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Addressing the pandemic of physical inactivity one patient at a time 2012

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Addressing the pandemic of physical inactivity one patient at a time C Raina Elley Peter Wall Institute of Advanced Studies visiting scholar, Department Family Practice, UBC, Vancouver & A/Professor, University of Auckland, New Zealand  Introduction 1. Global pandemic of physical inactivity 2. Health benefits of physical activity 3. Public health initiatives and recommendations 4. Health care setting 5. Exercise on prescription 6. Effectiveness and cost effectiveness of the ‘Green Prescription’ 7. How are we prioritising our efforts (and funding)? Global pandemic of physical inactivity • Fourth leading risk factor for global mortality • Accounts for 6-10% of all deaths (Lee 2012) • Contributes towards multiple conditions: – Cardiorespiratory (heart disease and strokes) – Metabolic (diabetes and obesity) – Musculoskeletal (osteoporosis and osteoarthritis) – Cancer (breast and colon) – Functional decline and falls in older adults – Depression  Wen CP, Wu X (2012) Lancet 380: 192-193; Lee  et al (2012) Lancet 380: 219-229; World Health Organisation (2010) Global recommendations on physical activity for health. http://gamapserver.who.int/gho/interactive_charts/ncd/risk_factors/physical_inactivity/atlas.html Definitions • Physical activity: – Bodily movement produced by skeletal muscle that requires energy expenditure • Exercise: – Planned and repetitive activity for physical fitness • Recommended (at least): – 30 minutes moderate intensity 5 days / week – (e.g. brisk walking but can hold a conversation) – 3-4hrs/week for weight-loss or cancer risk – Less for other benefits (e.g. balance and function in older adults)   US Dept Health & Human Services (2008), Physical Activity Guidelines Report; Swedish NIPH (2010) Physical Activity in the Prevention and Treatment of Disease; WHO (2010) Global recommendations on physical activity for health Health benefit of physical activity • Also depends on: – Fitness of person (relative benefit most in sedentary) – Intensity, Duration and Frequency – Type of exercise (affects particular muscles, organs and bones/joints involved) – Length of “training” – Dose-response: (often) “Some is good, more is better”    Swedish National Institute Public Health (2010) Physical Activity in the Prevention and Treatment of Disease Epidemiological evidence for recommended levels of physical activity: • Associated with reduced risk of: – All-cause mortality     20-30% – CVD mortality      20-30% – Colon cancer     30% – Breast cancer     20-40% – Lung, endometrial, ovarian cancer  20-30% – Depression     15-30% – Type 2 diabetes    40-60% – Osteoporotic fracture    20-60%    U.S. Dep Health & Human Services, (2008) Physical Activity Guidelines Advisory Committee Report; Lee  et al (2012) Lancet 380: 219-229; Vainio H, Bianchini F (2002) Weight control and physical activity Public health initiatives and recommendations Lancet issue July 2012: • Systems approach – inter-sectorial – individual, social, cultural and environmental level  • Including low income countries where transition: – from under-nutrition to obesity; – from active rural to sedentary urban  Kohl et al. (2012)" Lancet 380(9838): 294-305 International Recommendations • WHO Global Strategy on Diet, Physical Activity and Health (2004) • WHO Non Communicable Disease (NCD) Action Plan (2008) – Transport policies to promote active commuting, such as walking and cycling, – Urban planning that promote space for recreational activity – Fostering inter-sectorial collaborations for physical activity promotion, and – Surveillance of population physical activity levels World Health Organisation (2010) Global recommendations on physical activity for health http://www.who.int/dietphysicalactivity/publications/9789241599979/en/index.html International Recommendations • International Society for Physical Activity and Health (GAPA) – Toronto Charter (2009): – Evidence-based