the environmental dimension
of malta’s ill-health
and action to prevent obesity,
diabetes, cardiovascular disease
and dementia
supplement I:
Physical Exercise and Health
3
PHYSICAL EXERCISE AND HEALTH
Mens sana in corpore sano.
“There is now concern that the pivotal importance of physical activity is underestimated and
underappreciated by public health authorities and clinicians”
Blair SN. Br J Sports Med 2009;43:1-2.
Promoting physical activity has come to be regarded as a “best buy” in terms of public health.
Morris JN. Med Sci Sports Exerc1994;26:807-14
Our challenge is to find methods of making this wonder drug (exercise)
more palatable to more people more often.
Promotion of cycling and health: Editorial. BMJ 2010; 341:c5405
Increasing regular physical activity must become a key public health goal.
Regular physical increases general health and decreases the likelihood of suffering from dementia in old age.
Malta needs a lifestyle change to reverse the trend to physical inactivity and obesity.
We are in danger of going soft from living too comfortably.
Background
1.
Lack of physical activity is one of the greatest health threats facing developed nations
today.(1) According to the World Health Organisation, insufficient physical activity is the
fourth leading risk factor for premature mortality.(19)
2.
Malta’s record on physical exercise is appalling. In a recent report on a world-wide survey
published in the ‘Lancet’, Malta was reported as the least physically active country in the
world with 72% of Maltese people qualifying as inactive.(10) Another report found that
about as many Maltese children, 74%, were physically inactive and that 42.7% of children
watched three or more hours of television during the average weekday, one of the highest
rates in the EU.(11)
3.
It has been suggested that if the majority of an adult population did not engage in
exercise, then physical inactivity becomes the dominant factor in the causation of chronic
disease.(7-9) Given our serious exercise deficit, this is must be the case in Malta.
4.
In spite of overwhelming scientific evidence of the enormous health benefits of physical
fitness gained through regular exercise, our successive Government Health and Transport
administrations in Malta have failed to give physical exercise the priority it deserves. It
remains the Cinderella of public health policies.
5.
From an environmental aspect, there exist in Malta more obstacles than incentives to
building physical exercise into peoples’ daily routine. People of all ages are robbed of
the opportunity and stimulus to engage in the most easily available mobility options as
walking or cycling on a daily basis by roads designed only for traffic and transport policies
heavily biased to favouring private car transport. One could almost conclude that the
policies of successive Government admnistrations and Health and Transport authorities
are to hinder people from being physically active. People are rewarded for using their car
supplement I: physical exercise and health
4
for transportation by promises of road improvements and more parking facilities while
nothing is being done to encourage those who might otherwise opt for active mobility.
6.
Promoting physical exercise as part of childrens’ daily activities depends on the safety of
their immediate road and school environment. This principle is ignored and children in
Malta do not do enough exercise.
Health Benefits of Physical Exercise
7.
The place of exercise in healthy living is a concept that has only recently been re-defined.
8.
The importance of physical activity for health only started to be recognised after 1958
following publication of a report by an epidemiologist, Dr Jeremy Morris, on the results
of a survey which confirmed the hypothesis that physical activity afforded protection
against coronary heart disease.(2) The rest is history. Without exception, successive
waves of studies on exercise up to today have consistently reinforced the message that
exercise has enormous potential for enhancing health. The testimony of this evidence
supports the thesis that exercise results in a reduced risk of great many diseases,
leading to a longer and healthier life. The accumulated evidence on the beneficial
effects of exercise is so striking that physical activity is now regarded as a potential
“wonder drug,” to the extent that the benefits of regular physical activity on health,
longevity, and wellbeing are believed to easily surpass the effectiveness of any drugs
or other medical treatment.(3)
9.
The importance of exercise in risk reduction for a raft of non-communicable diseases,
including in particular obesity, type 2 diabetes and cardiovascular disease is beyond
dispute.(12,18) Physical inactivity is now regarded as one of the biggest health threats
facing developed countries today(1) and a major contributor to the global burden of
disease.(19) International consensus on the value of regular moderate physical activity was
established in 1995.(20)
10. In spite of this, the recognition of the importance of physical activity by policy makers still
lags behind(94) so that physical exercise remains a neglected intervention in both physical
and mental health care.(95)
11. While it is conceded that exercise alone is insufficient as a sole means for losing weight,
the available literature leaves no doubt that, in addition to the benefits of regular exercise
being complementary to weight reduction, exercise also increases cardiovascular fitness
and this is more important than weight reduction.( 4-6) Though the benefit of exercise has
continued to be demonstrated over the years, it may be that attention has been diverted
from it by controversies over dietary restriction and weight reduction in the obese.
