"Medicine, Faculty of"@en . "Family Practice, Department of"@en . "DSpace"@en . "University of British Columbia. Peter Wall Institute for Advanced Studies"@en . "Elley, Carolyn Raina"@en . "2012-11-27T23:44:14Z"@en . "2012-11-08"@en . "A presentation delivered by C. Raina Elley on November 8, 2012 in the Neville Scarfe Building at the University of British Columbia (UBC). Dr. Elley is a visiting scholar in the Department of Family Practice at UBC from September to November 2012. She is from the University of Auckland, New Zealand, where she is Associate Professor and Director of Research at the Department of General Practice and Primary Health Care."@en . "https://circle.library.ubc.ca/rest/handle/2429/43618?expand=metadata"@en . "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 \u00E2\u0080\u0098Green Prescription\u00E2\u0080\u0099 7. How are we prioritising our efforts (and funding)? Global pandemic of physical inactivity \u00E2\u0080\u00A2 Fourth leading risk factor for global mortality \u00E2\u0080\u00A2 Accounts for 6-10% of all deaths (Lee 2012) \u00E2\u0080\u00A2 Contributes towards multiple conditions: \u00E2\u0080\u0093 Cardiorespiratory (heart disease and strokes) \u00E2\u0080\u0093 Metabolic (diabetes and obesity) \u00E2\u0080\u0093 Musculoskeletal (osteoporosis and osteoarthritis) \u00E2\u0080\u0093 Cancer (breast and colon) \u00E2\u0080\u0093 Functional decline and falls in older adults \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 Physical activity: \u00E2\u0080\u0093 Bodily movement produced by skeletal muscle that requires energy expenditure \u00E2\u0080\u00A2 Exercise: \u00E2\u0080\u0093 Planned and repetitive activity for physical fitness \u00E2\u0080\u00A2 Recommended (at least): \u00E2\u0080\u0093 30 minutes moderate intensity 5 days / week \u00E2\u0080\u0093 (e.g. brisk walking but can hold a conversation) \u00E2\u0080\u0093 3-4hrs/week for weight-loss or cancer risk \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 Also depends on: \u00E2\u0080\u0093 Fitness of person (relative benefit most in sedentary) \u00E2\u0080\u0093 Intensity, Duration and Frequency \u00E2\u0080\u0093 Type of exercise (affects particular muscles, organs and bones/joints involved) \u00E2\u0080\u0093 Length of \u00E2\u0080\u009Ctraining\u00E2\u0080\u009D \u00E2\u0080\u0093 Dose-response: (often) \u00E2\u0080\u009CSome is good, more is better\u00E2\u0080\u009D Swedish National Institute Public Health (2010) Physical Activity in the Prevention and Treatment of Disease Epidemiological evidence for recommended levels of physical activity: \u00E2\u0080\u00A2 Associated with reduced risk of: \u00E2\u0080\u0093 All-cause mortality 20-30% \u00E2\u0080\u0093 CVD mortality 20-30% \u00E2\u0080\u0093 Colon cancer 30% \u00E2\u0080\u0093 Breast cancer 20-40% \u00E2\u0080\u0093 Lung, endometrial, ovarian cancer 20-30% \u00E2\u0080\u0093 Depression 15-30% \u00E2\u0080\u0093 Type 2 diabetes 40-60% \u00E2\u0080\u0093 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: \u00E2\u0080\u00A2 Systems approach \u00E2\u0080\u0093 inter-sectorial \u00E2\u0080\u0093 individual, social, cultural and environmental level \u00E2\u0080\u00A2 Including low income countries where transition: \u00E2\u0080\u0093 from under-nutrition to obesity; \u00E2\u0080\u0093 from active rural to sedentary urban Kohl et al. (2012)\" Lancet 380(9838): 294-305 International Recommendations \u00E2\u0080\u00A2 WHO Global Strategy on Diet, Physical Activity and Health (2004) \u00E2\u0080\u00A2 WHO Non Communicable Disease (NCD) Action Plan (2008) \u00E2\u0080\u0093 Transport policies to promote active commuting, such as walking and cycling, \u00E2\u0080\u0093 Urban planning that promote space for recreational activity \u00E2\u0080\u0093 Fostering inter-sectorial collaborations for physical activity promotion, and \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 International Society for Physical Activity and Health (GAPA) \u00E2\u0080\u0093 Toronto Charter (2009): \u00E2\u0080\u0093 Evidence-based strategies to target whole population \u00E2\u0080\u0093 Address environmental, social and individual determinants of physical inactivity \u00E2\u0080\u0093 Equity