inactivity: what’s all the fuss dr william bird mrcgp mbe © 2014 intelligent health

Inactivity: What’s all the Fuss

Dr William Bird MRCGP MBE

© 2014 Intelligent Health

“Physical inactivity is the fourth leading cause of death worldwide”


http://www.thelancet.com/home

In the UK 17% of deaths are caused by inactivity


Cardiorespiratory Fitness

Obesity Smoking Hypertension High Cholesterol Diabetes0

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Men Women

Axis Title

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utab

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Attributable fractions (%) for all-cause deaths in 40 842 (3333 deaths) men and 12 943 (491 deaths) women in the Aerobics Center Longitudinal Study.

Blair S N Br J Sports Med 2009;43:1-2

Cardiorespiratory Fitness

Obesity Smoking Hypertension High Cholesterol Diabetes0

2

4

6

8

10

12

14

16

18

Men Women

Axis Title

Attrib

utab

le F

racti

on %


Attributable fractions (%) for all-cause deaths in 40 842 (3333 deaths) men and 12 943 (491 deaths) women in the Aerobics Center Longitudinal Study.


The most impact is from Inactive to doing something

Kay-Tee Khaw et al 2006

Men Women0

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Inactive Mod Active Active


Learning Points

1. Physical Inactivity is 4th leading cause of death2. Only 30% of the UK population are active enough

for their health3. Low fitness is the most important risk factor to

combat in primary care4. Getting people who are inactive to doing something

has the greatest benefits


Causes of Stress and Free Radicals

Chronic Stress

People Place Purpose

e

Chronic Stress

Physical Inactivity

Chronic Inflammation

• Low grade long term inflammation is the fundamental root cause of:– Diabetes– Cardiovascular Disease– Cancers– Dementia (secondary to visceral fat)

– Depression and Anxiety – Arthritis and many other conditions


People Purpose PlaceChronic Stress

Stress Hormones

Mitochondrial damage / Inflammation

Physical InactivityAnd other poor health

behaviours

Cancers Cardiovascular Diabetes DementiaDepression

Mitochondria as a key component of the stress response.Manoli et al. Trends in Endocrinology and Metabolism Vol 18 No 5 2007

How Does Physical Activity Work?

1) Anti-inflammatory2) Anti-aging


Visceral fat reduction with exercise

Lean Obese Type 2 Diabetes

-25

-20

-15

-10

-5

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Fat loss after 13 weeks of walking 60 mins a day and no weight loss

S/C Fat Viseral Fat

Axis Title

% L

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of F

at


Lee S et al. J Appl Physiol 2005;99:1220-1225

Anti-Inflammatory - Fat 0.4kg loss of visceral fat is associated with an 81% reduction

in mortality


Anti-inflammatory - Muscles

© 2012 Intelligent Health/NHS London

Contracting Muscles• Release powerful Anti-

inflammatories called Myokines that increase 100 fold after exercise.

…they also• Reduce insulin resistance

and mediate 75% of glucose uptake

• Burn more calories at rest than fat

• Protect joints

Learning Points

5. Chronic inflammation is the foundation of most long term conditions

6. Physical activity is a powerful anti-inflammatory through 2 mechanisms;

7. reducing visceral fat and8. by releasing Myokines from exercising muscle


Physical activity creates more healthy mitochondria and slows the effect of aging

Sedentary

Mitochondrial DNA

Reactive Oxidative Species

Anti-Oxidants

Mitochondria

Oxidative Phosphorylation


Physically Active

Mitochondrial DNA

Reactive Oxidative Species

Oxidative Phosphorylation

Anti-oxidants

Mitochondria


Learning Points

9. Mitochondria determine life expectancy and are key to healthy aging

10.When inactive mitochondria release free radicals that can destroy both the mitochondria and the cell itself.

11.When active free radical production almost ceases, new mitochondria are created and the cell is cleared of metabolites


Bone Density


• Physical activity increases the bone density in teenagers and this lasts all their life

• Bed rest leads to !% reduction of bone density each month


Physical Activity increases the strength and thickness of articular cartilage and prevents deterioration of the joint.

Patients with OA must continue to be active to increase function and reduce pain

Joints


The Brain

Physical Activity Prevents • Depression by 30%• Dementia by 40%


Natural Killer CellsThese cells target viruses and cancer cells and are released during physical activity. Their levels subside after about six hours.

