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JFSF Vol 3, No 2, June 2018, p.56-57

doi: 10.22540/JFSF-03-056



Only the strong: Why we need more focus on strengthening and balance activities in physical activity

Jessica D. Kuehne1, Michael G.T. Brannan2

  1. Centre for Ageing Better, London, UK
  2. Public Health England, UK

Muscle and bone health, as well as the ability to balance, each contribute to the overall health and functionality of an individual. They also play an important role in enabling healthy ageing. On the other hand, low levels of strengthening can lead to a decline in muscle mass with age and a range of associated health issues, such as increased risk of falls, sarcopenia and other health issues.

As a result, muscle strengthening and balance activities are a key element of the UK Chief Medical Officers’ (CMOs) physical activity guidelines for health, as outlined in Start Active, Stay Active1.

The benefits of strength and balancing activities are well established. However, when it comes to the promotion of physical activity by the health sector, much greater emphasis is placed on the aerobic component of the guidelines than on muscle and bone strengthening and balance. As such, the full benefits of incorporating muscle and bone strengthening and balance elements into physical activity routines are often overlooked or forgotten by commissioners of physical activity programmes and services, by healthcare professionals prescribing physical activity2, and by physical activity providers and exercise professionals themselves.

The impact of this is reflected in the data. The latest Health Survey for England data show that just 31% of men and 23% of women over the age of 16 meet both the aerobic and muscle strengthening guidelines compared to 66% of men and 58% women meeting just the aerobic guidelines. In those over the age of 65, these figures drop dramatically to just 13% of men and 10% of women meeting both the aerobic and muscle strengthening guidelines3.

This has consequences for both individuals and health and social care services. NICE guidance identifies low muscle strength and poor balance in later life as the most common preventable risk factors for falls4. In 2016/17, there were 210,000 falls-related emergency hospital admissions among people aged 65 and older in England5. Many people lose independence and the ability to carry out activities of daily living after a fall. Falls are the cause of 95% of all hip fractures6. Of those who suffer a hip fracture, only a minority will completely regain their previous abilities. For example, among patients followed up four months after having a hip fracture, just 10% reported they could move around freely without the help of a walking aid7. It has been estimated that hip fractures cost the NHS over £1 billion per year8.

To address this public health issue, the Centre for Ageing Better, in partnership with Public Health England, funded the UK CMOs’ Expert Group on Physical Activity to undertake an evidence review on muscle and bone strengthening and balance activities for health and wellbeing.

This work aims to improve understanding of the benefits of muscle and bone strengthening and balance at different stages of life and for specific health outcomes, including whether there are particular ages where muscle and bone strengthening and balance are most important. It sought to identify what types of physical activities are effective in developing strength and balance, including what activities are safe and efficacious for individuals with specific challenges such as osteoporosis, vertebral fractures, frailty and dementia. The review explored what the key barriers are to undertaking these activities and how they could be overcome. Finally, it explored measurement options for population level surveillance of muscle and bone strengthening and balance activities. The series of papers in this issue not only elucidate the key evidence in this area, they will be used as part of the larger evidence review process of this year’s UK Physical Activity Guidelines Review.

Evidence and guidance on their own are not sufficient to effect change. Translating this evidence into practice, service provision and commissioning of physical activity programmes will require national and local leadership. Therefore, Public Health England and the Centre for Ageing Better are publishing a separate report with suggestions for action and implementation for the public, practitioners and policy makers. This review represents a first step in laying the foundations for embedding strengthening and balance activity into individuals’ routine physical activity, not only in later years but throughout life.

  • • The Centre for Ageing Better is an independent charitable foundation, bringing about change for people in later life today and for future generations. Practical solutions, research about what works best, and people’s own insight are all sources that they draw on to help make this change. Ageing Better share this information and support others to act on it, as well as trying out new approaches to improving later lives.
  • Public Health England exists to protect and improve the nation’s health and wellbeing and reduce health inequalities. It does this through world-class science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. PHE is an operationally autonomous executive agency of the Department of Health.


  1. Department of Health, Physical Activity, Health Improvement and Protection. Start Active, Stay Active: A report on physical activity from the four home countries’ Chief Medical Officers. London: 2011.
  2. Chatterjee R, Chapman T, Brannan MG, Varney J. GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. British Journal of General Practice 2017;67(663):668-675.
  3. Joint Health Surveys Unit of NatCen Social Research and the Research Department of Epidemiology & Public Health at UCL. Health Survey for England, 2016. NHS Digital. 2017. https:// / dataand-information / publications / statistical / health-survey-for-england/ health-survey-for-england-2016
  4. National Institute for Health and Care Excellence. Quality standard 86: Falls in older people. 2015.
  5. Public Health England. Emergency hospital admissions due to falls in people aged 65 and over. Public Health Outcomes Framework. 2017.
  6. Parkkari J, Kannus P, Palvanen M, et al. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int 1999;65(3):183-7.
  7. Boulton C, Bunning T, Johansen A, et al. National Hip Fracture Database (NHFD) annual report 2017. Royal College of Physicians. 2017.
  8. Leal J, Gray AM, Prieto-Alhambra D et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporosis Int 2016;27(2):549-58.