Welcome to physical activity – an interactive workshop designed to assist GPs and their practice staff to increase the physical activity of their patients to improve their health.

QUIZ Question 1 It makes sense to focus on interventions that make the most difference by using the number needed to treat (NNT). All of the following are true EXCEPT: A. To prevent one breast cancer over 5 years, 2451 women need to have mammograms B. GPs need to advise 102 people about physical activity for one person to achieve an increase in physical activity with a 20–30% risk reduction in all cause mortality C. GPs need to treat 67 people with hyperlipidaemia who have 1% risk of coronary heart disease with a lipid lowering agent for 5 years to prevent one cardiovascular disease event D. To identify one colorectal cancer, 1374 people need to have bowel cancer screening.

Question 2 What proportion of Australians aged 18–75 years do not engage in a healthy amount of physical activity?

A. Three-quarters B. Almost half C. One-quarter D. One-fifth.

Question 3 What were the annual direct costs attributable to physical inactivity in 2000?

A. $400 000 B. $4 million C. $40 million D. $400 million.

Question 4 Ben is aged 45 years. His partner has just delivered their first child. Ben wants to see his daughter grow up, and asks advice to reduce his risk of an early death. He is a nonsmoker, normotensive, with a BMI of 24.5 kg/m 2 . The most important way Ben can reduce his overall risk is to: A. Eat a Mediterranean diet B. Drink one glass of red wine per day C. Do regular physical exercise D. Keep his triglycerides within normal limits.

Question 5 Which of the following groups of people report the least physical activity in their leisure time?

A. People in their early 20s B. Indigenous Australians C. People in the highest socioeconomic group D. School children.

Question 6 You attend your old school reunion and catch up with old friends, none of whom smoke. Which classmates now have the greatest cardiovascular benefit from physical activity?

A. Bill manages a plumbing company. In his 20s he was a state hockey mid field legend B. Darren is a journalist. He hated sport at school, because of short sightedness, but now cycles to work every day C. Chris is a computer engineer. He keen on tennis and he played regularly in local competitions until 5 years ago D. Tony is in sports administration. He played State of Origin matches as a youngster, continued as a player/manager, but stopped 9 years ago, due to a knee injury.

Question 7 Con, aged 62 years, has chronic heart failure, hypertension and intermittent claudication, and is frustrated by his disability. You explain the signs of when to stop exercising (chest pain) and that regular physical activity can do all of the following EXCEPT: A. Increase his walking distance B. Reduce his blood pressure C. Increase his cardiac functional capacity D. Increase his risk of stroke.

Question 8 You are advising the staff of a local aged care facility who are introducing an exercise program. You state that, in the elderly, there is evidence for the benefit of regular exercise for all of the following EXCEPT: A. Preventing falls B. Reversing X-ray changes in osteoarthritis C. Pain management in osteoarthritis D. Reducing the risk of osteoporosis.

Question 9 Peter attends for a 45-year-old health check. He says that he has heard that physical activity can prevent cancer. You tell him that physical activity reduces the incidence of all the following cancers EXCEPT: A. Prostate B. Breast C. Colon D. Endometrial.

Question 10 Roberta, aged 53 years, is a bookkeeper. She has impaired glucose tolerance. You recommend regular physical activity, which may do all of the following EXCEPT: A. Be effective in preventing type 2 diabetes if Roberta is normal weight B. Be particularly effective in preventing type 2 diabetes if Roberta is obese C. Decrease insulin sensitivity D. Reduce her risk of death or illness from cardiovascular disease.

Question 11 Jannette, aged 54 years, has a BMI of 28 kg/m little physical activity. You advise her to: 2 . She was diagnosed with type 2 diabetes 6 weeks ago and has followed a recommended diet. Her HbA1c is 8.1% with no evidence of peripheral neuropathy or retinopathy. She does A. Take part in regular physical activity (brisk walking for 30 min/day) B. Commence oral metformin 500 mg twice per day C. Include regular physical activity (brisk walking for 10 min/day) three times per week D. Include regular physical activity (brisk walking for 30 min/day) once a screening stress ECG excludes silent cardiac ischaemia.

Question 12 Sylvia, aged 66 years, presents with low mood and self esteem, poor sleep and appetite, recent comfort eating, and has stopped enjoying playing in the town band. After diagnosing mild to moderate depression, you recommend the following to Sylvia EXCEPT: A. Multivitamin tablets B. Antidepressant therapy C. Cognitive behavioural therapy D. Regular physical activity.

Question 13 There are national guidelines on the definitions of levels of physical activity. Which of the following is FALSE?