12. Ekelund et al., 2015,(21 ) recently drew attention to the importance of exercise by showing
that the health benefit of exercise is approximately double the expected health benefit
from reduction of obesity. In a long-term study in 334,161 participants it was shown that
all-cause mortality was significantly reduced by 16% to 30% by physical activity. In other
words, the reduction of disease and premature deaths attributable to physical inactivity
was double the reduction achieved by reduction of obesity. The benefit of exercise
the environmental dimension of malta’s ill-health
5
was observed even in subjects who were only moderately physically active in this and
other studies.(89) This led to the conclusion that doing exercise equivalent to just a 20
minute brisk walk each day can reduce the risk of premature death from causes related to
physical inactivity and that efforts to encourage even small increases in activity in inactive
individuals may be beneficial to public health.
13. Health gains from exercise are especially noticeable in previously physically inactive
people who take up moderate physical activity.(23,24)
Economical and other Benefits of Physical Exercise
14. Given the right conditions, physical exercise should be accessible to all.
15. In public health terms physical activity, is considered a “best buy treatment” and a “wonder
drug”. It offers wide-ranging benefits. These include reductions in the risk of obesity,
coronary heart disease and type 2 diabetes, the latter being itself a strong risk factor for
dementia - in addition to a long list of other benefits (32,33)
16. Costing of measures aimed at promoting exercise regularly show that the saving in
health costs resulting from improvement in fitness of a population outweigh the cost of
implementing general (environmental and other) measures aimed at creating conditions
which encourage healthy lifestyles.
17. A report “Exercise, the miracle cure” based on analysis of more than 200 separate pieces
of research published by the UK Academy of Medicine (2015) studied the positive impact
that regular physical activity could have on the nation’s health.(84) The report stated that
savings to the NHS from exercise were “incalculable”. The report summary specifically
quoted the example of type 2 diabetes which was costing the state billions of pounds - a
disease which could be prevented if people did just 30 minutes of physical activity five
times a week. The Academy went as far as suggesting the diagnostic term “sedentary
death syndrome” for lack of exercise.
18. While stating that the effect of even a small amount of regular exercise is better than
many drugs, the following list of benefits was specified:
•
•
•
•
•
The chances of developing heart disease can be cut by over 40%
The risk of ever having a stroke can be reduced by 30%
The risk of ever developing dementia can be reduced by as much as 30%
The risk of breast cancer can be reduced by as much as 25% with regular exercise
The risk bowel cancer can be reduced by as much as 45%
19. In an editorial the British Medical Journal commented on the report(85) that it was
extraordinary how long it is was taking mainstream medicine to accept the importance of
physical activity when exercise has repeatedly been shown to be one of the top modifiable
risk factors for chronic disease. It went on to say that promoting physical activity remains
a major challenge in the modern environment with our lifestyle designed to reduce or
eliminate physical activity at every opportunity.
supplement I: physical exercise and health
6
20. The editorial went on to say that success at the population level required changes to
government perception and that increased physical activity entailed changes to the
built environment, better public transport, an improved urban infrastructure that creates
walkable spaces, provision of facilities for physical activity and the implementation of
policies that promote active workplaces and schools. The editorial ends with the following
statement: “But, most of all it requires a comprehensive change in culture and mindset.
Without political endorsement and multifaceted strategies, the role of doctors will remain
marginal. We can promote change, support change, and facilitate change, but we cannot
make it happen alone.”
21. Added to the known and proven health benefits of ecercise are recent findings that a
life-long physically active lifestyle has the potential to prevent or mitigate the impact of
dementia. This adds to the importance of encouraging physical exercise on a nationwide
basis. This section reviews recent new evidence pointing to lack of physical activity as a
major risk factor for dementia.
Costs of Physical Inactivity
22. The cost of inactivity across the EU is estimated at €80.4 billion per year, chiefly through
excess non-communicable diseases: coronary and other heart disease, stroke, overweight,
type II diabetes, colorectal and breast cancer.(87) The contribution of inactivity to the UK
disease burden is nearly double that of the European average. Since Malta and the UK
share similarities in obesity rates and physical exercise, this is probably representative of
direct health costs of inactivity in Malta.
