Since 2011, the UK Chief Medical Officers’ (CMOs) guidelines on physical activity have included strength recommendations. However, there is limited evidence that these recommendations are getting through to those who need them. In this blog, Dr Ashley Gluchowski outlines how older adults are engaging with the guidelines, and whether more can be done by public health officials and local authorities to remove barriers to activity.

• Less than half of 50 – 74-year-olds in England are meeting the strength recommendations.
• There is a lack of detail and options in the CMOs’ guidance around what constitutes strength training, and how intensely it should occur
• Older adults also report a lack of ability-appropriate classes, as well as a lack of strength training encouragement from healthcare professionals

One in three older adults in the UK are classed as inactive, while one in six deaths are linked to physical inactivity. As our population ages – with 25% expected to be over 65 by 2050 – the impact of inactivity on older people’s health, social and mental wellbeing, and quality of life will increase, as will the burden placed on healthcare systems.

A lack of muscular strength has been linked with disability, disease, and all-cause mortality. The most effective way to build strength is through progressive resistance training, and in 2020, the WHO updated their public-facing infographic on physical activity to include moderate to vigorous strength recommendations for older adults. However, this has not been well-reflected in the UK Chief Medical Officers’ (CMOs) guidance. In the UK, more emphasis is placed on physical activity and aerobic exercise, while the strength-training infographic makes no mention of muscles to be used, session duration, or intensity of effort.

“I’m pretending I’m not old”

Researchers from The University of Manchester interviewed 15 participants between 65 and 77, all of whom were classified as ‘highly active’, to find out how aware older adults are of the strength training guidance, and how they perceived their compliance with it. Some were completely unaware of the strength component of the CMOs’ recommendations, while others felt they did enough aerobic exercise to ignore strength training. Other participants thought that they were meeting the strength guidelines, but described activities that were in fact aerobic, such as walking, or cycling.

Some participants were aware that they were not meeting the strength recommendations, but felt the guidance was vague on what constituted strength training. Some participants felt they needed specialised equipment for strength exercises, but were reluctant to engage in a traditional gym environment, citing issues such as boredom or intimidation.

“I’d rather do something useful. But just going to a gym and doing this for an hour, what’s the point?” Male, 66 years

“I don’t like the atmosphere and the structure of gyms, you know, that people are sort of making lots of [grunting sound effects].” Female, 71 years

For those who had access to classes for older people, they felt the exercises were not strenuous enough to justify their continued participation. One theme that emerged from the interviews was a perception that exercise classes for older people fail to cater to the needs of the ‘young old’ – those over 50 but younger than 80.

“I don’t need to do chair-based exercises or the walks that are for older people, because I can still walk further than that, so they are just not relevant to me at the moment. I’m not really into the older adults stuff yet. I’m pretending I’m not old.” Female, 70 years

This unmet need was pointed out by both the youngest and oldest participants in the study. There was a feeling that, after retirement, they had been forgotten by public services.

Recommendations

The study’s participants have suggested that the strength guidelines themselves may need to pay more attention to the specific needs of diverse cohorts of older adults to be more effective. For example, participants suggested that specific messages tailored to older adults who consider themselves as active would increase their motivation to engage and meet the guidelines. This adds to the growing number of reports suggesting that a lack of detailed guidance on exercise guidelines is a major barrier for older adults wishing to engage with exercise but don’t have the information necessary to feel confident enough to do so.

The strength component that is embedded within the CMO guidance does not display important variables such as intensity of effort and session duration as it does for its well-known, and better adhered to aerobic guidelines. Not performing an evidence-based dose of strength training will result in an absence of substantial benefit, another barrier to strength training participation and adherence. If older adults are not able to benefit from their strength training, their ‘fitness’ decreases, and they become less willing and able to participate in resistance training at intensities or durations that are required to maintain their strength and health. This will only perpetuate the problems that come along with a sedentary and ageing population. As such, these findings recommend that the next set of older adult guidelines take more of a co-production approach to better meet the needs of diverse cohorts.

Of course, awareness or knowledge of guidelines alone do not necessarily translate to behaviour change. Over 70% of adults who were made aware of physical activity guidelines ultimately made no change to their physical activity levels. However, adults were twice as likely to report an increase in their activity levels when they heard about activity guidelines from their healthcare professional or from more than one source. Unfortunately, participants insisted that they had no discussions with their health or exercise professionals regarding the importance or benefits of strength or strength training. Just one of the 15 participants could recall seeing a part of the infographic in a public space.

Notably, these seemingly healthy, community-dwelling older adults reported significantly less contact with healthcare professionals or exercise specialists overall, an important consideration for future CMO dissemination strategies. Increasing messaging sources, especially from health and exercise professionals, is an easy way to normalise strength training and encourage uptake. Furthermore, healthcare professionals, exercise professionals, and older adults all need distinct information within guidelines to promote, refer, prescribe, or carry out evidence-based strength training.

With NHS waiting lists at record levels, it is imperative that healthcare policy pivots towards a preventative approach with adults who are approaching retirement age, to reduce pressure on services and improve the quality of life of the UK’s citizens. Maintaining an active lifestyle in later life is one crucial aspect of reducing disease and disability burden, and the CMOs’ guidance must be updated to reflect the importance of strength training in this, along with better training for healthcare and exercise professionals around what is recommended for younger older adults.