A. Low physical activity equals watching television, reading a book, surfing the internet B. Medium physical activity is going for a brisk walk, playing doubles tennis C. Vigorous activity makes you ‘huff and puff’ D. Vigorous activity includes football, netball, soccer, running, swimming laps or training for sport.

Question 14 Clare, aged 37 years, attends for her 2-yearly Pap test. She has little time for exercise, and admits not knowing how much exercise she should do. Which best represents the current national recommendations for her physical activity?

A. Jogging for 40 minutes, 2–3 times per week B. Two 15 minute brisk walks each day, as often as possible C. Normal pace walking for 20 minutes every day D. A 10 minute fast run every day.

Question 15 You have gained Clare’s interest and she wants to know more about physical activity. Which of the following is TRUE? A. If Clare buys a pedometer she should aim for 5000 steps per day B. There is no extra benefit for Clare of doing further exercise once she has done two 15 minute brisk walks C. Clare will gain extra benefit from regular vigorous physical activity such as playing singles tennis D. Clare can challenge her sister Vicki to a game of tennis. Vicki is 7 months pregnant.

Question 16 Clare wants to keep her two sons (aged 7 and 11 years) active. All of the following recommendations are true EXCEPT: A. Limit their time on computer games, television, the internet to <2 hours per day B. The boys need at least 60 minutes of moderate to vigorous physical activity per day C. Clare can enrol the family in the local gym – studies show long term impact on physical activity levels D. Clare can set up a walking-bus group to take the children to school.

Question 17 Graham, aged 44 years, is a welder with mildly elevated blood pressure (BP). You recommend a reduction in salt intake and regular physical activity. Which of the following will help Graham most with reducing his BP?

A. Playing golf, walking the dog and cycle racing will all equally help B. Cycle racing is better than walking the dog C. Playing golf is better than walking the dog D. Cycle racing is better than playing golf.

Question 18a You discuss with your practice manager ways you can facilitate physical activity in the practice and consider a walking group or an exercise physiologist under a team care arrangement. Which of your following patients should NOT be invited to participate?

A. Ella, aged 24 years, who has moderate aortic regurgitation following rheumatic fever B. Chelsea, aged 78 years, who had a complicated myocardial infarction 4 months ago C. Josef, aged 67 years, who has uncontrolled hypertension D. Denise, aged 84 years, who had cataract surgery 1 week ago.

Question 18b You are still going through your patient list to work out who should be invited to the practice physical activity group. Which of the following patients should be invited?

A. Mini, aged 65 years, who has severe aortic stenosis B. Mary, aged 15 years, who has acute glandular fever C. Boris with uncontrolled heart failure due to alcoholic cardiomyopathy D. Miriam who has a BMI of 42 kg/m 2 .

Question 19a Khai, aged 59 years, was recently discharged from hospital following an uncomplicated myocardial infarction (MI). He wants your advice on physical activity. Your rural area has limited rehabilitation facilities. You tell Khai all of the following EXCEPT: A. If he is asymptomatic he can return to his prior low and moderate activities within 2 weeks B. He can resume sexual activity when he can walk two flights of stairs comfortably C. Daily walking is encouraged immediately D. He should wait a week to 10 days before resuming sexual activity.

Question 19b Khai, aged 59 years, was recently discharged from hospital following a MI. You work in a rural area with limited access to rehabilitation facilities. You advise Khai that he must stop exercising when he: A. Begins to feel hot B. Becomes thirsty C. Notices that his breathing has increased in frequency D. Experiences chest tightness or claudication.

Question 20a Max, a 19-year-old student, has type 1 diabetes and has started running at lunchtime. He is 80 kg and currently takes: • glargine (25 units every morning), and • rapid acting insulin (10 units with breakfast, 8–10 units with lunch, depending on the carbohydrates, and 10 units with dinner).

You tell Max all of the following EXCEPT: A. He should test his capillary blood glucose (BGL) before, during and after exercise until a safe plan is established B. He may need carbohydrate before, during or after the exercise C. He may need more insulin on the days that he goes running D. The effect of intense physical activity on reducing blood sugar levels may persist for 12–24 hours after the exercise.

Question 20b Max is keen to start running. He asks if you have any other advice to give him. You tell him all of the following EXCEPT: A. His good control means that he is safe to go running on his own B. He should start slowly and build up the length and his speed over weeks C. He should carry a medi-alert or other identification D. He should stretch before exercising.

Question 21 Rupa has type 2 diabetes (BMI of 29.2 kg/m recommend Rupa to: 2 ), and currently takes metformin 850 mg three times per day and glimepiride 2 mg per day. During motivational interviewing, Rupa says she may join a walking group but wants a reminder on adjusting medication. You A. Omit her metformin on the days she goes walking B. Take chocolate bars on her walks in case of hypoglycaemia C. Eat a healthy snack before going for a walk D. Take a healthy snack on her walk in case she develops symptomatic hypoglycaemia.

