Physical Activity for the Management and Prevention of ...
Physical Activity for the Management and Prevention of Disease -Key Evidence and Practice Dr Onebieni Ana BSc(Hons), MBBS, MSc SEM, MRCGP A little about me 6 years SEM experience Clinical champion - Physical activity, Public health England MRCGP MSc SEM, Queen Mary's, London 2012 Foundation training Oxford deanery, 2010 MBBS , St Georges London, 2008 BSc(Hons), Leicester, 2003 A 2
Getting to know you A 3 National approach to physical activity National framework domains, Everybody Active, Every Day 4 National Strategy outcomes, Sporting Future Public DCMS (2015) Sporting Futures
PublicHealth HealthEngland England(2014) (2014)Everybody EverybodyActive, Active,Every EveryDay Day. HMG (2015) Sporting Future: A Strategy for an Active Nation. Objectives 1. Become familiar with the definitions, guidelines and evidence base for physical activity and inactivity. 2. Understand the importance of physical activity for prevention and management of disease. 3. Develop understanding and knowledge in integrating physical activity and
brief interventions into clinical practice. 4. Learn how to utilise the behaviour change model to apply very brief interventions into clinical practice. 5. Gain experience in the use of motivational interviewing through role play. 6. Understand the association between physical activity and specific chronic conditions through speciality-specific slides. A 5 Discussion What motivates you to be physically active? How many times in the past two weeks have you: asked patients about smoking? asked patients about physical activity? What motivates or prevents you from asking patients about physical activity?
Images courtesy NHS Image Bank A 6 Physical activity: Why is it important? What are the benefits of physical activity? If physical activity were a drug, what conditions would we market it for? A 7 The Miracle cure and best buy in public health? What if there was one prescription that could prevent and treat dozens of diseases,
such as diabetes, hypertension and obesity? Would you prescribe it to your patients? Photo Andrea Williams. Purple Trainers, Creative Commons License Certainly! Robert E. Sallis, M.D., FACSM, Exercise is Medicine Advisory Board Chairman 8 How efficacious is health professional advice? 9 Permission granted from Exercise Works. Infographic designed by Toteshealth Physical activity: what counts?
Sleep Sedentary Light intensity Moderate intensity Vigorous intensity A 10 Tremblay et al. (2010) Appl Physiol Nutr Metab
Q1: What are the UK Chief Medical Officers guidelines on physical activity for adults? 1. 150 minutes of moderate intensity activity in durations of at least ten minutes/week Or 75 minutes of vigorous intensity activity Or a combination of both 2. Muscle-strengthening activity at least 2 days/week 3. Limit time spent sitting for extended periods 4. For older adults (65+) - Balance and coordination activities at least two days/week A 11 Department of Health (2011) Start Active, Stay Active Q1: What are the UK Chief Medical Officers guidelines on physical activity for adults?