approaches, reduce disparities, cultural sensitivity \u00E2\u0080\u0093 Sustainable partnerships at all levels \u00E2\u0080\u0093 Build capacity and support research, practice, policy, evaluation and surveillance \u00E2\u0080\u0093 Life-course approach; \u00E2\u0080\u0098Make healthy choices, easy choices\u00E2\u0080\u0099 \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 Exercise is Medicine: \u00E2\u0080\u0093 \u00E2\u0080\u009CCalling on all health care providers to assess and review every patient\u00E2\u0080\u0099s physical activity program at every visit\u00E2\u0080\u009D \u00E2\u0080\u00A2 Charter (2010) and guiding principles: \u00E2\u0080\u0093 Exercise and physical activity important to health and prevention and treatment of many chronic diseases \u00E2\u0080\u0093 More should be done to address physical activity and exercise in healthcare settings \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 NCDs committee of the United Nations (2011) discussed ways to promote healthy lifestyles, including increasing physical activity levels \u00E2\u0080\u00A2 Non-communicable diseases (NCD) responsible for >60% global deaths: \u00E2\u0080\u0093 Cardiovascular diseases \u00E2\u0080\u0093 Cancer \u00E2\u0080\u0093 Chronic respiratory diseases \u00E2\u0080\u0093 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: \u00E2\u0080\u00A2 Street connectivity and walkability \u00E2\u0080\u00A2 Safe streets, \u00E2\u0080\u00A2 Lower speeds and volume of traffic, \u00E2\u0080\u00A2 Proximity of recreational areas \u00E2\u0080\u00A2 Proximity to shops \u00E2\u0080\u00A2 Aesthetics \u00E2\u0080\u00A2 Bike paths \u00E2\u0080\u00A2 Good public transport systems \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 Physical Activity in the Prevention and Treatment of Disease Exercise-based cardiac rehabilitation following heart attack (MI) \u00E2\u0080\u00A2 Reduced odds of: \u00E2\u0080\u0093 repeat MI by 47%, \u00E2\u0080\u0093 fatal MI by 37% \u00E2\u0080\u0093 all-cause mortality by 26% \u00E2\u0080\u00A2 Compared with statins: \u00E2\u0080\u0093 repeat MI by 31% \u00E2\u0080\u0093 fatal MI by 43% \u00E2\u0080\u0093 CVD mortality by 25% \u00E2\u0080\u0093 (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? \u00E2\u0080\u00A2 Blood pressure (3/2 \u00E2\u0080\u0093 7/5mmhg) \u00E2\u0080\u00A2 Lipids (triglycerides) \u00E2\u0080\u00A2 PA improves: \u00E2\u0080\u0093 cardiorespiratory fitness, \u00E2\u0080\u0093 cardiac muscle size and efficiency \u00E2\u0080\u0093 oxygen use from blood \u00E2\u0080\u0093 micro-vascular development + heart blood supply \u00E2\u0080\u0093 peripheral vessel responsiveness \u00E2\u0080\u00A2 PA reduces: \u00E2\u0080\u0093 peripheral vascular resistance \u00E2\u0080\u0093 platelet clotting and risk of coagulation \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 Exercise improves glucose control (HbA1c -0.6 to -0.9%) \u00E2\u0080\u00A2 Exercise + diet reduces progression from pre-diabetes to T2DM by 50-60% \u00E2\u0080\u0093 Malmo \u00E2\u0080\u0093 Da Qing \u00E2\u0080\u0093 DPP Bone, muscle and joint health Physical activity improves: \u00E2\u0080\u00A2 Osteo- and rheumatoid arthritis: \u00E2\u0080\u0093 Function & pain without increase in adverse effects \u00E2\u0080\u00A2 Osteoporosis: \u00E2\u0080\u0093 Bone mineral density (weight bearing /resistance PA) \u00E2\u0080\u0093 Reduced osteoporotic fractures (vertebral) \u00E2\u0080\u00A2 Risk of falls in older adults: \u00E2\u0080\u0093 Balance, fitness and muscle strength \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 Depression \u00E2\u0080\u00A2 Anxiety \u00E2\u0080\u00A2 Sleep \u00E2\u0080\u00A2 Quality of life \u00E2\u0080\u00A2 Immune response \u00E2\u0080\u00A2 Cognitive and physical function in dementia \u00E2\u0080\u00A2 \u00E2\u0080\u009CEverything that gets worse when you grow older gets better when you exercise\u00E2\u0080\u009D (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 \u00E2\u0080\u00A2 More severe injuries/events more common: \u00E2\u0080\u0093 Contact sports (football, ice hockey, boxing, judo) \u00E2\u0080\u0093 Vigorous exercise (running, squash, gymnastics) \u00E2\u0080\u0093 Added hazards (horse-riding, skiing, road cycling) \u00E2\u0080\u00A2 Minor musculoskeletal injuries/falls: \u00E2\u0080\u0093 Moderate exercise (walking, golf, swimming) \u00E2\u0080\u0093 \u00E2\u0080\u0098Untrained\u00E2\u0080\u0099 or frail \u00E2\u0080\u00A2 Benefits outweigh adverse effects U.S. Dep Health & Human Services, Physical Activity Guidelines Advisory Committee Report. (2008) Health care settings \u00E2\u0080\u00A2 Family practice: \u00E2\u0080\u0093 In Canada, adults visit their family physician 3.1 visits/year, annually \u00E2\u0080\u0093 The most sedentary & those with most to gain (e.g. chronic disease) tend to attend more often \u00E2\u0080\u0093 People expect to receive health advice from their doctor \u00E2\u0080\u0093 High levels of trust in advice \u00E2\u0080\u0093 Ideal place to promote physical activity Petrella RJ Canadian Family Physician 56(5): e191-200 Promoting physical activity through family practice \u00E2\u0080\u00A2 What may improve effectiveness? \u00E2\u0080\u0093 Behavioural approaches \u00E2\u0080\u0093 Patient goal setting \u00E2\u0080\u0093 Written exercise prescription \u00E2\u0080\u0093 Individually-tailored follow-up by trained staff \u00E2\u0080\u00A2 Exercise on prescription? \u00E2\u0080\u0093 Green prescription program in New Zealand \u00E2\u0080\u0093 Motivational interviewing and goal setting \u00E2\u0080\u0093 Exercise script from family physician or nurse \u00E2\u0080\u0093 Telephone and mail support from exercise facilitators \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 Aim: Assess effectiveness of Green Prescription \u00E2\u0080\u00A2 Design: Cluster randomized controlled trial 2000-2003 \u00E2\u0080\u00A2 Study population: \u00E2\u0080\u0093 \u00E2\u0080\u0098less active\u00E2\u0080\u0099 \u00E2\u0080\u0093 40-80 years \u00E2\u0080\u00A2 Setting: \u00E2\u0080\u0093 all urban and rural family practices \u00E2\u0080\u0093 central Waikato \u00E2\u0080\u00A2 Outcome measures (over 12 months): \u00E2\u0080\u0093 physical activity \u00E2\u0080\u0093 quality of life \u00E2\u0080\u0093 blood pressure \u00E2\u0080\u0093 adverse events \u00E2\u0080\u0093 cost effectiveness Screening for \u00E2\u0080\u0098less active\u00E2\u0080\u0099 \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 74% family physicians (n = 117) \u00E2\u0080\u00A2 42 family practices \u00E2\u0080\u00A2 2,984 adult patients screened \u00E2\u0080\u00A2 45% screened as \u00E2\u0080\u0098insufficient\u00E2\u0080\u0099 activity \u00E2\u0080\u00A2 67% of eligible participated (n = 878) \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 Significant improvement in \u00E2\u0080\u0098role physical, bodily pain, general health and vitality\u00E2\u0080\u0099 of the SF36 QOL parameters \u00E2\u0080\u00A2 No significant increase in falls or injuries Elley et al, (2003) BMJ 326: 793 Costs (societal perspective) \u00E2\u0080\u00A2 Direct costs of programme delivery \u00E2\u0080\u00A2 Participant costs of exercise participation \u00E2\u0080\u00A2 Costs of primary and secondary care utilisation \u00E2\u0080\u00A2 Allied health therapies \u00E2\u0080\u00A2 Time off work (lost productivity) \u00E2\u0080\u00A2 Program cost/participant: $NZ170 \u00E2\u0080\u00A2 Cost of converting one \u00E2\u0080\u0098sedentary\u00E2\u0080\u0099 adult to \u00E2\u0080\u0098active\u00E2\u0080\u0099 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 \u00E2\u0080\u00A2 Barriers: \u00E2\u0080\u0093 lack of time (e.g. priorities of work or family); \u00E2\u0080\u0093 health and psychological limitations; \u00E2\u0080\u0093 bad weather; \u00E2\u0080\u0093 unsuitable local environment (e.g. lack of sidewalks or places to walk) \u00E2\u0080\u00A2 Enablers: \u00E2\u0080\u0093 internal motivators, spiritual benefits, commitment, guilt; \u00E2\u0080\u0093 \u00E2\u0080\u0098significant others\u00E2\u0080\u0099 , continuing support; \u00E2\u0080\u0093 social interaction during exercise; \u00E2\u0080\u0093 commitment or contracts made to others Elley et al (2007) Aus Fam Physician 36: 1061-1064 Effectiveness of the enhanced Green Script \u00E2\u0080\u00A2 Design: Individual RCT over 2 years (2005-2008) \u00E2\u0080\u00A2 Study population: \u00E2\u0080\u0093 