Question 22 Fred, aged 69 years, is a retired road train driver. He started smoking at age 14 years and stopped 2 years ago after developing chronic obstructive pulmonary disease. He wants to know if it is safe to take his grandchild for walks. You tell him: A. Walking is likely to decrease his respiratory function B. Walking with his granddaughter is dangerous, as he may not be able to cope if there is an emergency C. Going out for walks is not recommended as it will increase his exposure to viral infections D. Going out for regular walks is likely to increase his respiratory function.

SLIDE PRESENTATION

The impact of physical activity on health

There are many health benefits of physical activity These include: • all cause mortality risk reduced by 50% • cardiovascular disease risk reduced by up to 50% • hypertension prevention and management • stroke risk reduced by up to 30% • type 2 diabetes prevention (risk reduced by 30–50%) and management.

There are many health benefits of physical activity • • • • • • These include: cancer risk (colon, breast) reduced osteoarthritis management (pain control, maintenance of muscle strength, joint structure and function) osteoporosis risk reduction falls risk in the elderly reduced by resistance exercises weight management and reduction (when combined with dietary changes) mental illness (anxiety, depression and subjective feelings of stress) prevention and management.

Health impact – overall mortality • Low levels of physical activity are associated with marked increases in all cause mortality rates. In 2003: there were 13 491 deaths in Australia attributable to physical inactivity • physical inactivity was responsible for 6.6% of the total burden of disease and injury in Australia.

Energy expenditure is positively associated with longevity.

Health impact – risk of cardiovascular disease The risk of fatal and nonfatal cardiovascular events is 1.5–2 times higher for physically inactive people than for moderately active people.

• Regular physical activity throughout life reduces the incidence and fatality rate of cardiovascular disease by up to 50% • For sedentary patients it may never be too late to become physically active.

The greatest health benefit of physical activity is seen in people who change their physical activity status from sedentary to moderately active.

Health impact – existing cardiovascular disease Having cardiovascular disease (CVD) does not prevent physical activity – it makes it more important.

• By being regularly active, people with CVD can decrease their chance of dying from another heart attack by 25% • Exercising by walking three times per week, to the level that causes pain, relieves intermittent claudication for many people.

Health impact – hypertension prevention and management, stroke risk reduced by up to 30% • • • Regular physical activity can reduce: blood pressure by an average of 4 mmHg (SBP) and 2.5 mmHg (DBP) decrease the risk of ischaemic stroke in older adults favourably influence lipid profiles.

Health impact – type 2 diabetes prevention and management Regular physical activity can: • improve insulin sensitivity and reduce the risk of type 2 diabetes by 30–50% • delay or prevent progression to diabetes for people with prediabetes (impaired fasting glucose and/or impaired glucose tolerance) • reduce the risk of type 2 diabetes equally in older and younger age groups • be particularly effective in preventing type 2 diabetes in obese people • reduce the risk of diabetes related death.

Health impact – cancer risk (colon, breast) reduced In primary prevention, routine physical activity is associated with a: • 30–40 % relative risk reduction in the incidence of colon cancer compared to inactive people • 20–30 % relative risk reduction in the incidence of breast cancer compared to inactive women.

Health impact – cancer risk (colon, breast) reduced In secondary prevention, physical exercise: • improves the prognosis in people receiving treatment for breast and colon cancer • is associated with reduced cancer related death and reduced recurrences • is associated with an improvement in overall quality of life and health status.

Health impact – osteoarthritis What is the relationship between exercise and osteoarthritis (OA)?

• • Recreational sport probably does not cause OA Excessive activity (high impact and torsional loading) with an abnormally aligned joint may lead to joint degeneration and OA.

• • Overall, benefits of physical activity outweigh the risks in the role in: pain control of osteoarthritis maintaining muscle strength and joint structure and function.

Health impact – osteoporosis Routine physical activity is important in: • preventing loss of bone mineral density and osteoporosis, particularly in postmenopausal women • secondary preventive action to fight against osteoporosis • reducing the risk of fractures among active people.

Health impact – the risks of falls in the elderly reduced by resistance exercises • Falls in the elderly are a major cause of morbidity and mortality • Musculoskeletal fitness is important for elderly people and can help maintain functional independence • Regular physical activity can prevent frail elderly people losing their remaining musculoskeletal reserve and entering a cycle of inactivity and further dependence.

Health impact – weight management and reduction (when combined with dietary changes) • Exercise has a positive effect on body weight (and CVD risk factors) in people who are overweight or obese. This is particularly so if combined with a healthy eating plan.