strategies to target whole population – Address environmental, social and individual determinants of physical inactivity – Equity approaches, reduce disparities, cultural sensitivity – Sustainable partnerships at all levels – Build capacity and support research, practice, policy, evaluation and surveillance – Life-course approach; ‘Make healthy choices, easy choices’ – Advocate to decision makers and communities   The Toronto Charter http://www.globalpa.org.uk/pdf/torontocharter-eng-20may2010.pdf  Kohl et al. (2012)" Lancet 380(9838): 294-305 International Recommendations • Exercise is Medicine: – “Calling on all health care providers to assess and review every patient’s physical activity program at every visit” • Charter (2010) and guiding principles: – Exercise and physical activity important to health and prevention and treatment of many chronic diseases – More should be done to address physical activity and exercise in healthcare settings – ACSM and AMA making efforts to bring a greater focus on physical activity and exercise in healthcare settings      http://exerciseismedicine.org/physicians.htm International Recommendations • NCDs committee of the United Nations (2011) discussed ways to promote healthy lifestyles, including increasing physical activity levels  • Non-communicable diseases (NCD) responsible for >60% global deaths: – Cardiovascular diseases – Cancer – Chronic respiratory diseases – Diabetes   http://www.un.org/apps/news/story.asp?NewsID=39642&Cr=non-communicable+diseases&Cr1=#.UKvG6Ic8CSo Public Policy and Planning: Regional Urban and regional planning: • Street connectivity and walkability • Safe streets, • Lower speeds and volume of traffic, • Proximity of recreational areas • Proximity to shops • Aesthetics • Bike paths • Good public transport systems • Sports and recreational programs    Bauman et al Lancet 380: 258-271 Swedish NIPH 2010, ISBN 978-91-7257-715-2 http://www.fyss.se/wp-content/uploads/2011/02/fyss_2010_english.pdf Healthcare setting • Physical Activity in the Prevention and Treatment of Disease Exercise-based cardiac rehabilitation following heart attack (MI) • Reduced odds of: – repeat MI by 47%, – fatal MI by 37% – all-cause mortality by 26%  • Compared with statins: – repeat MI by 31% – fatal MI by 43% – CVD mortality by 25% – (all-cause mortality by 16%*)  * Primary and secondary prevention. Lawler PR et al (2011) Am Heart J 162: 571-584.e572; Ward S, et al. (2007) A systematic review and economic evaluation of statins for the prevention of coronary events. Health Technology Assessment (Winchester, England) 11: 1-160 http://www.umm.edu/graphics/images/en/19389.jpg How does Physical Activity do it? • Blood pressure (3/2 – 7/5mmhg) • Lipids (triglycerides) • PA improves: – cardiorespiratory fitness, – cardiac muscle size and efficiency – oxygen use from blood – micro-vascular development + heart blood supply – peripheral vessel responsiveness • PA reduces: – peripheral vascular resistance – platelet clotting and risk of coagulation – arterial stiffness and atherosclerosis formation   Whelton et al (2002) Ann Intern Med 136: 493-503; Kelley & Kelley (2008) Prev Cardiol 11: 71-75; Chudyk et al (2011) Diabetes Care 34: 1228-1237; U.S. DHHS (2008), Physical Activity Guidelines; Swedish NIPH (2010) Physical Activity in the Prevention and Treatment of Disease; Elley et al (2006)  N Z Med J 119: U1996. Management and prevention of type 2 diabetes Knowler WC, N Engl J Med 2002;346(6):393-403; Eriksson, et al (1991) Diabetologia 34(12): 891-898; Pan, et al. (1997). Diabetes Care 20(4): 537-544. Chudyk et al (2011) Diabetes Care 34: 1228-1237; Kelley (2008) Prev Cardiol 11: 71-75 • Exercise improves glucose control (HbA1c -0.6 to -0.9%) • Exercise + diet reduces progression from pre-diabetes to T2DM by 50-60% – Malmo – Da Qing – DPP Bone, muscle and joint health Physical activity improves: • Osteo- and rheumatoid arthritis: – Function & pain without increase in adverse effects • Osteoporosis: – Bone mineral density (weight bearing /resistance PA) – Reduced osteoporotic fractures (vertebral) • Risk of falls in older adults: – Balance, fitness and muscle strength – Reduced risk and rate of falls (by 15-40%) Gillespie (2012) Cochrane Database Syst Rev 9: CD007146; Swedish NIPH (2010) Physical Activity in the Prevention and Treatment of Disease; Sinaki et al. (2002) Bone 30: 836-841 Evidence for many other conditions • Depression • Anxiety • Sleep • Quality of life • Immune response • Cognitive and physical function in dementia • “Everything that gets worse when you grow older gets better when you exercise” (Lee, 2012)  Rimer et al. (2012) Exercise for depression. Cochrane Database Syst Rev; Swedish National Institute of Public Health (2010); Physical Activity Guidelines Advisory Committee (2008) U.S. Department of Health and Human Services The hazards of physical activity • More severe injuries/events more common: – Contact sports (football, ice hockey, boxing, judo) – Vigorous exercise (running, squash, gymnastics) – Added hazards (horse-riding, skiing, road cycling) • Minor musculoskeletal injuries/falls: – Moderate exercise (walking, golf, swimming) – ‘Untrained’ or frail • Benefits outweigh adverse effects U.S. Dep Health & Human Services, Physical Activity Guidelines Advisory Committee Report. (2008) Health care settings • Family practice: – In Canada, adults visit their family physician 3.1 visits/year, annually – The most sedentary & those with most to gain (e.g. chronic disease) tend to attend more often – People expect to receive health advice from their doctor – High levels of trust in advice – Ideal place to promote physical activity   Petrella RJ Canadian Family Physician 56(5): e191-200 Promoting physical activity through family practice • What may improve effectiveness? – Behavioural approaches – Patient goal setting – Written exercise prescription – Individually-tailored follow-up by trained staff  • Exercise on prescription? – Green prescription program in New Zealand – Motivational interviewing and goal setting – Exercise script from family physician or nurse – Telephone and mail support from exercise facilitators – Started 1998; rolled out nationally 2000    Eden et al(2002) Ann Intern Med 137: 208-215; Petrella et al (2010) Can Fam Physician 56: e191-200 Effectiveness of the Green Prescription • Aim: Assess effectiveness of Green Prescription • Design: Cluster randomized controlled trial 2000-2003 • Study population: – ‘less active’ – 40-80 years • Setting: – all urban and rural family practices – central Waikato • Outcome measures (over 12 months): – physical activity – quality of life – blood pressure – adverse events – cost effectiveness    Screening for ‘less active’ • As a rule, do you do at least half an hour of moderate or vigorous exercise (such as walking or a sport) on five or more days of the week? Participation rates • 74% family physicians (n = 117) • 42 family practices • 2,984 adult patients screened • 45% screened as ‘insufficient’ activity • 67% of eligible participated (n = 878) • 85% completed 12 month follow-up (n = 750) CVD Characteristics of Less Active Adults in Primary Care 0 10 20 30 40 50 60 70 80 90 100 % Htn BMI>25 BMI>30 Diabetes Prior CVD Any CVD risk Elley et al Prev Med 2003;37(4):342-348 Proportion of participants achieving 2.5 hours per week of moderate or vigorous leisure activity NNT=10. 3 0 5 10 15 20 25 30 35 1 2 % Control Intervention NNT = 10.3 Elley et al; BMJ 326: 793 Change in moderate or vigorous leisure physical activity over one year 0 10 20 30 40 50 60 Leisure physical activity P<0.05 Diff = 34 mins Mins/week Elley et al; BMJ 326: 793 Change in blood pressure -3 -2.5 -2 -1.5 -1 -0.5 0 Systolic BP mmHg Diastolic BP mmHg Control Intervention P=0.2 P=0.2 Elley et al; BMJ 326: 793 Quality of life and adverse effects • Significant improvement in ‘role physical, bodily pain, general health and vitality’ of the SF36 QOL parameters • No significant increase in falls or injuries Elley et al, (2003) BMJ 326: 793 Costs (societal perspective) • Direct costs of programme delivery • Participant costs of exercise participation • Costs of