Guest blog via Satish Pandey @SatishKTM
“Exercise has been called a miracle drug that can benefit every part of the body and substantially extend lifespan.” The Lancet Series on Physical Activity (Jul 2012) 
When I very recently read The Guardian’s piece on Pizza Hut's 2,880-calorie monster, I was reminded of the long queue that had greeted Pizza hut and KFC grand opening in Kathmandu back in late November 2009. I remember saying to myself “is this the beginning of the end?” These fast food joints are not always associated with healthy eating and when placed in an environment, like Kathmandu, where physical inactivity is endemic, these can wreak havoc on the locals’ health condition. For obvious reasons, I feared the worst but couldn’t share my concerns with a population that seemed delirious about the new ‘happening place’ in town.
Arguments about our genes aside, physical inactivity and unhealthy diet make a deadly combination for proliferation of non-communicable diseases (NCDs). In Kathmandu, a city devoid of parks, open spaces, side-walks, bike-lanes and affordable gyms, conversations about ‘staying active’ isn’t a commonplace. To be fair on most people, Kathmandu doesn’t actually provide the most comfortable opportunity to ‘sweat it out’. So, while our diets may not yet have reached catastrophic proportions in terms of calorie intake, the absence of easy and ample opportunities to get physical exercise is very worrying. Improvisation, then, becomes the key.
Why should we worry about physical inactivity and other risk factors?
It is believed that globally physical inactivity causes 6–10% of all deaths from the major NCDs (coronary heart disease, type 2 diabetes, and breast and colon cancers). Physical inactivity also causes 9% of premature mortality, or more than 5·3 of the 57 million deaths that occurred worldwide in 2008.
The World Bank report, “Risking your Health” (.pdf) mentions that ‘growing share of the burden of diseases across the world is associated with risky behavior by individuals” naming drug use, smoking, alcohol, unhealthy eating and unsafe sex as the key risky behaviors. The report highlights the increasing obesity in the developing world as a result of “nutrition transition” leading to the “paradox of coexistence of both undernutrition and overnutrition in the same population”.
Should we be worried in Nepal?
Nepal recently published the 2013 STEPS Survey report. Smoking, alcohol consumption, physical activity and fruit/vegetable consumption all impact (positively or negatively) the prevalence of several NCDs. The survey in Nepal found the prevalence of current smoking to be 18.5% (27% in men) while the average age of starting to smoke was 18.2 years. The survey also found the prevalence of alcohol consumption to be around 28% among men with current drinkers gulping 6.5 standard drinks in a single occasion. The fruit consumption was found to be close to 2 days in a week while vegetables were consumed 4.8 days per week. Overall daily per capita consumption of fruits and vegetable was 1.8 servings on an average day (recommended is at least 5 servings).
We should be concerned about 21% of the people surveyed being overweight or obese and 22.7% having hypertension (including those already taking medication). Low utilization of health care facilities is evident from the fact that 89.2% had never been tested for blood sugar levels. In summary, of all the people surveyed, 84.5% had 1 –2 and 15.1% had 3-5 risk factors (current daily smokers, less than 5 servings of fruits & vegetables per day, low level of activity, overweight (BMI ≥ 25 kg/m2), raised BP (SBP ≥ 140 and/or DBP ≥ 90 mmHg or currently on medication for raised BP) present at the time of the survey. This is a major area of concern from NCD perspective.
In another systematic review 73.6% men and 90% female (25-64 years) of Nepal were found to be physically inactive. Another article has showed the hospital based NCD prevalence in Nepal to be 31%, out of which chronic obstructive pulmonary disease (43%) and cardiovascular disease (40%) were the two most common diseases.
What can people in Kathmandu do about it?
Despite paucity of long-term studies, a positive long-term influence of physical activity has been suggested. The minimum recommended physical activity for adults is 150 minutes of moderate aerobic exercise or 75 minutes of vigorous aerobic exercise per week, or an equivalent combination. It is very essential that over a long term, people get the exercise needed.