Health impact – mental illness prevention and management • Aerobic exercise training has antidepressant and anxiolytic effects and protects against harmful consequences of stress in adults • Activity in the elderly can lower depression scores • Exercise has positive short term effects on self esteem in children and young people.

Health impact – other benefits Other benefits of physical exercise: • improved cognitive function and dementia prevention • improved asthma control and exercise tolerance in chronic obstructive pulmonary disease and cystic fibrosis • increased muscle strength in patients with peripheral neuropathy • decreased symptoms of fibromyalgia (aerobic exercise) • some patients with chronic fatigue syndrome benefit from exercise • may have a role in the treatment of sleep problems in older people.

Does physical activity have any risks?

Physical activity is a ‘wonder drug’, but does have some risks. The following conditions need clinical assessment before exercise: • unstable angina • uncontrolled hypertension • severe aortic stenosis • uncontrolled diabetes • complicated myocardial infarction (within 3 months) • untreated heart failure or cardiomyopathy • symptoms such as chest discomfort or shortness of breath on low exertion • resting heart rate >100 bpm.

How much exercise is enough?

A. 1 hour of any activity that raises heart rate to 120% of resting rate, three times per week B. At least 40 minutes vigorous activity, at least 3 days per week C. Moderate intensity physical activity for at least 30 minutes on most or preferably all days of the week.

Promoting physical activity

Reflection on current practice 1. What is your current role in promoting physical activity?

2. What strategies do you use to promote physical activity?

3. What percentage of your patients do you talk to about physical activity?

4. What percentage of your patients with conditions would benefit from physical activity?

5. What are the most common conditions or attributes patients present with that would benefit from physical activity?

There is evidence that GP intervention promotes physical activity • Professional guidance, self direction plus ongoing professional support can lead to a consistent increase in physical activity over a year • Home based activity was more effective than activity at a special facility (eg. gym) • Interventions should be targeted toward particular groups and tailored to the individual.

What are the main barriers to promoting physical activity in general practice?

• Time • Limited resources • Lack of training • Lack of financial incentive for GPs • Not liking telling people what to do • Own level of physical activity • Other.

How can these barriers be overcome?

What is the ‘best’ or most common excuse you have heard from your patients about why they don’t exercise?

Anticipating patients’ excuses allows you to be prepared with an appropriate response that encourages then to continue exercising.

Changing your practice premises to promote physical activity • Is there easy access for prams and strollers?

• Does your practice have a bicycle stand?

• Is there physical activity information, such as posters and pamphlets on display?

Practical tips to promoting physical activity using the 5As Ask: identify patients who can benefit from an activity script • Waiting room checklist • Waiting room poster • Patient record prompts • Prompts by practice staff.

Assess current physical activity level and readiness to change • Physical activity assessment tool • Is the patient active enough for health benefits?

• Exclude contraindications for a patient at higher risk.

Practical tips to promoting physical activity using the 5As Advise: provide tailored advice • Give feedback on current activity level • Discuss individual benefits • Discuss individual barriers • Negotiate and set realistic goals.

Assist: write activity prescription • Record individual details • Individualise the prescription • Consider referral • Set review dates.

Practical tips to promoting physical activity using the 5As Arrange referral and follow up • Refer to local physical activity provider • Consider referral to tertiary services (eg. exercise physiologist) for patients at higher risk • Organise follow up in 2–4 months for review.

Case study: Barry talks to Dr Nancy Huang

Case study: Barry talks to Dr Nancy Huang Ask and Assess • What was the impact of the waiting room material on Barry’s willingness to talk about physical activity?

Case study: Barry talks to Dr Nancy Huang Ask and Assess • Barry’s height is 180 cm and his weight is 95 kg • Identify the risk factors for cardiovascular and other diseases that Barry has.

Case study: Barry talks to Dr Nancy Huang Barry’s risk factors for cardiovascular and other diseases: • he is physically inactive • his abdominal circumference is 100 cm (the risk of CVD increases at a waist circumference of over 94 cm (men) and 80 cm (women) • for a height of 180 cm, Barry at 95 kg is overweight: his body mass index is 29.3 kg/m² • he has a diet high in processed, fast food, chocolate and soft drinks • he has mild hypertension • he has a family history of heart disease.

Case study: Barry talks to Dr Nancy Huang Ask and Assess • Name three diseases or conditions for which Barry’s risk is increased.

Case study: Barry talks to Dr Nancy Huang A full list would consist of: • ischaemic heart disease • stroke • type 2 diabetes • osteoarthritis • fatigue • sleep apnoea • colon cancer.