primary and secondary care utilisation • Allied health therapies • Time off work (lost productivity) • Program cost/participant:  $NZ170  • Cost of converting one ‘sedentary’ adult to ‘active’ state and sustained at 12 months:       $NZ1,756 Elley et al (2004) N Z Med J 117: U1216 Cost Effectiveness of the Green Script Barriers and enablers to exercise • Barriers: – lack of time (e.g. priorities of work or family); – health and psychological limitations; – bad weather; – unsuitable local environment (e.g. lack of sidewalks or places to walk) • Enablers: – internal motivators, spiritual benefits, commitment, guilt; – ‘significant others’ , continuing support; – social interaction during exercise; – commitment or contracts made to others Elley et al (2007) Aus Fam Physician 36: 1061-1064 Effectiveness of the enhanced Green Script • Design: Individual RCT over 2 years (2005-2008) • Study population: – 1089 less active 40-75 year old women • Setting: – Women’s Health Research Centre, University of Otago – 17 Wellington family practices • Outcome measures (over 2 years): – physical activity – quality of life – clinical parameters – adverse events – cost effectiveness    Rose SB, Lawton BA, Elley CR, et al (2007) BMC Public Health 7: 166; Lawton BA, Rose SB, Elley CR et al. (2008) BMJ 337: a2509; The Intervention • 10 minutes brief exercise advice and ‘Green Script’ from family practice nurse • Exercise facilitator telephone support for 9 months (av. 5 calls) • Face-to-face follow-up with nurse at 6 months • Motivational interviewing techniques and moderate intensity exercise (e.g. walking, swimming, other community activities) Results: Completing 2½ hours/week Intervention Control Baseline  10.3% 11.4% 12 months  42.8% 30.3% 24 Months  39.3% 32.8% (p <0.0001) Lawton et al, BMJ 2008;337:a2509; Rose et al, BMC Public Health 2007; 7 (166) • Some improved quality of life parameters • But ‘role physical’ worse • Increased falls and minor injuries • No difference in health care utilisation Proportion of participants in each group achieving >=150mins physical activity in past week at baseline, 12- and 24-months 0.0 10.0 20.0 30.0 40.0 50.0 Baseline 12-mths 24-mths Time %  p a rt ic ip a n ts Intervention Control P<0.001 Lawton etal, BMJ 2008;337:a2509; Rose etal, BMC Public Health 2007; 7 (166) ‘Enhanced’ Green Prescription Cost of moving one person from ‘inactive’ to ‘active’ primary care/community exercise interventions 331 551 720 884 957 1,962 3,673 3,924 0 1000 2000 3000 4000 5000 Enhanced Green Prescription (12 months) Automated telephone advice (Handley et… Enhanced Green Prescription (24 months) Print material, PA advice (Sevick et al.… Green Prescription (Elley et al. 2004) Centre based behavioural training… Phone delivery, PA advice (Sevick et al.… Centre based PA advice (Sevick et al.… Cost (in 2008 Euro equivalents) Muller-Riemenschneider et al. (2009) Br J Sports Med ;43:70-76; Lawton et al. (2008) BMJ 337: a2509; Elley CR, Garrett S, et al. (2011) Br J Sports Med 45: 1223-1229; Garrett S, Elley CR et al. (2011) Br J Gen Pract 61: e125-133 Cost Utility • Quality Adjusted Life Year (QALY) – International standard measure that takes into account the impact a pharmaceutical or other medical intervention has on quality and quantity of life.  • Cost per QALY gained (cost-utility) – Based on economic analyses of RCTs – Criteria for funding pharmaceutical interventions – <$20,000/QALY gained is considered good value – >$100,000/QALY is considered very poor value  Cost per QALY gained comparisons* • Green prescription PA program: – $1,677 per QALY (range $675 to $30,644)  • Statins (cholesterol-lowering drugs): – $15,956 - $27,125  (2o prevention) – $15,956 - $76,590 (1o prevention high-risk)        * Converted to Canadian dollars Dalziel Segal & Elley (2006) Aust N Z J Public Health 30: 57-63; Ward et al. (2007) A systematic review and economic evaluation of statins for the prevention of coronary events. Health Technology Assessment (England) 11: 1-160, iii-iv; Cost utility (cost per QALY) for different physical activity