Dr Kate Little has recently been appointed as a GP Clinical Champion for Physical Activity for SE England. She discusses the health benefits of physical activity and the health risks of being sedentary, sharing some ideas around how we as clinicians could have conversations with our patients to encourage them to be more active and how this might reduce the national pill burden and dramatically improve peoples’ physical and emotional wellbeing.
There is now a vast amount of evidence showing that by getting people active we can significantly improve morbidity and mortality in the UK (better than most drugs we prescribe), as well as saving the NHS up to 15% of its total budget. For example, by getting the most inactive people moderately active, there is a 3-year difference in life expectancy. The stats are pretty compelling.
Physical inactivity is one of the top ten non-communicable causes of mortality globally and one of the top ten causes of ill health in England
Physical inactivity is one of the top ten non-communicable causes of mortality globally and one of the top ten causes of ill health in England 1,2,3. In the UK, the number of people reaching international guidelines for physical activity falls behind most developed countries. For example, we are around 50% less active than the USA.
Nearly one-fifth of men and one-quarter of women are classified as physically inactive. This means that they are doing less than 30 minutes of moderate intensity activity a week.
There are significant inequalities concerning levels of activity, relating to disability, age, gender and socio-economic status. People with disabilities are half as likely to participate in regular activity. The least active of these include those with sensory impairments, learning difficulties and severe and enduring mental illnesses.
For example, we are around 50% less active than the USA.
Also significant is the steep socio-economic gradient, and the barriers relating to ethnicity and culture. This is particularly evident in recent immigrants, and Asian women and girls.
So what are the guidelines?
The Chief Medical Officer’s guidelines for adults (including those over 65 years) recommend that we:
- Do 150 minutes of moderate or 75 minutes of vigorous activity a week.
Both mean getting warm and an increase in heart rate and respiratory rate. Moderate exercise is described as being able to talk but not sing, whereas vigorous exercise reflects not being able to do either.
Not surprisingly, what may be moderate for one person, may be vigorous for another and vice-versa, dependent on factors such as age, mobility and fitness.
The good news is that the health benefits are there even by doing 10-minute bursts of activity. So, small activities - that brisk walk or cycle to the station, or choosing to walk instead of driving when doing the school run - can all add up and make a difference. Getting physically active does not mean having to join a gym or don a leotard!
- Spend less time sedentary.
Being sedentary is a risk factor for ill-health independent of level of physical activity. The evidence suggests that being sedentary can, for example, double our risk of developing diabetes, even if you are doing high levels of physical activity at other times. This has implications for us as GPs, particularly for those of us with remote calling systems.
It is not yet known how often we should get up and move, so it is suggested that we take regular breaks during the working day and avoid sitting for long periods when at home. One way to do this, might be getting up and moving during ad breaks while watching TV.
- Do muscle-strengthening activities at least twice a week.
These can be formal, such as yoga, pilates or going to the gym. Alternatively, they can be simple things, easy to integrate into everyday life, such as carrying heavy bags (backs allowing) or using the free fitness apparatus in many outdoor recreational areas.
For adults over 65 years, it is recommended that they do activities that improve balance 2-3 times a week as well. These can include Tai Chi, bowls and dance.
What are the health benefits of being physically active?
The evidence confirms that physical activity can help reduce the risk of disease, including:
- Cardiovascular disease, stroke and type 2 diabetes
- Breast and colon cancer
- Alzheimer’s dementia, depression, and musculoskeletal ill-health.
It has also been shown to improve quality of life through better symptom control.
The evidence also shows that physical activity can help treat over 20 conditions, including cancer, diabetes, cardiovascular disease, osteoarthritis, lower back pain, COPD, asthma, depression and anxiety.
How does physical activity reduce our risk of disease?
Chronic low-grade systemic inflammation is thought to be the root cause of many disease processes. Being active reduces our overall systemic inflammation through two main paths: a reduction in pro-inflammatory visceral (often intra-abdominal) fat and an increase in anti-inflammatory myokines released from the muscle.
Being sedentary adversely affects our health by increasing the release of free radicals. These damage our cells and promote the systemic inflammation linked to disease. Therefore, reducing our time spent sitting can reduce this damage significantly, reduce cell death, and therefore disease.
How can we translate this information into action?
To do this we need to find out what motivates people to move. An effective way of achieving this is by understanding and tapping into people’s values. This enables us to tailor the evidence and present a compelling argument that will resonate best with them.
Values will clearly vary from individual to individual, but most groups will have some shared motivating factors.
For example, a grandmother may be motivated to stay active so that she can see and possibly even look after her grandchildren. She may also be motivated by the fact that being active could reduce her chances of Alzheimer’s dementia by 20-30%8, and that by staying active, she will maximize her chance of retaining her independence.
On the other hand, a middle-aged man might be motivated by the reduced risk of death and by being more likely to avoid drugs that might affect his performance.
As clinicians, we are well placed to have these conversations, particularly in general practice. We see many people several times over the years and each of these contacts presents an opportunity. Those that we see regularly, such as people with long-term conditions, often stand to gain the most by getting active.
We also see people at times of great transition, such as retirement or having a baby, where they might be more receptive to making changes in their lifestyle.
How can we help our patients change their behaviour and become more active?
Motivating the public to take on more personal responsibility for their health by embracing changes to their lifestyles, is arguably the key to the success of the NHS in the 21st century. However, encouraging our patients to become more active is not easy or straightforward. But as we can see from the evidence, if we can motivate people to shift from being completely inactive to moderately inactive this could make a huge difference to their mortality and morbidity.
Many of you will have heard of motivational interviewing, a method of facilitating behaviour change. This has a strong evidence base in addiction services and could also be applied to physical activity. For example, you might ask, “I wonder if you have ever thought of becoming more active as a way of reducing your risk of diabetes?” and then asking what they see as the barriers and motivating factors, rather than saying “If you don’t become more active, you will double your risk of diabetes.”
There are other frameworks that can also be used to encourage our patients to become more active. NICE, for example recommends the “Five A’s” – Ask, Advise, Assess, Assist and Arrange follow-up.
What is important is that you find a method that you are comfortable with and that works for you and your patient. We are all under immense pressure to deal with the presenting problem(s) and all the other “must-do” tasks within a consultation. This is all done within a very short space of time. However, talking about physical activity does not need to take long. Thirty seconds at the end of a consultation may just be enough to raise the concept and give permission to talk about it at further follow-ups.
Discussing the health benefits of physical activity is vital. As well as improving the nation’s health, this could save the NHS billions. I hope that after reading this, you will feel inspired to have more of these conversations with your patients, and encourage them to become more active. It could be transformational.
Resources for patients
One You, Public Health England’s adult health campaign, launched in March 2016.
This campaign offers advice on how individuals can eat better, be more active, stop smoking and consider their alcohol consumption. There is a How are you? quiz to help people assess their health. This provides a health score, which then links to free and personalised information, apps and tools. If quiz participants enter their postcode, they can also be directed to health and wellbeing resources and services in their local area.
Public Health England (PHE) are offering free workshops to clinicians delivered by GP Clinical Champions. If you are interested in finding out more, please contact the PHE National Team PhysicalActivity@phe.gov.uk for more information.
Suggested further reading
- BMJ modules by Dr. William Bird on physical activity. (Free to non-BMA members too.)
- BMJ module on motivational interviewing by Dr Stephen Rollnick. (Also free to non-BMA members.)