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					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/m2.
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/m2. 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
little physical activity. You advise her to:
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/m2.
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/m2), 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
recommend Rupa to:
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                              8
d) Getting off the bus and walking 5 min to work                       2
e) Ironing and vacuuming for 1.5 hours                                 9
f) Taking the escalator or lift up three flights                       1
g) Getting off the bus early and walking 15 min 2x/day                 6
h) Gardening and mowing for 1 hour                                     10
i) Shopping online for 1 hour                                          5
j) Cooking for 30 min.                                                 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                                  Time and activity
1 jam doughnut                        90 min playing soccer
1 medium banana                       15 min walking
1 can of light beer                   11 min cycling
1 can of beer                         33 min walking
1 meat pie and 1 small French fries   55 min dancing
Case study: Barry talks to Dr Nancy Huang
Food                          Kilojoules         Time and activity
1 jam doughnut                1360 kJ            55 min dancing
1 medium banana               365 kJ             11 min cycling
1 can of light beer           260 kJ             15 min walking
1 can of beer                 585 kJ             33 min walking
1 meat pie and French fries   1880 kJ; 1089 kJ   90 min playing soccer
Heart Foundation sedentary and active energy
comparisons
Sedentary                                        Active
Waiting 30 min for food home delivery (63 kJ)    Cooking for 30 min (105 kJ)
Using a lawn service (0 kJ)                      Gardening and mowing each for 30 min (1505 kJ)
Letting the dog out the door (8 kJ)              Walking the dog for 30 min (523 kJ)
Driving 40 min, walking 5 min, parking (92 kJ)   Walking 15 min to bus stop twice per day (500 kJ)
Hiring someone to clean and iron (0 kJ)          Ironing and vacuuming each for 30 min (635 kJ)
Heart Foundation sedentary and active energy
comparisons
Sedentary                                          Active
Taking escalator or lift up three flights (1 kJ)   Walking up three flights of stairs (63 kJ)
Parking as close as possible, 10 sec walk (1 kJ)   Parking further away, walking 2 min (33 kJ)
Using remote control to change channel (<4 kJ)     Getting up and changing television channel (13 kJ)
Driving to corner shop to get the paper (8 kJ)     10 min walk to corner shop (167 kJ)
Shopping online for 1 hour (125 kJ)                Shopping at the mall, walking 1 hour (606–1003 kJ)
Drive to local shops for lunch (8 kJ)              Meet a friend and walk 20 min to local cafe (334 kJ)
Play a computer game for 30 min (80 kJ)            Play a ball game for 30 min (546 kJ)
Getting of bus and walking 5 min to work (84 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     Minimum time (min)   Times per day   Pace
1        5–10                 2               Stroll
2        10–15                2               Comfortable
3        15–20                2               Comfortable
4        20–25                1–2             Comfortable/stride out
5        25–30                1–2             Comfortable/stride out
6        30                   1–2             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                          B
Management of presenting   Modification of health-seeking
problems                   behaviour

C                          D
Management of continuing   Opportunistic health promotion
problems
Neighbour’s consultation model

Connecting       Allow the patient to talk
Summarising      What’s going on?
Handing over     What can be done? Agree options
Safety netting   What if?
Housekeeping     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.

				
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