Case study: Barry talks to Dr Nancy Huang Ask and Assess Using the following questions, a physical assessment is completed for Barry: • How many times per week do you usually do 20 min or more of vigorous intensity physical activity that makes you sweat or puff and pant?

• How many times per week do you usually do 30 min or more of walking?

• How many times a week do you usually do 30 min or more of other moderate intensity physical activity that increases your heart rate or makes you breathe harder than normal?

Case study: Barry talks to Dr Nancy Huang • Barry’s total score is 2 (he does two lots of 30 min or more moderate intensity physical exercise) • Barry’s delivery job may give him the equivalent of 1 hour of moderate physical activity per week • The recommended level of physical activity is equivalent to five points or more (at least 2.5 hours of moderate intensity activity per week).

Case study: Barry talks to Dr Nancy Huang Advise • What would you say to Barry about his current activity level?

A possible response could be: ‘Barry you’re not moving enough to stay healthy. Your activity level is below the recommended minimum’.

Case study: Barry talks to Dr Nancy Huang Advise • How would you summarise the benefits of physical activity to Barry?

Case study: Barry talks to Dr Nancy Huang A possible response may include: • Barry, if you increase your physical activity it’s likely that you will have a better quality and longer life • you’ll enjoy your family more and be there for them • the specific benefits of increasing your physical activity are likely to be an increase in sense of wellbeing, self esteem, energy levels, and improvements in sleep • physical activity decreases the risk of cardiovascular disease, decreases blood pressure, improves cholesterol levels and decreases the risk of diabetes and osteoarthritis.

Case study: Barry talks to Dr Nancy Huang Advise • What do you see as the potential barriers to increased physical activity for Barry?

Case study: Barry talks to Dr Nancy Huang The most likely barriers for Barry are: • time • family pressures • financial pressures.

Case study: Barry talks to Dr Nancy Huang Potential medical contraindications to increasing physical activity that need to be excluded: • unstable angina • symptoms on low activity (eg. chest discomfort, shortness of breath) • uncontrolled hypertension or uncontrolled cardiac failure • uncontrolled diabetes (eg. blood glucose <6 mmol/L or >15 mmol/L) • severe aortic stenosis • acute infection or fever • resting heart rate >100 bpm/resting arrhythmia • recent complicated acute MI (<3 months).

Case study: Barry talks to Dr Nancy Huang • Barry has no contraindications to increasing physical activity.

Case study: Barry talks to Dr Nancy Huang Your prescription for an active lifestyle • Document Barry’s recommended physical activity program in his history • Ensure Barry has clear advice about this program • Useful tools to assist this process are available, eg. Lifescripts program (www.health.gov.au/lifescripts).

Case study: Barry talks to Dr Nancy Huang Assist • Any physical activity should be encouraged, but it is useful to know the relative benefits of different forms of exercise.

Case study: Barry talks to Dr Nancy Huang Assist Put the following activities in increasing order of their kilojoule expenditure: a) Walking the dog for 30 min b) Walking up three flights of stairs c) Shopping at a mall, walking for 1 hour d) Getting off the bus and walking 5 min to work e) Ironing and vacuuming for 1.5 hours f) Taking the escalator or lift up three flights g) Getting off the bus early and walking 15 min 2x/day h) Gardening and mowing for 1 hour i) Shopping online for 1 hour j) Cooking for 30 min.

Case study: Barry talks to Dr Nancy Huang Assist Put the following activities in increasing order of their kilojoule expenditure: a) Walking the dog for 30 min 7 b) Walking up three flights of stairs 3 c) Shopping at a mall, walking for 1 hour d) Getting off the bus and walking 5 min to work e) Ironing and vacuuming for 1.5 hours f) Taking the escalator or lift up three flights g) Getting off the bus early and walking 15 min 2x/day 8 2 9 1 6 h) Gardening and mowing for 1 hour i) Shopping online for 1 hour j) Cooking for 30 min.

10 5 4

Case study: Barry talks to Dr Nancy Huang Assist Match each food intake to the energy expenditure of each activity for a person weighing 70 kg.