23. Health costs associated with physical inactivity the United States are estimated at between
US $24.3 billion and $37.2 billion or 3.7% of total health care costs.(34 ) Conversely, if 10%
of adults walked regularly, the potential annual savings in US health costs of treating
heart disease are estimated at $5.6 billion. The savings would be especially high if men
aged 35–64 years and women aged 55–64 years walked more.(35) The economic burden of
physical inactivity in England was estimated a €9.5bn.(36)
How much Exercise?
24. It has been suggested that there is no low threshold at which exercise starts to exert
a benefit; the benefit starts from low levels of exercise. Even short periods of standing
and light walking for a minute or two shows a discernable beneficial effect in people of
sedentary habits or occupation, an example being getting up and walking for a minute
or two during television commercials.
25. Lowering the goal posts might exceptionally be considered in people who are not
motivated to make the extra effort of complying fully with the recommended weekly
target of 150 minutes of moderate exercise. This applies to the most inactive group of
people in whom the greatest gain from modest increase in exercise might be expected. (23,27)
As people get older, lighter activity may also become more relevant for sustaining the
strength, flexibility, and balance required for independent living.(28)
the environmental dimension of malta’s ill-health
7
26. Others have argued that falling short of the recommended physical exercise targets is
not enough to prevent obesity and that more exercise is needed to stop weight regain
in obese people who have lost large amounts of weight(29,30) and, since the health risks in
adults who sit for more than seven hours on working days, as in office work, tend to be
higher, recommendations should continue to aim higher.
27. In addition to adhering as much as possible to standard physical activity guidelines.and
adults should be advised both to breakup up sitting time at work.(31)
Physical Activity and Cognitive Decline
28. Physical activity appears to enhance brain function and cognitive agility. The results of
longitudinal studies, many based on large-scale population-based cohorts, are concordant
in finding a positive relationship between physical activity and cognition.(37-54)
29. Some studies also suggest an overlap between social leisure activities which involve
both cognitive and physical activities in bringing about an associated improvement in
cognitive function. (55,56)
30. A meta-analysis of twelve prospective cohort studies that investigated the association
between physical activity and cognitive decline in non-demented subjects demonstrated
reduction in risk of cognitive decline by 35% and 38%, respectively in subjects who
indulged in high and moderate levels of physical exercise. Based on the result of the metaanalysis it was concluded that the findings highlighted the important role of physical
activity in the protection of mental functions even in subjects without neurodegenerative
disease.(57)
31. Other investigators demonstrated a positive association between physical exercise and
cognitive performance, especially executive function, in adults.(96-100)
32. The benefit from physical exercise may extend to subjects already afflicted with dementia
and related cognitive impairments by virtue of retardation of brain atrophy.(101,102)
Physical Activity and Dementia
33. In addition to preserving cognitive vitality, there is new evidence (reviewed below) that
physical exercise may positively influence the course of dementia by postponing its onset
or even preventing its occurrence altogether. This adds to the urgency of encouraging
people to be more active.
34. If, as appears to be the case, exercise is an intervention that offers the potential of
delaying the appearance of dementia by just a few years, this could dramatically reduce
the burden of this disease on society and public health-care systems.(58 ) This beneficial
effect is mediated partly through preventing vascular disease, but exercise is also believed
to make the brain more resistant to the effects of brain disease that lead to dementia
possibly through a beneficial effect on cognitive function.
supplement I: physical exercise and health
8
35. Prospective observational studies have shown risk reduction of dementia in more
physically active individuals. A positive correlation between cognitive function and
objectively measured cardiorespiratory fitness has been observed(61) and individuals who
regularly participated in physical activities as walking, hiking, bicycling and swimming,
were less likely to be diagnosed with dementia with reductions from the expected rate
as high as 34%.(62-66) Both walking speed and distance correlated with a reduced risk
for dementia;(67) this suggested a quantitative relation between the amount of physical
activity and decrease in the risk of dementia or cognitive decline.
