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Addressing the pandemic of physical inactivity one patient at a time Elley, Carolyn Raina Nov 8, 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. 2. 3. 4. 5. 6.  Global pandemic of physical inactivity Health benefits of physical activity Public health initiatives and recommendations Health care setting Exercise on prescription 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 CVD mortality Colon cancer Breast cancer Lung, endometrial, ovarian cancer Depression Type 2 diabetes Osteoporotic fracture  20-30% 20-30% 30% 20-40% 20-30% 15-30% 40-60% 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  Healthcare setting • Physical Activity in the Prevention and Treatment of Disease  Swedish NIPH 2010, ISBN 978-91-7257-715-2 http://www.fyss.se/wp-content/uploads/2011/02/fyss_2010_english.pdf  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 • 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  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  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 100 90 80 70 60  % 50 40 30 20 10 0 Htn  BMI>25  BMI>30  Diabetes  Prior CVD  Elley et al Prev Med 2003;37(4):342-348  Any CVD risk  Proportion of participants achieving 2.5 hours per week of moderate or vigorous leisure activity 35  %  30 25 20  Control  15  Intervention  10 5 0 1  NNT=10. 2 3 NNT = 10.3 Elley et al; BMJ 326: 793  Change in moderate or vigorous leisure physical activity over one year 60  Mins/week  50  P<0.05 40  Diff = 34 mins  30 20 10 0  Leisure physical activity Elley et al; BMJ 326: 793  Change in blood pressure 0 -0.5 -1  Control Intervention  -1.5 -2 P=0.2  P=0.2  -2.5 -3 Systolic BP mmHg  Diastolic BP mmHg  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)  Cost Effectiveness of the Green Script •  Program cost/participant:  •  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  $NZ170  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)  • • • •  Some improved quality of life parameters But ‘role physical’ worse Increased falls and minor injuries No difference in health care utilisation Lawton et al, BMJ 2008;337:a2509; Rose et al, BMC Public Health 2007; 7 (166)  ‘Enhanced’ Green Prescription Proportion of participants in each group achieving >=150mins physical activity in past week at baseline, 12- and 24-months P<0.001  % participants  50.0 40.0 30.0  Intervention  20.0  Control  10.0 0.0 Baseline  12-mths  24-mths  Time  Lawton etal, BMJ 2008;337:a2509; Rose etal, BMC Public Health 2007; 7 (166)  Cost of moving one person from ‘inactive’ to ‘active’ primary care/community exercise interventions Centre based PA advice (Sevick et al.…  3,924  Phone delivery, PA advice (Sevick et al.…  3,673  Centre based behavioural training…  1,962 957  Green Prescription (Elley et al. 2004) Print material, PA advice (Sevick et al.…  884 720  Enhanced Green Prescription (24 months) Automated telephone advice (Handley et…  551 331  Enhanced Green Prescription (12 months) 0  1000  2000  3000  4000  5000  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) Pirmary Care supervised w alking programme (Gusi 2008) Physical activity/nutrition programme in community setting mailed (Dzator 2004) Physical activity/nutrition programme in community setting interactive (Dzator 2004) Green Prescription for inactive adults (Dalziel 2005) Alexander technique counselling and Rx for exercise for back pain (Hollinghurst 2008) Water exercise programme for hip/knee OA (Cochrane 2005)  Exercise for back pain (UK Beam 2004)  Primary Care exercise class for over 65s (Munro 2004) Supervised, gym-based exercise classes + advice for inactive adults (Issacs 2007) Automated telephone support + nurse management for type 2 diabetes (Handley 2008) Instructor-led w alking programme + advice for inactive adults (Isaacs 2007)  0  10,000  20,000  30,000  40,000  50,000  Cost per QALY  Garrett S, Elley CR et al. (2011) Br J Gen Pract 61: e125-133  60,000  70,000  80,000  90,000  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  $10.6 million  Total on CVD meds  $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  FLIP  Recruitment of people with pre-diabetes  Baseline Evaluation Intervention Group (75)  Control Group (75)  1° care physician completes ILRx with patient ILRx copies to: patient, chart, facilitator, coordinator  Telephone call from lifestyle change facilitator within 10 days  Monthly calls from lifestyle change facilitator  Evaluation at 6 months  Usual Care  Conclusions: 1. 2. 3. 4. 5.  Global pandemic of physical inactivity Health benefits of physical activity Public health initiatives and recommendations Healthcare settings- complementary to policy 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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