Food

1 jam doughnut 1 medium banana 1 can of light beer 1 can of beer 1 meat pie and 1 small French fries

Time and activity

90 min playing soccer 15 min walking 11 min cycling 33 min walking 55 min dancing

Case study: Barry talks to Dr Nancy Huang

Food

1 jam doughnut 1 medium banana 1 can of light beer 1 can of beer 1 meat pie and French fries

Kilojoules

1360 kJ 365 kJ 260 kJ 585 kJ 1880 kJ; 1089 kJ

Time and activity

55 min dancing 11 min cycling 15 min walking 33 min walking 90 min playing soccer

Heart Foundation sedentary and active energy comparisons

Sedentary

Waiting 30 min for food home delivery (63 kJ) Using a lawn service (0 kJ) Letting the dog out the door (8 kJ) Driving 40 min, walking 5 min, parking (92 kJ) Hiring someone to clean and iron (0 kJ)

Active

Cooking for 30 min (105 kJ) Gardening and mowing each for 30 min (1505 kJ) Walking the dog for 30 min (523 kJ) Walking 15 min to bus stop twice per day (500 kJ) Ironing and vacuuming each for 30 min (635 kJ)

Heart Foundation sedentary and active energy comparisons

Sedentary

Taking escalator or lift up three flights (1 kJ) Parking as close as possible, 10 sec walk (1 kJ) Using remote control to change channel (<4 kJ) Driving to corner shop to get the paper (8 kJ) Shopping online for 1 hour (125 kJ) Drive to local shops for lunch (8 kJ) Play a computer game for 30 min (80 kJ) Getting of bus and walking 5 min to work (84 kJ)

Active

Walking up three flights of stairs (63 kJ) Parking further away, walking 2 min (33 kJ) Getting up and changing television channel (13 kJ) 10 min walk to corner shop (167 kJ) Shopping at the mall, walking 1 hour (606–1003 kJ) Meet a friend and walk 20 min to local cafe (334 kJ) Play a ball game for 30 min (546 kJ) Getting of the bus one stop earlier, walking 15 mins to work (252 kJ)

Comparison of kilojoule content of foods and drinks • One croissant (plain medium, 50 g) with 2 tsp butter and 2 tsp jam (1095 kJ); two pieces wholemeal plain toast (30 g each) with 1 tsp margarine and 1 tsp jam per slice (945 kJ) • Ham and salad sandwich with 2 tsp margarine (1105 kJ); pasta carbonara (1 cup pasta with cream, bacon, cheese and egg sauce) (1990 kJ) • A packet potato crisps (50 g) (1045 kJ); 1 medium apple (150 g) (270 kJ) • 1 glass cola soft drink (250 mL) (460 kJ); 1 glass water (0 kJ).

Comparison of kilojoule content of foods and drinks • 1 medium T-bone steak with fat (1255 kJ); 1 medium T-bone steak, trimmed of visible fat (960 kJ) • Chicken breast with skin, roasted without added fat (100 g) (920 kJ); Chicken breast without skin, roasted without added fat (100 g) (605 kJ) • 1 fillet white fish, eg. flake fried in batter (150 g) (1,725 kJ); 1 fillet white fish, eg. flake steamed, poached or grilled (150 g) (630 kJ).

If this is all getting too serious … Have a laugh.

United States researchers found that while laughter cannot replace exercise, about 15 minutes of genuine laughter per day increases energy expenditure by about 50–170 kJ.

Case study: Barry talks to Dr Nancy Huang Arrange • Follow up is an important part of advising patients about physical activity • Barry will also need his BP monitored, so review at 1 month is recommended • Review at 2–4 months is recommended for people who are well • A computerised or manual recall system can be established so that a reminder is sent to Barry • This reminder can be by mail, text message or email • Sending reminders can be delegated to other members of the general practice team to automate or follow through on.

Recommending physical activity in different patient groups The elderly population • The least physically active people have the most to gain from exercising – it’s never too late to start • Physical activity can help delay the need for full time care • Physical activity improves muscle strength, balance and can prevent falls • Regular walking is the most straightforward activity to suggest • If elderly people are carers, short time respite care may be needed so that the carer can exercise and remain healthy.

Recommending physical activity in different patient groups Work commuters • A full time job and a long commute to work leaves little time for exercise • Do workplaces provide onsite facilities?

• Each extra kilometre a commuter walks or cycles rather than drives, improves health and reduces carbon emissions • Use stairs, not lifts • Lifestyle changes that are built into your routine last longer than those requiring specific equipment (eg. gyms).

Recommending physical activity in different patient groups People with a disability • 19% of the Australian population has a disability • Participation rates are much lower than the general population • Physical activity is important in maintaining function and preventing further disability • Access to suitable physical activity programs can be a challenge for people with a disability.

Recommending physical activity in different patient groups Parents with young children • Looking after young children is physically demanding • Parents at risk of insufficient physical exercise are those who commute to sedentary jobs.

• Take children for a walk in the pram (this also provides a break from crying children) • Take toddlers for a walk to look at ‘anything’ • Walk to a park and push children on a swing • Take children outside and throw a ball (or throw a soft ball inside) • Go swimming and lie down in the toddler pool to exercise • Meet with other parents and take turns minding children while others swim or exercise nearby.

