence to inform and advocate for greater investment in policy interventions that increase physical activity levels. This study calls for urgent action by countries to prioritise investments in interventions that reduce this modifiable risk factor. WHO’s Global Action Plan on Physical Activity provides clear guidance on evidence-based policy recommendations, which if implemented by countries will improve health, reduce the burden on health systems, and save money.
Making the investment case for physical activity is key to informing decision making and prioritising resources and generating political and societal support for policy implementation. Estimating the health and economic costs of continuing with no action to reduce levels of physical inactivity is the first step in building a case for investment in physical activity.
We aimed to estimate the cost to public health-care systems of inaction on physical inactivity. This study is the first global estimate of the number of new (incident) cases of disease and their associated public health-care costs that would occur from 2020 to 2030 and to present the costs that could potentially be averted if levels of physical inactivity were reduced or eliminated.
Results
We estimated that 499·2 million new cases of preventable NCDs and mental health conditions would occur globally, from 2020 to 2030, if the current prevalence of physical inactivity does not change. 234·6 million (47%) of these new cases would be hypertension and 215·7 million (43%) would be due to depression and anxiety (figure 1). 368·4 million (74%) new cases would occur in LMICs, and of the total number of new cases of NCDs and mental health conditions due to physical inactivity 125·9 million (25%) would occur in the Western Pacific region and 103·5 million (21%) in the South-East Asia region (figure 2). Results of the analyses by country and WHO region and World Bank income classification are given in the appendix (pp 35, 49).
Figure 1Total global number and proportion of new cases of non-communicable diseases and mental health conditions attributed to physical inactivity, 2020–30
Figure 2Number and proportion of new cases of non-communicable diseases and mental health conditions attributed to physical inactivity by WHO region and World Bank country-income level, 2020–30
We estimated the global cost of all preventable NCDs and mental health conditions to reach INT$523·9 billion (US$301·8 billion) for the period 2020–30, approximately INT$47·6 billion (US$27·4 billion) per year (table; appendix pp 51–75). The costs of treatment and management of NCDs and mental health conditions varied such that although dementia accounted for only 3% of preventable new cases, the disease accounted for 22% of total direct health-care costs (figure 3). Furthermore, type 2 diabetes accounted for 2% of preventable cases but 9% of all costs, and cancer accounted for 1% of all cases but 15% of all costs (figure 3).
TableDirect public health-care costs (in 1 000 000 INT$) attributable to physical inactivity, 2020–30
Figure 3Total global proportion of new cases and direct health-care costs of non-communicable diseases and mental health conditions attributed to physical inactivity, 2020–30
Although most (74%) new cases would occur in LMICs (figure 2), high-income countries would bear the largest proportion of economic costs (63%; figure 4). The economic burden attributable to physical inactivity was highest in the European region (32%), followed by the region of the Americas (25%), Western Pacific region (20%), Eastern Mediterranean region (13%), South-East Asia region (8%), and African region (2%; figure 5).
Figure 4Costs and proportions of direct health-care costs of new cases of non-communicable diseases and mental health conditions attributed to physical inactivity by World Bank country-income level, 2020–30
Figure 5Total direct health-care costs and proportion of costs of new cases of non-communicable diseases and mental health conditions attributed to physical inactivity by WHO region and World Bank country-income level, 2020–30
New cases of preventable diseases would vary from 154 million to 860 million cases, when assessing the lower and upper bounds of RRs, with costs varying from INT$182 billion to INT$900 billion for these RRs (table). When dealing with uncertainties around costs estimates, a variation of –50% would reduce the cost of inaction to INT$344 billion (US$164 billion) and a variation of –30% by INT$499 billion (US$219 billion; appendix p 77).
Discussion
We estimated that the total cost of physical inactivity globally would be approximately INT$520 billion over an 11-year period (2020–30) if global levels of physical activity are not increased. Of particular concern is the high burden of physical inactivity seen in preventable cases of dementia and cancers because, despite the relatively lower incidence of these conditions compared with other NCDs, these diseases incur a high cost because of requirements of diagnosis, treatment, and long-term management. Furthermore, although most predicted new cases of NCDs would occur in LMICs, high-income countries will bear a larger proportion of the economic burden. This finding reflects the increased coverage and cost of health care in wealthy countries compared with lower-income settings. Our findings also highlight the high number of cases of depression and anxiety, rates of which steadily increased during the COVID-19 pandemic.
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Incidence and prevalence of those mental health disorders can also be effectively reduced by increasing physical activity levels, which would also help to reduce costs to health-care systems and increase wellbeing.
This is the first study to assess the global cost of inaction to the public health-care system of new (incident) cases of NCD and mental health diseases due to physical inactivity that could be prevented; therefore, the comparison with previous studies is limited. One prominent study by Ding and colleagues
used a prevalence approach, whereby new and existing cases were included in the cost estimate associated with physical inactivity.
Although Ding and colleagues’ assessment gives policy makers the economic value associated with the treatment and management of NCD cases, their assessment does not provide an estimate of the potential costs averted (ie, savings) if physical inactivity were reduced or eliminated, because most chronic diseases cannot be averted once they exist (appendix p 3). Thus, their estimate of INT$31·2 billion (in 2013 prices) in direct health-care costs to the public health system would be higher than our reported INT$47·6 billion (in 2020 prices) if replicated today and conducted with the same seven health outcomes studied here; however, direct comparison of costs between these studies is not appropriate because of important methodological differences.
One other global study reported the potential global economic benefits of a reduction in physical inactivity levels in terms of productivity gains and deaths averted.