Learning Points

12. PA retains bone density13. Inactivity leads to degradation of the

articular cartilage14. PA reduces the risk of developing

depression, dementia and anxiety 15.PA strengthens the endothelium and reduces

existing atheroma16. PA boosts Natural Killer Cells


Risk of cardiovascular disease mortality by

cardiorespiratory fitness and body mass index categories, 2316

men with type 2 diabetes at baseline,

179 deaths.


Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. © 2012 Intelligent Health/NHS London

Physical Activity and Diabetes


Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. © 2012 Intelligent Health/NHS London

Physical Activity and Diabetes

Physical Activity abolishes the increased CVD risk in Diabetes

<3 hrs a week no Diabetes

<3 hrs a week with Diabetes

>3 hrs a week with Diabetes

>3 hrs a week no Diabetes

0

0.5

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1.5

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2.5

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Follow up of 53,973 Norwegian Men 1750 deaths from CVD > 3 hours vs < 3 hours a

week of PA


Diabetes Care March 2013 vol. 36 no. 3 690-695

Børge Moe Eivin EilertsenTom I.L. Nilsen

http://care.diabetesjournals.org/search?author1=B%C3%B8rge+Moe&sortspec=date&submit=Submit



http://care.diabetesjournals.org/search?author1=Eivin+Eilertsen&sortspec=date&submit=Submit



http://care.diabetesjournals.org/search?author1=Tom+I.L.+Nilsen&sortspec=date&submit=Submit

http://care.diabetesjournals.org/search?author1=Tom+I.L.+Nilsen&sortspec=date&submit=Submit

Cancer and Physical ActivityBreast cancer 24% reduced risk of disease recurrence1. Advice is therefore to increase activity even during chemo/Rx therapyProstate cancer 90 minutes of brisk walking a week can reduce the risk of all-cause mortality by up to 50%2

Colon cancer Can improve survival by about 25%3.

[1] Ibrahim, E., & Al-Homaidh, A. (2010). Physical activity and survival after breast cancer diagnosis: meta-analysis of published studies. Medical Oncology. doi:10.1007/s12032-010-9536-x.[2]Kenfield SA (2010) Physical activity and mortality in prostate cancer (In regular vigorous physical activity found to have survival benefits for prostate cancer patients AACR frontier in cancer prevention research conference by Tuma R). Oncol Times 32: 29–33[3] Meyerhardt JA, Heseltine D, Niedzwiecki D, Hollis D, Saltz LB, Mayer RJ, Schilsky RL, Fuchs CS (2005) The impact of physical activity on patients with stage III colon cancer: findings from intergroup trial CALGB 89803. Proc Am Soc Clin Oncol 24: 3534. © 2014 Intelligent Health


Coronary Stent Vs 12 months of exercise 20 mins a day

71% event freeMedical Cost $7000More readmissions

80% event freeMedical Cost $3400

Circulation. 2004 Mar 23;109(11):1371-8. Epub 2004 Mar 8

The Heath Burden of Inactivity in Suffolk


Suffolk County Number Number reduced

if 100% population becomes active

Cost due to inactivity

Deaths (39-79) 2747 490

Diabetes(Prevalence)

30,789 4,130 2,620,537

CHD (Emergency admissions)

1,495 165 £7,602,313

Breast Cancer(New Cases)

487 99 £854,605

Bowel Cancer 402 80 £1,085,154Stroke £1,884,081Cost (total for Suffolk for 1 year)

£14,046,686

Cost (per 100,000) £1,894,165

Health Benefits of Physical Activity

Those patients who are inactive have:–38% more days in hospital–5.5% more GP visits–12% more nurse visits

REF: Department of Health 2009 Let’s Get Moving


Walk!• 5.4 million adults in England (20%)

would take vigorous exercise by walking at a speed of 3mph1.

• Walking at 3mph demonstrates minimum fitness of 6 METS.

• Australian men2 age >70 measured walking speed at usual pace.

• Walking speed of 2 mph was most predictive of mortality over 5 years

• No men walking at speeds of 3 mph were caught by Grim Reaper.

ALWAYS START WITH MORE WALKING

1.Estimates of the number of people in England who attain or exceed vigorous intensity exercise by walking at 3 mph Paul Kelly, Marie Murphy, Pekka Oja, Elaine M. Murtagh, Charlie Foster Journal of Sports Sciences Vol. 29,Iss. 15 20112.Stanaway FF et al How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and over:BMJ. 2011; 343: d7679. © 2014 Intelligent Health

Screening Question 1) “In the past week how many days have you done a

total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? This may include sport, exercise, brisk walking or cycling?”