36. A long term observational study in a cohort of nearly 20,000 healthy, well educated,
and affluent adults from Texas who had a fitness test at a mean age of about 50 years,
measured the association between objectively measured midlife cardiorespiratory fitness
levels and development of all-cause dementia in advanced age. The results suggested
that higher midlife fitness levels are associated with lower hazards of developing allcause dementia later in life. The fittest study participants had a significantly lower hazard
of dementia hazard ratio when compared to the least fit participants. This suggests that
higher fitness levels earlier in life may lower risk for dementia later in life, independently
of cerebrovascular disease.(59) The results of this study led to the suggestion that simply
telling people to do more exercise rarely works but telling people that engaging in
physical exercise gives them a chance to reduce their risk of dementia in later life might
be a powerful motivator.(60)
37. The findings of a 35-year study which monitored five healthy behaviours (regular exercise,
non-smoking, maintaining a healthy bodyweight, healthy diet, low alcohol intake) in 2,235
men found that exercise had a strong correlation with positive outcomes in relation to
both cognitive impairment and dementia. The study showed a 36% reduction in odds for
cognitive impairment and dementia in the subgroup who pursued a healthy lifestyle. (68)
38. Some longitudinal observational studies in older populations which did not specifically
study the effect of physical exercise did not reveal a relationship between fitness or
physical activity and cognition or dementia; (69-71 ) other studies yielded conflicting results
because too many lifestyle issues were studied at once. Also some results were judged
negative because the results, though positive did not reach statistical significance.(72)
39. The results of major prospective studies published up to January 2014 which specifically
investigated the effects of physical activity on cognitive decline and dementia were
subjected to a rigorous meta-analysis by Blondell et al (2014).(73) All identified studies were
subjected to quality assessment and only those of sufficient methodological validity were
selected. Twenty-one studies met the criteria. The results of the meta-analysis confirmed
that, in the population covered by the studies that were analysed, higher levels of physical
activity protected against both cognitive decline and dementia. The results of the metaanalysis for cognitive decline and dementia are summarised, respectively, in Figure 1
and 2.
the environmental dimension of malta’s ill-health
9
Figure 1. The association between high physical activity and cognitive decline. (Blondell et al 2014).
Figure 2. The association between high physical activity and dementia (Blondell et al, 2014).
40. Another meta-analysis by Hamer and Chida (2009) of 16 prospective studies on the
influence of physical activity on the subsequent development of dementia supported
the conclusion that physical activity can decrease the risk of dementia and Alzheimer’s
disease.(74)
supplement I: physical exercise and health
10
41. Exercise also reduced Alzheimer’s disease biomarkers, including amyloid and tau protein
in subjects who already have dementia.(88)
Mechanism
42. Dementia is due to blood vessel (cerebrovascular) disease in about one fourth of cases. In
addition to being an independent cause of dementia, cerebrovascular disease may also
accelerate the emergence or progression of dementia symptoms in Alzheimers disease. A
physically active lifestyle may prevent dementia or retard the progression of brain disease
to dementia by preventing blood vessel disease.
43. Exercise may improve cerebral blood flow and consequently improve supply of oxygen
and nutrients to the brain;(75,76) this might protect against neuropathology.(77) Regular
physical exercise can decrease the incidence of type 2 diabetes, a risk factor for dementia,
by over 50%.
44. Exercise might also positively influence cognitive function by preventing stress and
thereby reducing cortisol levels.(81) Decrease of depressive symptoms might also play
a role.(77) Other additional mechanisms to explain the positive influence of exercise on
dementia risk have been suggested; these are based on a positive neurotrophic effects
such as exercise–induced release of neurotrophins, improved synaptic connections,
promotion of neuronal growth and survival(79,80)
Conclusion
45. Exercise is the element which unites most prevention initiatives, it is also regarded as a
fundamental means of improving the physical and mental health of individuals.(91)
46. Exercise as a preventive treatment is feasible, cost effective and has an inherent overall
positive public health impact. Of the lifestyle factors identified by Norton et al (2014), lack of
exercise, smoking and poor educational attainment, were regarded as having the greatest
potential for harm and recommended that they should be targeted to reduce the risk.
47. The wide-ranging benefit bestowed by physical exercise also emerges as the common
denominator which runs through all the domains reviewed in this report. Physical
exercise is the common key factor in the prevention of diabetes, vascular disease, obesity
and many other diseases. This alone is an overriding justification for encouraging regular
physical activity on a national basis. In addition to this there is undisputable evidence of
the efficacy of physical activity in preventing cardiovascular disease and obesity.
