Inactivity: What’s all the Fuss
Dr William Bird MRCGP MBE
© 2014 Intelligent Health
“Physical inactivity is the fourth leading cause of
death worldwide”
© 2014 Intelligent Health
In the UK 17% of deaths are caused
by inactivity
© 2014 Intelligent Health
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
16
14
Attributable Fraction %
12
10
8
6
4
2
0
Cardiorespiratory
Fitness
Obesity
Smoking
Hypertension
High Cholesterol
Diabetes
Axis Title
Men
Women
© 2014 Intelligent Health
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
18
16
Attributable Fraction %
14
12
10
8
6
4
2
0
Cardiorespiratory
Fitness
Obesity
Smoking
Hypertension
High Cholesterol
Diabetes
Axis Title
Men
Women
© 2014 Intelligent Health
The most impact is from Inactive to
doing something
Kay-Tee Khaw et al 2006
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Men
Women
Inactive
Mod Active
Active
© 2014 Intelligent Health
Learning Points
1. Physical Inactivity is 4th leading cause of death
2. Only 30% of the UK population are active enough
for their health
3. Low fitness is the most important risk factor to
combat in primary care
4. Getting people who are inactive to doing something
has the greatest benefits
© 2014 Intelligent Health
Causes of Stress and Free Radicals
People
Place
Chronic Stress
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
© 2014 Intelligent Health
People
Chronic
Stress
Purpose
Place
Physical Inactivity
Stress Hormones
And other poor health
behaviours
Mitochondrial damage / Inflammation
Depression
Cancers
Cardiovascular
Diabetes
Dementia
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-inflammatory
2) Anti-aging
© 2014 Intelligent Health
Visceral fat reduction with exercise
Fat loss after 13 weeks of walking 60 mins a day and
no weight loss
Lean
Obese
Type 2 Diabetes
0
% Loss of Fat
-5
-10
-15
-20
-25
Axis Title
S/C Fat
Viseral Fat
Lee S et al. J Appl Physiol 2005;99:1220-1225
© 2014 Intelligent Health
Anti-Inflammatory - Fat
0.4kg loss of visceral fat is associated with an 81% reduction
in mortality
© 2014 Intelligent Health
Anti-inflammatory - Muscles
Contracting Muscles
• Release powerful Antiinflammatories 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
© 2012 Intelligent Health/NHS London
Learning Points
5. Chronic inflammation is the foundation of
most long term conditions
6. Physical activity is a powerful antiinflammatory through 2 mechanisms;
7. reducing visceral fat and
8. by releasing Myokines from exercising muscle
© 2014 Intelligent Health
Physical activity creates more healthy
mitochondria and slows the effect of aging
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
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
© 2014 Intelligent Health
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
© 2014 Intelligent Health
Joints
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
© 2014 Intelligent Health
The Brain
Physical Activity Prevents
• Depression by 30%
• Dementia by 40%
© 2014 Intelligent Health
Natural
Killer Cells
These cells target viruses
and cancer cells and are
released during physical
activity. Their levels
subside after about six
hours.
© 2012 Intelligent Health/NHS London
Learning Points
12. PA retains bone density
13. Inactivity leads to degradation of the
articular cartilage
14. PA reduces the risk of developing
depression, dementia and anxiety
15.PA strengthens the endothelium and reduces
existing atheroma
16. PA boosts Natural Killer Cells
© 2014 Intelligent Health
Physical Activity and Diabetes
Risk of cardiovascular
disease mortality by
cardiorespiratory
fitness and body mass
index categories, 2316
men with type 2
diabetes at baseline,
179 deaths.
Blair S N Br J Sports Med 2009;43:1-2
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
© 2012 Intelligent Health/NHS London
Physical Activity and Diabetes
Blair S N Br J Sports Med 2009;43:1-2
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
© 2012 Intelligent Health/NHS London
Physical Activity abolishes the
increased CVD risk in Diabetes
Follow up of 53,973 Norwegian Men 1750
deaths from CVD > 3 hours vs < 3 hours a
week of PA
3
Børge Moe
Eivin Eilertsen
Tom I.L. Nilsen
2.5
2
Diabetes Care
March 2013
vol. 36 no. 3
690-695
1.5
1
0.5
0
<3 hrs a week no <3 hrs a week with >3 hrs a week with >3 hrs a week no
Diabetes
Diabetes
Diabetes
Diabetes
© 2014 Intelligent Health
Cancer and Physical Activity
Breast cancer
24% reduced risk of disease recurrence1. Advice is therefore
to increase activity even during chemo/Rx therapy
Prostate cancer
90 minutes of brisk walking a week can reduce the risk of allcause 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 free
Medical Cost $7000
More readmissions
Circulation. 2004 Mar
23;109(11):1371-8.