2) GPPAQ

Outcome Read Code

Inactive 138X

Moderately Inactive 138Y

Moderately Active 138a

Active 138b

The basics of all Behaviour change

Dissatisfaction•The first stage is an understanding that the status quo is damaging

Life could be better

•…and then that life could be a lot better to reverse this damage

Feeling helped•This is the feeling that there is support and help available

Make it easy


Exploring Decisional Balance

Good Not So Good

Not Changing

1. Advantages of Status Quo

2. Downside of Status Quo

Changing 4. Advantages of changing

3. Downside of changing

Ask questions in order 1 – 4

Brief Intervention (basics)

• Motivation to change cannot be imposed.• Ambivalence = “I would like to change... but”• It is the patient’s task not the health

professional’s to sort out this ambivalence. • Direct persuasion is not an effective method

for resolving ambivalence.

Brief Intervention

Open Ended QuestionsAffirmationsReflectionsSummarising

Importance Confidence Ruler

1 2 3 4 5 7 6 8 9 10

Not at all Confident/Important

Very Confident/Important

“On a scale of 1-10, how important is it to you right now to (be more physically active)?What number would you give yourself?” “On a scale of 1-10, how confident are you right now that you could xxxxxxxxxx if you wanted to? What number would you give yourself?”

What works in Changing Behaviour1

• Goal Setting• Self Monitoring• Frequent and Prolonged Contact• Feedback and Reinforcement• Incentives• Problem Solving• Preventing Relapse• Motivational Interviewing

1 REF: Artininian N et al, Interventions to Promote Physical Activity and Dietry Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults: A Scientific Statement From the American Heart Association Circulation 2010, 122:406-441

Reality Check

• 270,000 inactive people aged 40-79 in Suffolk• Decide to reach 67500 (25%) in one year• Each one has two appointments (135,000)• That’s 2800 a week and 562 a day.• If everyone uses organised sessions just once

a week then there would need to be 67,500.• That’s 8000 health walks• We need to think differently!


The Active Community


Work GP

SchoolStreet

Park

Sport


7 Best Buys in Physical ActivityBr JSportsMed 2012;46:709–712

1. School programme to integrate physical activity.2. Transport policies that favour walking and cycling.3. Urban design to promote activity for everyone4. Physical activity and embedded in Healthcare.5. Public education, including mass media to raise

awareness and change social norms6. Community-wide programs 7. Sport for all


Suffolk: The Most Active County

• A clear vision and a common metric • Training of healthcare providers • Training of sports and physical activity providers • Interventions to reduce the health inequalities gap.

“PA is a means to an end rather an end in itself”• Create scale • A strong clear leadership to implement this strategy.• Provide rigorous monitoring and evaluation


PA is a means to an end


http://www.youtube.com/watch?v=aUaInS6HIGo

Beat the Street (Local)• Sensors placed at bus

stops, shops, schools and surgeries in Caversham (population 30,000).

• 13,000 cards distributed by: Schools, GPs, Work.

• Aim to walk or cycle around the world (twice)over 3 months

• More walking the more books donated to schools

• Spot prize every week• School leaderboard


Beat the Street (Local)

400,500 swipes50,000 miles walked / cycled

£6000 raised for books20% of whole population

participatingAll schools, all GPs, most businesses participated

Reasons to take part in Beat the Street


Winning points for Caversham or a school

Getting more exercise for myself or my family

Travelling in a more environmentally friendly way

Spending more time with family and friends

Saving money on travel

Easy to do / would be walking anyway

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

86%

52%

45%

30%

19%

18%

18%

7%

4%

3%

3%

1%

COMMUNITY ENGAGEMENT

• All GP Practices will be distributingcards and information and targeting specific groups.

• All Primary schools have been invited

• Local media will be contacted

• Reading Sports organisations

“Beat the Street was a success for the whole schoolcommunity and we are really pleased to have the opportunity to join in again. We know that the details have been modified and made even moreexciting for the children and we can't wait to get started.”John Cosgrove, Head of Christ the King, Whitley

51

130 beat boxes1 at every school8-10 in Town Centre

WHERE?

Community Prescription

Summary

• Inactivity is as important as smoking• Don’t use weight loss as an indicator of being

successfully active.• You can safely be overweight and fit• Brief advice helps change patient’s behaviour• Regular prompts, goals and self monitoring all

help sustaining a change in behaviour


inactivity: what’s all the fuss dr william bird mrcgp mbe © 2014 intelligent health

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