The authors report costs of between US$314 billion and $446 billion per year (in 2019 prices), depending on the levels of physical activity, but did not report separately the potential direct costs to health-care systems.
Given the scarce published evidence on the economic impact of physical inactivity on public health-care systems, our study contributes useful new data and aims to stimulate further research.
We used the latest available prevalence estimates of physical inactivity from WHO and forecasted estimates of disease incidence for seven health outcomes. However, we are likely to have underestimated the total cost of physical inactivity as we only considered expenditures related to the initial treatment of new cases of NCDs (usually costs related to the first year of treatment) per year, not the accumulated costs of the treatment, complications, and management of these new cases over the years; nor did we include the costs associated with mortality. Chronic conditions, and particularly multiple chronic conditions per patient, accrue a disproportionate burden to health systems and so inclusion would greatly increase the economic impact of physical inactivity to public health care. Furthermore, because of methodological challenges, we did not include the costs associated with productivity losses or deaths. The addition of these costs would better reflect the higher health and economic burden of physical inactivity.
Additionally, our analysis used a narrow definition of physical inactivity that excluded details on muscle strengthening because of the absence of any global data. If muscle strengthening were included, the prevalence of physical inactivity would likely be higher and its inclusion would result in even greater costs to public health systems. Future studies should use a wider definition of physical inactivity when appropriate global data are available.
Lastly, when country data were not available on health-care costs, we extrapolated costs from the EU28 to other countries and assumed, as in Ding and colleagues,
that the cross-country differences in disease-specific costs per case are solely driven by the differences in overall health-care expenditure per capita. Given the scarcity of costing data, especially in LMICs, the methodology of using weighting factor to extrapolate EU28 costs is arguably the best available approach as a proxy to calculate health-care costs in lower-income settings.
However, better data and further methodological development are needed to produce more robust and contextualised evidence in lower-income settings. Despite these limitations, this study provides important new insights on the global health and economic burden of physical inactivity to public health-care systems in all countries.
The results of this study should not be interpreted as the total cost that would be avoided if physical inactivity were reduced. An underlying assumption of the PAF is that the removal of the exposure would not affect other risk factors.
This assumption might not hold because, for example, individuals who become more active might also adopt a better diet, stop smoking, and decrease alcohol consumption, making the interpretation of the physical activity PAF for diseases difficult. Additionally, an intervention will not necessarily lead to the complete removal of new cases of diseases, corresponding to an effectiveness of 100%, even if a multisectoral approach is implemented, as recommended in the WHO Global Action Plan on Physical Activity 2018–30. Even if programmes and infrastructure are provided to support people to be more active, not everyone would opt to be physically active.
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Thus, for this study, we cautiously interpret the PAF as the proportion of disease risk in the total population that could be reduced or eliminated.
Additionally, estimating the total avoidable costs of physical inactivity requires calculating the net cost of interventions implemented to increase physical activity—ie, the total benefits of reducing levels of physical inactivity minus the costs of interventions to promote physical activity.
Future work should undertake net cost analyses once the necessary data on an agreed set of interventions are available.
All government-policy decision makers are faced with competing demands on limited financial and human resources and consequently require information on the cost of not acting to increase physical activity. These data can support the development and strengthening of national investment cases and resource mobilisation to support the implementation of policy and programmes that enable more people to be more active, more often.
Modelling of cost-of-inaction and return-on-investment analyses have been important contributors to national and global progress on other NCD risk factors such as tobacco control.
Yet, to date, few economic analyses have been done on physical inactivity despite recognition of the urgent need for such research.
This study shows that without effective action to increase levels of physical activity by 2030, countries will incur substantial costs in terms of preventable new cases of NCDs. Additionally, countries will not reap the associated benefits that increasing physical activity can have on other important national agendas, such as reducing air pollution and fossil fuel consumption through increased walking and cycling and the wider effects of increasing sports participation on social and economic development.
Despite WHO’s Global Action Plan on Physical Activity providing countries with clear guidance on a set of effective and adaptable physical activity interventions, national progress on implementing relevant policy has been slow and global levels of physical activity in adults remain little changed in over a decade.
The first WHO Global Status Report on Physical Activity reveals that although most countries report having a national policy on NCDs, which includes physical activity, a profound gap exists in relevant policy implementation.
This inaction perpetuates inequalities in levels of physical activity and health. Given that only 8 years remain to achieve the global target to reduce physical inactivity by a relative 15% from the 2010 baseline, the findings of this study should be used by advocates and decision makers to encourage mobilisation of resources and acceleration of the implementation of national policy commitments to reducing physical inactivity.
Additionally, global NCD prevention and management initiatives such as HEARTS,
Diabetes Compact,
Resolve to Save Lives, Decade of Healthy Ageing,
Mental Health Action Plan 2013–30,
and Second Decade of Action on Road Safety
should be used as opportunities to strengthen alignment and implementation of interventions on physical activity. Finally, the scientific community is encouraged to further advance methods and evidence on the health system and societal impact and economic returns from increasing physical activity. Coordinated and accelerated action to reduce the prevalence of physical inactivity will make a substantial impact and further investments and scaling up of multisectoral actions are needed to achieve this aim.
ACS and FCB designed the study and interpreted the data. ACS obtained and managed the data and conducted the data analysis. ACS, FCB, and JW wrote the manuscript. FM and AI estimated the incident costs of cancers. ACS, FCB, FM, and AI accessed and verified the data. All authors had access to all the data and critically reviewed the document.
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