Epub 2004 Mar 8
80% event free
Medical Cost
$3400
© 2014 Intelligent Health
The Heath Burden of Inactivity in
Suffolk
Suffolk County
Number
Deaths (39-79)
Diabetes
(Prevalence)
2747
30,789
1,495
CHD (Emergency
admissions)
Breast Cancer
487
(New Cases)
Bowel Cancer
402
Stroke
Cost (total for Suffolk for
1 year)
Number reduced
if 100%
population
becomes active
490
4,130
Cost due to
inactivity
165
£7,602,313
99
£854,605
80
£1,085,154
£1,884,081
£14,046,686
Cost (per 100,000)
2,620,537
£1,894,165
© 2012 Intelligent Health/NHS London
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
© 2014 Intelligent Health
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.
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 2011
2.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.
ALWAYS START WITH MORE WALKING
© 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
© 2014 Intelligent Health
Exploring Decisional Balance
Ask questions in order 1 – 4
Good
Not So Good
Not
Changing
1.
2.
Advantages of Status Quo Downside of Status Quo
Changing
4.
Advantages of changing
3.
Downside of changing
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 Questions
Affirmations
Reflections
Summarising
Importance Confidence Ruler
“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?”
Not at all
Confident/Important
1
2
3
Very
Confident/Important
4
5
6
7
8
9
10
What works in Changing Behaviour1
•
•
•
•
•
•
•
•
1
Goal Setting
Self Monitoring
Frequent and Prolonged Contact
Feedback and Reinforcement
Incentives
Problem Solving
Preventing Relapse
Motivational Interviewing
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!
© 2014 Intelligent Health
The Active Community
Work
GP
Street
School
Sport
© 2013 Intelligent Health
© 2013 Intelligent Health
Park
7 Best Buys in Physical Activity
Br JSportsMed 2012;46:709–712
1.
2.
3.
4.
5.
School programme to integrate physical activity.
Transport policies that favour walking and cycling.
Urban design to promote activity for everyone
Physical activity and embedded in Healthcare.
Public education, including mass media to raise
awareness and change social norms
6. Community-wide programs
7. Sport for all
© 2012 Intelligent Health/NHS London
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
© 2012 Intelligent Health/NHS London
PA is a means to an end
© 2012 Intelligent Health/NHS London
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
© 2012 Intelligent Health/NHS London
© 2012 Intelligent Health/NHS London
Beat the Street (Local)
400,500 swipes
50,000 miles walked / cycled
£6000 raised for books
20% of whole population
participating
All schools, all GPs, most
businesses participated
Reasons to take part in Beat the Street
Taking part in a local community…
Easy to do / would be walking anyway
1%
3%
Helping local education / schools /…
Saving money on travel
3%
4%
Getting children involved /…
7%
Spending more time with family and…
18%
The possibility of winning a prize /…
18%
Travelling in a more environmentally…
19%
Doing something positive for my…
30%
Getting more exercise for myself or…
45%
Having fun
52%
Winning points for Caversham or a…
0%
86%
10%
20%
© 2012 Intelligent Health
30%
40%
50%
60%
70%
80%
90%
100%
COMMUNITY ENGAGEMENT
• All GP Practices will be
distributing
cards and information and targeting
specific groups.
• All Primary schools have been
invited
“Beat the Street was a success for
the whole school
community and we are really
pleased to have the opportunity to
join in again. We know that the
details have been modified and
made even more
exciting for the children and we
can't wait to get started.”
John Cosgrove, Head of Christ the King,
Whitley
• Local media will be contacted
• Reading Sports organisations
51
WHERE?
130 beat boxes
1 at every school
8-10 in Town Centre
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
© 2014 Intelligent Health