The poor infrastructure in Kathmandu doesn’t make clocking the recommended weekly minutes an easy task. Those who can afford hit the gym but still not many are a regular yet. People living near the few available parks and newly “expanded” roads do make serious efforts to get their daily morning walk albeit challenged by the weather subject to different seasons. Going on morning walks, once a phenomenon more common among people already facing weight issues or having some clinically diagnosed condition requiring weight reduction, has now become more common. Morning walks remain a dangerous proposition though, especially in the absence of proper sidewalks and street lamps and the presence of reckless driving that shows scant respect to pedestrians.
There are those odd running and cycling groups that get their dose of week’s exercise on Saturday alone. Some bike to the office while many others walk to work. However, the numbers still don’t add up to tell us that it’s all going to be okay. The quickly changing diet, the level of daily stress, polluted environment and mostly sedentary lifestyle pose a serious threat to people’s health in Kathmandu.
The following might be some ideas on how to get active in Kathmandu:
Improvise – making excuses isn’t going to burn the excess calories, getting out of the bed to be active does. People in Kathmandu need to be creative to find opportunities to exercise. We need to make use of the little we have in terms of facilities. We need to quickly figure out what works for us and start doing it today. The key might still lie on being able to improvise. It might even take a combination of activities than just one form of activity that will enable us to get the regular exercise we need.
Going beyond health – some experts have suggested that promotion of physical activity shouldn’t be limited to just showing the health benefits but should also encompass information regarding what a person experiences (such as psychological well-being) and should be presented as something with “flexibility of being adaptable to a person’s circumstances (rather than vice versa)”.  The psychological benefit of doing some level of exercise needs to be internalized by all and should be the back bone of any physical activity promotion.
Beyond exercise – The Lancet series on physical activity (which was released coinciding with the Summer Olympics 2012) mentions physical activity to be more 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.” So, we should stop thinking about regular exercise as being the only form of physical activity and should consider other daily activities that will enable us to attain the minimum need. Using the stairs in the increasing number of high-rise buildings might be a very good place to start, for example.
Getting regular physical activity is always easier said than done. It’s even more so, if the environment doesn't make it any more conducive. In these conditions, one needs to fight against oneself to maintain proper self-discipline and at the same time grapple with challenges posed by poor infrastructure and ‘unfavorable’ weather. Getting out of bed itself then becomes a tedious experience, let alone getting up with a purpose to get active. We do, however, need to look around and we will see that despite these adversities, there are people who have shown enough resilience and resolve to keep the ball rolling on staying active. They are our role models that we need to look up to and try to emulate – not forgetting that being enterprising enough to make our exercise routine flexible to our needs and capabilities is where the secret to success will lie.
Photo credits used with permissions: cycling photographs to CCNN (Cycle City Network Nepal) and Satish Pandey
 The Lancet series of Physical Activity, Published online July 18, 2012 http://dx.doi.org/10.1016/S0140-6736(12)60954-4
 WHO. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization, 2009.
 Risking your health : causes, consequences, and interventions to prevent risky behaviors, The World Bank, November 2013
 In Nepal, this STEP survey was conducted between July 2012 to June 2013 following all three steps
 Non-communicable Diseases Risk Factors STEPS Survey Nepal 2013
 Physical activity patterns among South-Asian adults: a systematic review, International Journal of Behavioral Nutrition and Physical Activity 2013, 10:116 doi:10.1186/1479-5868-10-116, Chathuranga D Ranasinghe et al
 State of non-communicable diseases in Nepal, BMC Public Health 2014, 14:23 doi:10.1186/1471-2458-14-23
Gajananda Prakash Bhandari et al
 Long-term health benefits of physical activity – a systematic review of longitudinal studies, BMC Public Health 2013, 13:813 doi:10.1186/1471-2458-13-813, Miriam Reiner et al
 Global recommendations on physical activity for health. Geneva: World Health Organization; 2010.
Blog moderated by Ann Gates BPharm)Hons) MRPharmS
Founder and Director of Exercise Works!