1. 150 minutes of moderate intensity activity in durations of at least ten minutes/week Or 75 minutes of vigorous intensity activity Or a combination of both 2. Muscle-strengthening activity at least 2 days/week 3. Limit time spent sitting for extended periods 4. For older adults (65+) - Balance and coordination activities at least two days/week A 12 Department of Health (2011) Start Active, Stay Active Other UK Chief Medical Officers guidelines infographics 13
www.gov.uk/government/publications/start-active-stay-active-infographics-on-physical-activity 14 How many people do not meet the UK CMOs guidelines? 49% of disabled adults are physically inactive compared to 15% of non-disabled adults 15 How inactive is England by region? Inactive Region Men
Women South East 14% 23% South West 15% 23% North East 20%
30% Yorkshire & the Humber 19% 27% London 19% 28% East of England 20% 22%
East Midlands 19% 26% West Midlands 21% 25% North West 26% 31%
Why do we move so little? Image courtesy H Ridgley 16 Image Dick Marwede. Untitled, Creative Commons License Q2: How does the UK compare with the following countries for inactivity? USA France Netherlands Germany Australia Finland 17 A
Q3: How does inactivity compare with other noncommunicable disease risk factors for mortality? Overweight and obesity High blood glucose High blood pressure Tobacco use Physical inactivity A 19 Top five non-communicable disease risk
factors for mortality, high income countries 22.5 % of deaths 18 13.5 9 4.5 0 A 20 WHO (2009) Global health risks: mortality and burden of disease attributable to selected major risks 21 Inactivity is killing us
Decreasing activity levels since 1960s: o Adults are over 20% less active o By 2030 we will 35% less active Physical inactivity is responsible for: o 1 in 6 UK deaths o Up to 40% of many long-term conditions o Around 30% of later life functional limitation and falls Estimated 7.4 billion annual cost Image Shutterstock Ng SW, Popkin B (2012); Lee I-M, et al. (2012); Wen CP, Wu X (2012); WHO (2010); Ossa D & Hutton J (2002); Murray et al. (2013) Physical activity: Who gains the most? Years gained after age 40 150 Minutes
Greatest gains are in those who go from doing nothing to doing something. Biggest gain in years A 22 Moore et al. (2012) PLOS Medicine Key points Low physical activity is the seventh leading modifiable cause of death globally and ninth leading modifiable
cause of ill health in England. Getting inactive people to become active has greater health benefits than getting active people to do more activity get everybody active, every day. Something is better than nothing. Start small and build up gradually: just 10 minutes at a time builds up benefit. 23 Department of Health (2011) Start Active, Stay Active Q4: Physical activity reduces risk of which of the following conditions by at least 20%? Early death CHD and stroke
Hip fracture Type 2 diabetes Depression Colon cancer Hypertension Breast cancer Alzheimers disease Functional limitation, elderly A 24 Physical activity reduces the mortality and
morbidity risk of disease Disease Risk reduction Strength of evidence Osteoarthritis disability 22-80% Moderate Alzheimers disease 20-30% Moderate
Hip fracture 36-68% Moderate Depression 20-30% Moderate Early death 20-35% Strong CHD and stroke
20-35% Strong Type 2 diabetes 35-40% Strong Colon cancer 30-50% Strong Breast cancer
Strong A 25 Start Active, Stay Active (2011) based on US Department of Health and Human Services Physical Activity Guidelines Advisory Committee Report (2008), Washington DC How is physical activity protective? Chronic low-grade systemic inflammation is accelerated and in some cases the cause of: Diabetes Cardiovascular disease Cancers Dementia (secondary to visceral fat) Depression and anxiety Arthritis and many other conditions 26
Wang et al. (2013), Diabetes Care, Kushner et al., (2010), Arthritis Care Res A How is physical activity protective? Physical activity Muscle Visceral fat Anti-inflammatory myokines Systemic inflammation
27 Kushner et al., (2010), Arthritis Care Res, Kushner et al., (2010), Arthritis Care Res What about treatment? In addition to prevention, physical activity helps treat: Cancer Diabetes mellitus Cardiovascular disease Osteoarthritis and lower back pain Give them permission! not wear and tear, but wear and repair COPD and asthma Depression and anxiety
A 28 Department of Health (2011) Start Active, Stay Active Different visceral fat for the same BMI More healthy Less healthy A 29 Reprinted from Lancet Diab Endocrinol, Volume 1, Issue 2, Stefan, Hring et al., Metabolically healthy obesity: epidemiology, mechanisms, and clinical implications, Pages 152 to 162, Copyright 2013, with permission from Elsevier Different visceral fat for the same waist circumference Low waist circumference
