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 (3333 deaths) men and (491 deaths) women in the Aerobics Center Longitudinal Study. Blair S N Br J Sports Med 2009;43:1-2

© 2014 Intelligent Health Attributable fractions (%) for all-cause deaths in (3333 deaths) men and (491 deaths) women in the Aerobics Center Longitudinal Study. Blair S N Br J Sports Med 2009;43:1-2

The most impact is from Inactive to doing something Kay-Tee Khaw et al 2006 © 2014 Intelligent Health

Learning Points 1.Physical Inactivity is 4 th 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 Chronic Stress PeoplePlace 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 Purpose Place Chronic Stress Stress Hormones Mitochondrial damage / Inflammation Physical Inactivity And other poor health behaviours Cancers Cardiovascular Diabetes Dementia Depression Mitochondria as a key component of the stress response. Manoli et al. Trends in Endocrinology and Metabolism Vol 18 No

How Does Physical Activity Work? 1) Anti-inflammatory 2) Anti-aging © 2014 Intelligent Health

Visceral fat reduction with exercise © 2014 Intelligent Health Lee S et al. J Appl Physiol 2005;99:

Anti-Inflammatory - Fat 0.4kg loss of visceral fat is associated with an 81% reduction in mortality © 2014 Intelligent Health

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 and 8.by releasing Myokines from exercising muscle © 2014 Intelligent Health

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

Sedentary Mitochondrial DNA Reactive Oxidative Species Anti-Oxidants Mitochondria Oxidative Phosphorylation © 2014 Intelligent Health

Physically Active Mitochondrial DNA Reactive Oxidative Species Oxidative Phosphorylation Anti-oxidants 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 © 2014 Intelligent Health 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 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

© 2014 Intelligent Health The Brain Physical Activity Prevents Depression by 30% Dementia by 40%

© 2012 Intelligent Health/NHS London Natural Killer Cells These 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 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

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 and Diabetes

Physical Activity abolishes the increased CVD risk in Diabetes © 2014 Intelligent Health Diabetes Care March 2013 vol. 36 no Børge Moe Eivin Eilertsen Tom I.L. Nilsen

Cancer and Physical Activity Breast cancer 24% reduced risk of disease recurrence 1. 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 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: /s 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 Proc Am Soc Clin Oncol 24: © 2014 Intelligent Health

Coronary Stent Vs 12 months of exercise 20 mins a day 71% event free Medical Cost $7000 More readmissions 80% event free Medical Cost $3400 Circulation Mar 23;109(11): Epub 2004 Mar 8

The Heath Burden of Inactivity in Suffolk © 2012 Intelligent Health/NHS London Suffolk County NumberNumber reduced if 100% population becomes active Cost due to inactivity Deaths (39-79) Diabetes (Prevalence) 30,7894,1302,620,537 CHD (Emergency admissions) 1,495165£7,602,313 Breast Cancer (New Cases) 48799£854,605 Bowel Cancer40280£1,085,154 Stroke£1,884,081 Cost (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 © 2014 Intelligent Health

Walk! 5.4 million adults in England (20%) would take vigorous exercise by walking at a speed of 3mph 1. Walking at 3mph demonstrates minimum fitness of 6 METS. Australian men 2 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 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) GPPAQGPPAQ OutcomeRead Code Inactive138X Moderately Inactive138Y Moderately Active138a Active138b

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 GoodNot So Good Not Changing 1. Advantages of Status Quo 2. Downside of Status Quo Changing4. 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 O pen Ended Questions A ffirmations R eflections S ummarising

Importance Confidence Ruler 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 Behaviour 1 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:

Reality Check 270,000 inactive people aged in Suffolk Decide to reach (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 © 2013 Intelligent Health Work GP School Street Park Sport © 2013 Intelligent Health

7 Best Buys in Physical Activity Br 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 everyone 4.Physical activity and embedded in Healthcare. 5.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

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 © 2012 Intelligent Health

COMMUNITY ENGAGEMENT All GP Practices will be distributing cards 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 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 51

130 beat boxes 1 at every school 8-10 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 © 2014 Intelligent Health