48. It is now well established by high-quality scientific evidence that participation in regular
physical activity can prevent or delay type 2 diabetes, improves blood glucose control
and positively affect lipids, blood pressure, cardiovascular events, mortality, and quality
of life. The decrease in physical activity in Westernised societies is independently linked to
the increase in the prevalence and incidence of type 2 diabetes.(103) This must also apply
to Malta where the incidence of diabetes is unacceptably high.(104) This again points to
modifiable changes in our behaviour and environment.
the environmental dimension of malta’s ill-health
11
49. Attention has recently been drawn to the central position of exercise in the prevention and
management of the obese in a report issued on 25 March 2015 by the UK Parliamentary
Health Committee. The report urged doctors tell patients to focus more on physical
activity rather than dieting for obesity.(92,93) Based the compelling evidence that physical
activity in its own right has huge health benefits totally independent of a person’s weight,
the core message from this inquiry was that the benefits of exercise need to be clearly
communicated, regardless of weight, age, gender or other factor.(92)
50. Dealing with obesity should, above all, be preventive with emphasis on influencing
lifestyle on a national basis in such a way that obesity will not be favoured. This is especially
important because, once weight is gained, weight loss is difficult and, if achieved, it is
difficult to maintain.
51. Recent findings from a bone density study in children suggest a link between the amount
of lean muscle and healthy bone development in children and early childhood physical
activity. These findings point to the importance of early childhood physical activity to
optimise muscle and bone growth since bone strength and size are significant factors
in determining osteoporosis and fracture risk later in life. The investigators estimated
that a ten per cent increase in peak bone mass can be expected to delay the onset of
osteoporosis by 13 years.(86)
52. A physically active way of life offers a good chance of reducing the occurrence of vascular
disease and therefore of (vascular) dementia as well as delaying the onset of disability
in Alzheimer’s disease. On the basis of epidemiological and prospective observational
literature, it has been estimated that the population attributable risk of physical inactivity
for dementia in Europe and the USA is at least 20%.(82) It also appears likely that benefit
is conferred by aerobic exercise such as walking, swimming and bicycling, rather than
anaerobic exercise.(83) This has implications for the provision of an environment which is
specifically conducive to aerobic exercise.
Implications
53. In spite of the mounting evidence over the past half-century which has repeatedly
shown physical exercise to be one of the top modifiable risk factors for chronic disease,
successive Governments and Health Authorities in Malta have remained oblivious to
the health gains from physical activity, and presided over environmental and transport
policies which omitted encouraging physical activity.
54. Though obesity is now coming to be regarded as less of a threat to health than the
unfitness that accompanies it, it can be regarded as an index of the amount of physical
exercise practised in Malta on a national basis. Epidemiological evidence indicates that
we are among the fattest most physically inactive country in the world but this seems not
to be a cuase for worry.
55. We clearly need a lifestyle change to reverse our physically inactive way of life and
encouragement of exercise must now be considered the most urgent preventive measure
needed in Malta. Besides helping to bring down our high rate of obesity and type 2
diabetes in adults and children, it will also improve general cardiovascular fitness, and
supplement I: physical exercise and health
12
help to ensure healthy ageing and offer the best chance of reducing the future prevalence
of dementia.
56. As suggested in a recent BMJ editorial,(85) it is time that mainstream medicine – and that
includes our Health Department - accepts the importance of promoting physical exercise.
The editorial(85) could not have put it better; “…most of all it requires a comprehensive
change in culture and mindset. Without political endorsement and multifaceted strategies,
the role of doctors will remain marginal. We can promote change, support change, and
facilitate change, but we cannot make it happen alone.
57. As long as this change does not occur, Malta will remain among the countries with the
highest obesity globally and it will continue to share the excessively high obesity rate
with the UK and USA - both countries with the highest rates of car use for travel – as in
Malta.(90)
What needs to be Done
58. A physically active way of life needs to be encouraged from childhood onwards because
the habit of a physically active life is usually established during childhood and young
adulthood.
59. Education and awareness campaigns are the sheet string of health promotion but these
alone may not be enough because they leave it to individuals to respond. One suggestion
has been to advise people to do more exercise because it gives them a chance to reduce
the risk of dementia on the assumption that this might be a useful motivator.(60)
60. Government perception of exercise in Malta requires change. Nagging people about the
need to do exercise to achieve health doesn’t work. It is time to start enabling. Without
surroundings that make exercise an easy, pleasant option we will remain exactly where we
are.(105) For this to happen we need policies on the urban environment and infreastucture
which encourage people to build physical exercise into their daily routine.