alone is not an accurate measure of risk Low waist circumference AND low levels of intraabdominal fat are better markers of good health ASAT = subcutaneous abdominal adipose tissue 30 IAAT = intraabdominal adipose tissue A Reprinted from Obesity, Volume 20, Issue 1, Thomas, et al., The Missing Risk: MRI and MRS Phenotyping of Abdominal Adiposity and Ectopic Fat, Pages 76-87, Copyright 2012, with permission from Wiley
Sedentary behaviour Sedentary behaviour refers to activities that typically occur whilst sitting or lying down (not sleeping) and generally require very low levels of energy expenditure. Spending large amounts of time being sedentary is an independent risk factor for ill-health (e.g. all-cause and cardiovascular mortality, diabetes, some cancers and metabolic dysfunction). Photo Samuel Silva, It was a lazy Sunday again, Creative Commons License UK CMOs recommend minimising prolonged periods of sitting. Sit less, break up sitting time! 31
UK CMOs Guidelines on Physical Activity July 2011; DW Dunstan Diabetes Care 2012 A Why is sitting so bad? Prolonged sedentary behaviour disrupts: o Skeletal muscle metabolism o Lipid metabolism o Glucose metabolism o Circulation (venous thrombosis risk) o Systemic inflammation Just two minutes of walking has a physiological effect, e.g. improving postprandial glucose and insulin responses to food 32 Healy et al. 2008, Diab Care; Heally et al. 2011, Eur Heart J; Dunstan et al. 2012, Diab Care; Howard et al. 2013, Med Sci Sports Exerc; Tremblay et al. 2010; Appl Physiol Nutr Metab; Latouche et al. 2013, J Appl Physiol
Sedentary Oxidative phosphorylation Reactive oxidative species Anti-oxidants Mitochondrial DNA Mitochondria 2014 Intelligent Health Physically Active Oxidative phosphorylation Reactive oxidative species Anti-oxidants
Mitochondrial DNA Mitochondria 2014 Intelligent Health Clinical tips Consider mentioning physical activity in all consultations. Make every contact count! Just very brief advice, such as giving permission can be effective, especially in patients with long-term conditions. Arrange a follow up visit to re-discuss behaviour change and review goals NICE guidelines for chronic conditions available including Physical activity: brief advice for adults in primary care Moderate intensity activity differs by individual (it may be light walking for previously sedentary adults) make it achievable Give them Give permission!
35 NICE PH44 2013 Physical activity: brief advice for adults in primary care Questions so far? 36 5 As behaviour change model for brief advice ASK ASSESS ADVISE ASSIST ARRANGE
37 Make Every Contact Count free eLearning module; Lai DTC, et al. 2010. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews Workshop Activity Working in groups of three, allow six minutes per motivational interview consultation opportunity. Assume that the initial part of the consultation has been completed satisfactorily and the remaining six minutes are an opportunity to talk about physical activity. Each person select whether you will be: 1. Health care professional 2. Patient 3. Observer will feedback to the group After each case, spend a few minutes feeding back and then swap. 38 Case 1
John, 45 year old bus driver 3x elevated readings of HbA1c over past six months HbA1c = Marker of control of diabetes over 4 months Attended DESMOND and saw dietitian made some dietary changes No significant improvement in HbA1c
Discuss further options for diabetes management John shares that he used to play football when I was a lad 39 Case 2 Lucy, 49 year old accountant Breast cancer, post mastectomy adjuvant chemotherapy
Attended with husband (protective) Lacking energy, asking for a tonic Husband almost cancelled appointment as shouldnt leave the house Has a Labrador dog called Molly 40 Case 3
Raj is a 73 year old widower who lives on his own Doesnt leave the house very often now Spends a lot of time at home sitting watching tv 2 daughters worried about his blood pressure and mood Used to enjoy walking with his wife
41 Some available resources Clinical resources: Chief Medical Officers Physical Activity guidelines and infographics NICE Physical Activity pathway and guidance Key resources: Free BMJ E-learning modules: Physical activity and health by Dr William Bird; Motivational interviewing by Prof. Stephen Rollnick Active 10 website, mobile phone app and evidence briefing Lets talk about Physical Activity infographic Further reading: Welsh Deanery / Brian Johnson: Motivate2Move Royal Society of Public Health (RSPH): Physical activity impact pathway Public Health England and RSPH: Everyday Interactions Toolkit 42
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