Case study: Sylvia Hong • 83 years old, of Chinese descent, lives alone with her dogs in a retirement village • Medical history: MI 3 years ago, mild cardiac failure, osteoporosis • Current medication (all once daily): perindopril 5 mg, frusemide 40 mg, aspirin 100 mg, atorvastatin 10 mg • Sylvia does not want to take any medication for osteoporosis as she is ‘fed up’ of taking so many tablets for her heart • Sylvia does not want to be admitted to residential care.

How will increasing her physical activity levels benefit Sylvia in her aim to stay at home?

Case study: Sylvia Kong If Sylvia increases her physical activity she may: • have improved symptom control and increased functional capacity decrease her risk of falls and worsening osteoporosis.

• delay her loss of independence and the need for residential care, and may live longer.

Case study: Sylvia Kong What special advice would you give to Sylvia about increasing physical activity?

Case study: Sylvia Kong • Assure Silvia that physical activity, including resistance training, is safe for people with well compensated clinically stable heart failure • Sylvia can progress over time to achieve 30 minutes of moderate intensity physical activity on most days • Less intense and shorter bouts of activity with more rest periods may suffice for someone with advanced CVD • Encourage regular low to moderate level resistance activity, initially under the supervision of an exercise professional • Sylvia should warm up and warm down, and wear appropriate footwear and clothing.

Case study: Sylvia Kong A typical walking program for patients with CVD including survivors of acute MI involves:

Week

1 2 3 4 5 6

Minimum time (min)

5–10 10–15 15–20 20–25 25–30 30

Times per day

2 2 2 1–2 1–2 1–2

Pace

Stroll Comfortable Comfortable Comfortable/stride out Comfortable/stride out Comfortable/stride out

Case study: Sylvia Kong Before Sylvia starts exercising, a pre-activity evaluation is required, ie: • medication review • physical examination • history of prior physical activity.

Case study: Eddie Pocklington • 65 years old retired builder. Retired at age 60 years as he was getting too short of breath to work • Medical history: chronic obstructive pulmonary disease, smokes 10 cigarettes per day, no energy, low mood – ‘I’m just waiting to get worse, doctor’ • Does not enjoy playing cards with mates any more, defines physical activity as walking from the car to the shop to buy cigarettes.

What are the likely benefits of increased physical activity for Eddie?

Case study: Eddie Pocklington Likely benefits of increased physical activity for Eddie would be: • increased exercise capacity • increased energy and quality of life • improved sleep • improved mood.

Case study: Eddie Pocklington Exercise can also improve Eddie’s chance of successfully quitting, if he wants to give up smoking.

What advice will you give Eddie about starting physical activity and a basic regimen?

Advice about starting physical activity for Eddie • Medication review, physical examination and assessment of current physical activity before starting (contraindication screening) • Warm up, warm down, wear appropriate footwear and clothing • Find somewhere to walk at home – do a simple exercise routine • Walk each day, or at least 3–4 times per week • Start slowly, gradually increasing speed • Walk for a shorter duration initially (eg. 2 min/day), gradually increasing duration, until walking for 15–20 min) • It is normal to feel breathless while exercising but if feeling distressed, stop for a short time until breath returns • If this routine is too easy, longer exercise times may be required • Keep a record of exercise to see improvements.

Case study: Eddie Pocklington What symptoms should you tell Eddie to look for and stop his physical activity if he develops them?

Case study: Eddie Pocklington Eddie should watch out for: • squeezing, discomfort or pain in the centre of the chest, behind the breastbone +/- spreading to the shoulders, neck, jaw and/or arms • dizziness, light headedness or feeling faint • nausea • uncharacteristic excessive sweating • palpitations associated with feeling unwell • undue fatigue.

Summary In this presentation you’ve learnt about the health benefits of physical activity. After giving up smoking, encouraging your patients to be physically active is likely to have more impact on their health than any other intervention.

Conclusion – physical activity is an evidence based intervention • Promoting physical activity may be a new role to you and your practice • You now know that this is important, but may still find it hard to include this in your consultations • Your patients may be even less ready and willing to talk about physical activity than you are.

To prepare discussing physical activity with your patients: • display posters and provide resources in your waiting room and consulting room • provide information about local facilities such as the gym, walking group or exercise therapist • sell or hire pedometers.

Exercise, emotions and the 5As

Discussing physical activity in general practice consultation It is important to understand the concept of ‘safety netting’ to ensure that risk factors in patient management are not overlooked.

The ‘red book’ All adults should be advised to participate in 30 minutes of moderate activity on most, preferably all days of the week. Physical activity should be assessed every 12 months and at every visit for: • teenage girls • Indigenous Australians • people from non-English speaking background • people with chronic disease or cardiovascular disease.