61. Overall, general measures must start early in life and might include the following:
• Physical exercise must be encouraged outside of school and also in the pre-school
years.
• Basing increase in physical exercise by focusing on “decrease of physical inactivity”
might be an easier prescription to follow than an “increase in physical activity”.
• In order for children to be enabled to safely spend more time outside the (urban)
environment in which they grow needs to be made child-friendly.
• Ensure as far as possible that our architecture and urban design impacts positively
on public health. Restructure urban and education environments to facilitate physical
activity and discourage excessive car use.
• Enable bicycle use and active mobility.
• Ensure that elite-focused sports at school does not result in exclusion of other young
people from being encouraged to be physically active as, for instance, children who
are overweight or who have immature or late development of motor skills - who may
be in greater need of physical exercise.
the environmental dimension of malta’s ill-health
13
•
•
•
•
Inculcate a love of physical activity, sport and outdoor life from an early age.
Increase PE time at school.
Exempt tax on sports equipment, bicycles etc.
Reduce or remove psychological barriers to walking and cycling through better urban
design to provide an environment that encourages healthy behavior and lifestyles.
• Encourage parents to walk more with their children in free time.
• Stress the importance of limiting television viewing (and computer screen-time) time
to parents.
62. The encouragement of physical activity must continue through middle age because it has
been shown that people who were active when young but who ceased to be physically
active in middle age may lose the benefit of the exercise gained during their youth. Such
people suffer a higher rate of disease, decreased quality of life and illnesses in old age
than their peers who continued an active lifestyle into middle age.
• Aim educational measures must at all ages.
• Enable behavioural change to a healthier physical and mental lifestyle by a facilitating
environment.
• Promote health benefits of walking; convince public that walking is time well spent.
• Include the aspect of mental pursuits, social integration and inclusion of the aged.
• Make display posters and leaflets outlining recommendations for a healthy lifestyle
and diet widely available at hospital waiting rooms, health clinics, doctor’s consulting
rooms, post offices, government and other departments.
• Exploit media in the educative process – this includes radio, television and printed
media.
• Motivate physicians to prescribe physical activity to patients. However medicine
cannot take on a disproportionate responsibility for promoting health related physical
activity when influencing community behaviour requires a multifaceted approach.(86)
63. Reduce dominance of the car – discourage car-dependency to reduce street traffic.
•
•
•
•
•
•
•
•
•
•
•
•
•
Discourage car-dependence.
Make (urban) streets safer, especially for the aged and children.
Design streets to make walking a positive experience.
Provide environmental “Cues” and “nudges” to encourage people to indulge in regular
physical activity in ways that are sustainable in everyday use - ideally by building
physical activity into daily routine (ie, ‘background physical activity’).
Shift emphasis from facilitating car use (eg by providing car parks) to improving urban
“walkability”.
Promote/encourage active transport – cycling, walking.
Improve public transport.
Give highest priority to improving public transport.
Give low priority to creating car parks.
Introduce 30 km/h speed limits. (see appendix IIII)
Tame traffic - Introduce urban traffic limitation strategies.
Introduce traffic calming measures.
Aim to provide interconnected networks of shared spaces to encourage walking,
cycling and decrease driving.
supplement I: physical exercise and health
14
• Improve perception of bicycle as a means of staying healthy and as a valid means of
transport for short trips and errands.
• Give cyclists more protection at law.
• Place well-designed cycle racks in strategic secure positions at government offices,
supermarkets, hospital entrances etc to provide cues which might prompt people to
use bicycles.
• Find ways to incentivize bicycle use.
64. Discourage further ‘zoning’:
• Put (or preserve) activities of daily living within walking distance.
• Encourage mixed-function neighbourhoods. Preserve local grocers, shops, post offices
etc.
• Encourage creation of facilities in residential areas to provide a social focus for the
elderly or less well-off, to reduce their fear of going out and maximize their opportunity
to shop for fresh nutritious food. RER
• Reverse the trend whereby streets are becoming emptier of people as local street
shops continue to fall victim to distant shopping centres and supermarkets.
• Ensure survival of small neighbourhood grocers and corner supermarkets, which are
of importance to the elderly and less well-off.
• New supermarkets should be redirected nearer to town centres so that they can be
more easily reached on foot by all.
the environmental dimension of malta’s ill-health
15
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