16/06/2016

Prescribing Prevention
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dr Farrah Jawad is a registrar in Sport and Exercise Medicine.  She currently works at the Institute of Sport, Exercise and Health in London and co-ordinates the British Journal of Sports Medicine Trainee Perspective blog which can be accessed via http://blogs.bmj.com/bjsm/ .  She tweets at @FJSEM
It has been said that exercise, if it were a pill, would be prescribed for almost everyone and would be one of the most cost effective interventions available.  Low cardiorespiratory fitness has been shown to be a more important risk factor for all-cause mortality than hypertension, high cholesterol and smoking.1  One systematic review and meta-analysis has shown that self-reported physical activity reduced all-cause mortality by 29%.2  To put this into perspective, the commonly prescribed ACE-inhibitor reduces all-cause mortality by 10%3.  Low fitness has been shown to kill more people than smoking, diabetes and obesity combined.3  Individuals exercising just 15 minutes a day live approximately 3 years longer than inactive individuals.4
 
Prolonged sitting time is strongly associated with obesity, metabolic syndrome and type 2 diabetes, as well as Cardiovascular disease and Cancer. It is also associated with total mortality independent of daily moderate to vigorous intense physical activity. What this means is that it is better to be frequently active throughout the day rather than to exercise once a day for an hour and spent 16-hour days sitting.  This message is important to get across to patients as it has significant health implications.  

Most people presenting to their GP have a non-communicable disease, such as hypertension or diabetes.  Doctors, whilst knowing wide range of benefits of exercise, perhaps do not always realise the opportunities they have in clinic to propagate the physical activity message and offer advice on physical activity and being less sedentary.  The focus tends to be that of a disease service rather than a health service, and perhaps that is a reason why exercise prescription does not feature in many medical school curricula.  

Part of the problem with designing such curricula is that they are packed to the rafters because there is so much to cover; there is always a feeling that one topic has to come out in order to fit another topic in.  Perhaps the way to solve this is for lecturers to incorporate physical activity in each of their lectures on various diseases; the effects of physical activity are far-reaching.  Physical activity is beneficial in a number of diseases and normal physiological states, including: fibromyalgia and chronic pain syndromes,11,12  osteoarthritis,13,14 pregnancy,15 obesity,16 mild to moderate depression,17 diabetes mellitus types I and II,18 cardiovascular disease,19 chronic obstructive pulmonary disease.20

Being more physically active does not mean being sporty, and does not require special equipment or expensive gym memberships.  People can make even the smallest changes to their lifestyle – taking the stairs instead of the lift, getting off the bus a stop earlier and walking, for example – which can help to contribute to an overall increased level of physical activity.  
The UK Physical Activity Guidelines advice for adults (19-65) states:

  • Aim to be active daily. Activity should add up to over 150 minutes per week by participating, in at least 30 minutes of moderate intensity physical activity on 5 or more days a week, or in multiple bouts of 10 minutes or more.

  • Comparable benefits can be achieved through vigorous activity of 75 minutes a week or in a combination of moderate and vigorous activity.

  • Adults should also undertake physical activity to improve muscle strength on at least two days a week.

  • All adults should minimise extended sedentary (sitting) periods.13

The guidance for children aged 5 to 18 is that they should participate in a minimum of 60 minutes a day and up to several hours every day of moderate to vigorous intensity physical activity. Three days a week should include vigorous intensity activities that strengthen muscle and bone. This age group should also minimise the amount of time spent being sedentary (sitting) for extended periods.13    For under 5s capable of walking, they should spend a minimum of 180 minutes a day playing and being active, and those that cannot should be encouraged to play in safe environments and minimise time spent sitting or restrained.13

One way you can bring exercise into the consultation is by asking “The Exercise Vital Sign”:“On average how many days/ week do you engage in moderate or greater physical activity (like a brisk walk)?”, then, “On those days, how many minutes do you engage in activity at this level?”
This helps to start the discussion about physical activity and being less sedentary with patients.  It is important to extol the virtues of the different types of exercise as they have different positive effects, for example, aerobic exercise for cardiovascular fitness and muscular strength for mobility and falls prevention.  When tailoring advice regarding a specific programme of exercise for a patient, you can discuss the FITT principles:

  • Frequency - How many times a week to do the activity
  • Intensity – How hard to exert oneself during the activity
  • Type – The type of activity agreed with the patient
  • Time - How long the patient might participate in the activity in minutes

The FITT principles can help a clinician make sure all the bases are covered when discussing exercise prescription.  One example of how the FITT principles can be applied is if a patient, when prompted about any particular activity they might like to do more of, mentions walking, the clinician may then suggest that the patient walks at a moderate intensity, so they feel slightly sweaty and short of breath, for 30 minutes a day, five times a week as a goal. But that they might start with a lower intensity, time and frequency initially so that they can build up their fitness in time.