An independent person chooses to see you regarding a problem. It is your responsibility as a health professional to ensure that person leaves the consultation independent and better equipped to deal with that problem. It is all too easy to change this independent person into a dependent patient, with a problem they still don’t understand and with reduced confidence in their ability to cope with it.

Roger Neighbour, The Inner Consultation

Talk outline • Why physical activity matters • Physical activity recommendations • Role of general practice • Human behaviour change • Consultation models • Permission to speak • Role of cognitive dissonance • The cycle of change • Dealing with fall out.

Benefits of physical activity • All cause mortality risk reduced by 50% • Cardiovascular disease risk reduced by up to 50% • Hypertension prevention and management • Stroke risk reduced by up to 30% • Reduced risk of cancer of the colon and breast • Type 2 diabetes prevention (risk reduced by 30–50%) and management.

Benefits of physical activity • Osteoarthritis management (pain control, maintenance of muscle strength, joint structure and function) • Osteoporosis risk reduction • Falls risk in the elderly reduced by resistance exercises • Weight management and reduction – when combined with dietary changes • Mental illness prevention and management.

The best medicine No pharmaceutical intervention can match physical activity • Benefits wide range of problems • Minimal side effects.

National guidelines • 30 minutes/day of moderate intensity physical activity on most preferably all days of the week • 30 minutes/day can be continuous or accumulated in bouts of 10 minutes or more.

Heart Foundation and The RACGP

Role of general practice Systematic review evidence of effectiveness • Targeted interventions – targeted at most sedentary – to their stage of change • Tailored to the individual – brief advice specific to their needs – written information or activity script – follow up.

The 5As • Ask • Assess • Advise • Assist • Arrange.

Human behaviour change • Change can be exciting or daunting.

How can we put the 5As into practice to encourage change?

Reflection What motivates you to change?

Think of one change in your behaviour.

• What did you change?

• Why?

• What helped?

• What got in the way?

Findings • Combination of: – emotion – information – see value in change – belief that change is possible.

• Overcoming barriers to change.

Barriers to change Theory of reactance • Individuals are motivated to maintain autonomy – they resist coercion • People are likely to do the opposite of what you tell them • Change is more likely if you create perception that change was their idea.

Maslow’s hierarchy of needs

Permission to speak The 5As in the GP consult • Timing is important • A salutary tale from Yorkshire.

Consultation models • The medical model • Stott and Davis – the exceptional potential in every consultation for health promotion • Neighbour.

Scott and Davis model A Management of presenting problems B Modification of health-seeking behaviour C Management of continuing problems D Opportunistic health promotion

Neighbour’s consultation model Connecting Summarising Handing over Safety netting Housekeeping Allow the patient to talk What’s going on?

What can be done? Agree options What if?

What about me?

The 5As in a consult The 5As in a consult • Ask – connect – summarise • Assess – handing over • Advise • Assist • Arrange – safety netting • Advise – housekeeping.

Cognitive dissonance

Cycle of change

Precontemplation

Aim

Help the person to consider the possibility of change by providing information on the benefits of physical activity.

• Discuss risks of inactivity/existing condition • Discuss benefits of physical activity • Encourage person to think about being more active.

Contemplation

Aim

Help the person make a decision to change their physical activity behaviour.

• Offer verbal and written information about increasing physical activity • Discuss pros and cons and jointly problem solve perceived barriers to incorporating physical activity into their daily routine • Suggest ways to incorporate physical activity into their daily routine.

Preparation

Aim

Assist commitment to regular physical activity.

• Set a start date.

Action

Aim

Reinforce behaviour change through encouragement and support.

• Reinforce health benefits of physical activity • Feedback any improvement in risk factors • Congratulate person on achievements.

Maintenance

Aim

Support the person in maintaining new physical activity behaviour.

• Proactively identify potential triggers to relapse • Continue support and encouragement • Review level and type of activity • Feedback and improvements in risk factors • Renew physical activity prescription as person progresses.

Relapse

Aim

Help the person to identify reasons for relapse.

• Reassure the person that relapses are normal and provide opportunities for learning • Together reset more suitable activity goals • Return to contemplation stage.

Dealing with fall out • Patient’s perspective – cognitive – emotional • Health professional’s perspective

Dealing with fall out • Health professional advise – patients decide • Be honest • Be active • Be open with colleagues • Be realistic • Be responsible – delegate

Summary • Physical activity – the best medicine • Equip patients to live their lives • Target the sedentary • Tailor information to individual – avoid reactance – meet patient’s agenda first – create cognitive dissonance – use emotions positively – look after yourself too.