interventions (2008 Euros) 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 Instructor-led w alking programme + advice for inactive adults (Isaacs 2007) Automated telephone support + nurse management for type 2 diabetes (Handley 2008) Supervised, gym-based exercise classes + advice for inactive adults (Issacs 2007) Primary Care exercise class for over 65s (Munro 2004) Exercise for back pain (UK Beam 2004) Water exercise programme for hip/knee OA (Cochrane 2005) Alexander technique counselling and Rx for exercise for back pain (Hollinghurst 2008) Green Prescription for inactive adults (Dalziel 2005) Physical activity/nutrition programme in community setting interactive (Dzator 2004) Physical activity/nutrition programme in community setting mailed (Dzator 2004) Pirmary Care supervised w alking programme (Gusi 2008) Cost per QALY Garrett S, Elley CR et al. (2011) Br J Gen Pract 61: e125-133 How are we prioritising our efforts (and funding)?   2003 ACE inhibitors $23.0 million Alpha-blockers $4.5 million Beta-blockers $9.2 million Ca channel blockers $13.7 million Other CVD meds  Total on CVD meds $10.6 million  $64 million  Green Prescription $825,000   (Pharmac website, 2004) How are we prioritising our efforts (and funding)? • NZ in 2011: – $706 million on drugs – $53 million on statins – >$121 million on CVD drugs – Capped at $4 million on Green Script PA promotion – ($2.8 million on exercise cardiac rehabilitation in 2009) • Canada 2011: – $32 billion on drugs – $4 billion on statins (13%)  Interdisciplinary chronic disease collaboration: 2011 exec summary – new research on statins… http://icdc.ca/media/ICDC%20Statins_Executive%20Summary_Final_13Sept2011-1.pdf Pharmac annual report 2011, Wellington, New Zealand Utilisation of PA interventions • PA interventions in primary care in Canada – 16% of family physicians use exercise scripts – <50% of patients ever recall their doctor advising PA  • Exercise cardiac rehabilitation: – 20-30% post MI in Canada, UK, Aus (target 70%) – 17-18% in NZ and US  Petrella et al (2010) Can Fam Physician 56: e191-200; Petrella et al Arch Intern Med 167: 1774-1781; Grace S, (2011) Canadian Association of Cardiac Rehabilitation http://www.ccs.ca/advocacy/WTA/CMA_WTAl_CR-wait-time_data_available.pdf Research: Evidence for prevention of events? • Statins: – 170,000 participants followed ≥2 years (26 RCTs) • Blood pressure lowering meds: – 464,000 participants (>150 RCTs) • Exercise-based cardiac rehabilitation: – 6,111 participants (34 RCTs) • Exercise to lower BP: – 2,419 participants from (54 RCTs) • More exercise interventions research in health care settings is needed Cholesterol Treatment Trialists Collaboration, (2010) Lancet 376: 1670-1681; Law et al (2009) BMJ 338: b1665; Lawler et al (2011) Am Heart J 162: 571-584.e572; Whelton et al (2002) Ann Intern Med 136: 493-503. “FLIP” Facilitated Lifestyle Intervention Prescriptions Prof Martin Dawes and Diana Dawes and colleagues Depts Family Practice and Physical Therapy, UBC    Intensive Lifestyle Prescription  ILRx • Completed by patient and family physician • Signed by patient and physician - contract Weight Activity (getting stronger) Healthy Eating Evaluation at 6 months Usual Care Telephone call from lifestyle change facilitator within 10 days Monthly calls from lifestyle change facilitator Control Group (75) Recruitment of people with pre-diabetes 1° care physician completes     ILR x  with patient ILR x  copies to:        patient, chart, facilitator,        coordinator  Baseline Evaluation  Intervention Group (75)      FLIP Conclusions: 1. Global pandemic of physical inactivity 2. Health benefits of physical activity 3. Public health initiatives and recommendations 4. Healthcare settings- complementary to policy 5. Exercise prescription – effectiveness and cost-effectiveness 6. More research is needed 7. Could we improve the way we prioritise our efforts (and funding) at the individual, community and national level to help address the pandemic of physical inactivity? 

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