In summary, exercise can be a cheap and effective way of reducing morbidity and mortality, and we need to address potential barriers to exercise and the reduction of sedentary behaviour.  Even a short discussion with patients on the benefits of exercise is a start.  Active children grow up to be active adults and so intervening at a young age is important.  The Active Movement project ( www.activemovement.co.uk ) aims to do this by integrating low level activity into the normal day of schoolchildren.  

As clinicians, it is good to lead by example.  On Sunday 26th June 2016, why not walk, jog or run the Institute of Sport, Exercise and Health’s 5 or 10K race in Regent’s Park? ( http://www.iseh.co.uk/events/iseh-5k-and-10k-run-2016 ).  Perhaps I will see you there!

Some useful links:


References
  1. Blair SN. (2009) Physical inactivity: the biggest public health problem of the 21st century. British Journal of Sports Medicine; 43:1-2
  2. Nocon M, Hiemann T, Mϋller-Riemenschneider F, Thalau F, Roll S, Willich SN. (2008) Association of physical activity with all-cause and cardiovascular mortality: a systemic review and meta-analysis. European Journal of Cardiovascular Prevention and Rehabilitation.15:239-46
  3. Kahn KM, Tunnanja HA. (2011) As different as Venus and Mars: time to distinguish efficacy (can it work). British Journal of Sports Medicine; 45:(10): 759-60
  4. Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee M, et al. (2011) Minimum effort of physical activity for reduced mortality and extended life expectancy. The Lancet; 378:(9798): 1244-1253.
  5. Jakes RW, Day NE, Khaw KT, (2003) Television viewing and low participation in vigorous recreation are independently associated with obesity and markers of cardiovascular risk. EPIC-Norfolk population-based study. European Journal of Clinical Nutrition; 57:1089-1096.
  6. Hu FB, Leitzmann MF, Stampfer,MJ, et al.(2001) Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men. Archives of Internal Medicine; 161:1542-1548.
  7. Bertrais S, Beyeme-Ondoua JP, Czernichow S, et al. (2005) Sedentary behaviour, physical activity and metabolic syndrome in middle-aged French subjects. Obesity Research; 13:936-944.
  8. Dunstan DW, Salmon J, Owen N, et al. (2004) Aus Diab Steering Committee. Physical activity and television viewing in relation to risk of undiagnosed abnormal glucose metabolism in adults. Diabetes Care; 27:2603-2609.
  9. Katzmarzyk PT, Church TS, Craig CL. (2009) Sitting times and mortality from all causes, cardiovascular disease and cancer. Medicine and Science in Sports and Exercise; 41:998-1005.
  10. Edwardson CL, Gorely T, Davies MJ, et al. (2012) Association of Sedentary Behaviour with Metabolic Syndrome: A Meta-Analysis. PLoS ONE 7(4): e34916. doi:10.1371/journal.pone.0034916
  11. Rossy LA, Buckelew SP, Dorr N, Hagglund KJ, Thayer JF, McIntosh MJ, et al. (1999) A meta-analysis of fibromyalgia syndrome. Annals of Behavioural Medicine; 21:180-191
  12. Busch AJ, Barber KA, Overend TJ. (2002) Exercise for treating fibromyalgia syndrome. Cochrane Database Systematic Review; CD003786
  13. Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home countries' Chief Medical Officers.Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209 
  14. Devos-Comby L, Cronan T, Roesch SC. (2006) Do exercise and self-management interventions benefit patients with osteoarthritis of the knee? A metanalysis review. Journal of Rheumatology; 33:744-56.
  15. https://www.rcog.org.uk/globalassets/documents/guidelines/statements/statement-no-4.pdf
  16. Shaw KA, Gennat HC, O’Rourke P, Del Mar C. (2006) Exercise for overweight or obesity. Cochrane Database of Systematic Reviews  Issue 4. Art. No.: CD003817. DOI: 10.1002/14651858.CD003817.pub3
  17. Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub6.
  18. Borghouts LB, Keizer HA. Exercise and insulin sensitivity. A review. Int J Sports Med 2000;21:1-12.
  19. Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home countries’ Chief Medical Officers. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
  20. McCarthy B, Casey D, Devane D, et al. (2015) Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane database of systemic reviews. 2:CD003793. doi: 10.1002/14651858.CD003793.pub3