1089 less active 40-75 year old women \u00E2\u0080\u00A2 Setting: \u00E2\u0080\u0093 Women\u00E2\u0080\u0099s Health Research Centre, University of Otago \u00E2\u0080\u0093 17 Wellington family practices \u00E2\u0080\u00A2 Outcome measures (over 2 years): \u00E2\u0080\u0093 physical activity \u00E2\u0080\u0093 quality of life \u00E2\u0080\u0093 clinical parameters \u00E2\u0080\u0093 adverse events \u00E2\u0080\u0093 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 \u00E2\u0080\u00A2 10 minutes brief exercise advice and \u00E2\u0080\u0098Green Script\u00E2\u0080\u0099 from family practice nurse \u00E2\u0080\u00A2 Exercise facilitator telephone support for 9 months (av. 5 calls) \u00E2\u0080\u00A2 Face-to-face follow-up with nurse at 6 months \u00E2\u0080\u00A2 Motivational interviewing techniques and moderate intensity exercise (e.g. walking, swimming, other community activities) Results: Completing 2\u00C2\u00BD 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) \u00E2\u0080\u00A2 Some improved quality of life parameters \u00E2\u0080\u00A2 But \u00E2\u0080\u0098role physical\u00E2\u0080\u0099 worse \u00E2\u0080\u00A2 Increased falls and minor injuries \u00E2\u0080\u00A2 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) \u00E2\u0080\u0098Enhanced\u00E2\u0080\u0099 Green Prescription Cost of moving one person from \u00E2\u0080\u0098inactive\u00E2\u0080\u0099 to \u00E2\u0080\u0098active\u00E2\u0080\u0099 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\u00E2\u0080\u00A6 Enhanced Green Prescription (24 months) Print material, PA advice (Sevick et al.\u00E2\u0080\u00A6 Green Prescription (Elley et al. 2004) Centre based behavioural training\u00E2\u0080\u00A6 Phone delivery, PA advice (Sevick et al.\u00E2\u0080\u00A6 Centre based PA advice (Sevick et al.\u00E2\u0080\u00A6 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 \u00E2\u0080\u00A2 Quality Adjusted Life Year (QALY) \u00E2\u0080\u0093 International standard measure that takes into account the impact a pharmaceutical or other medical intervention has on quality and quantity of life. \u00E2\u0080\u00A2 Cost per QALY gained (cost-utility) \u00E2\u0080\u0093 Based on economic analyses of RCTs \u00E2\u0080\u0093 Criteria for funding pharmaceutical interventions \u00E2\u0080\u0093 <$20,000/QALY gained is considered good value \u00E2\u0080\u0093 >$100,000/QALY is considered very poor value Cost per QALY gained comparisons* \u00E2\u0080\u00A2 Green prescription PA program: \u00E2\u0080\u0093 $1,677 per QALY (range $675 to $30,644) \u00E2\u0080\u00A2 Statins (cholesterol-lowering drugs): \u00E2\u0080\u0093 $15,956 - $27,125 (2o prevention) \u00E2\u0080\u0093 $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)? \u00E2\u0080\u00A2 NZ in 2011: \u00E2\u0080\u0093 $706 million on drugs \u00E2\u0080\u0093 $53 million on statins \u00E2\u0080\u0093 >$121 million on CVD drugs \u00E2\u0080\u0093 Capped at $4 million on Green Script PA promotion \u00E2\u0080\u0093 ($2.8 million on exercise cardiac rehabilitation in 2009) \u00E2\u0080\u00A2 Canada 2011: \u00E2\u0080\u0093 $32 billion on drugs \u00E2\u0080\u0093 $4 billion on statins (13%) Interdisciplinary chronic disease collaboration: 2011 exec summary \u00E2\u0080\u0093 new research on statins\u00E2\u0080\u00A6 http://icdc.ca/media/ICDC%20Statins_Executive%20Summary_Final_13Sept2011-1.pdf Pharmac annual report 2011, Wellington, New Zealand Utilisation of PA interventions \u00E2\u0080\u00A2 PA interventions in primary care in Canada \u00E2\u0080\u0093 16% of family physicians use exercise scripts \u00E2\u0080\u0093 <50% of patients ever recall their doctor advising PA \u00E2\u0080\u00A2 Exercise cardiac rehabilitation: \u00E2\u0080\u0093 20-30% post MI in Canada, UK, Aus (target 70%) \u00E2\u0080\u0093 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? \u00E2\u0080\u00A2 Statins: \u00E2\u0080\u0093 170,000 participants followed \u00E2\u0089\u00A52 years (26 RCTs) \u00E2\u0080\u00A2 Blood pressure lowering meds: \u00E2\u0080\u0093 464,000 participants (>150 RCTs) \u00E2\u0080\u00A2 Exercise-based cardiac rehabilitation: \u00E2\u0080\u0093 6,111 participants (34 RCTs) \u00E2\u0080\u00A2 Exercise to lower BP: \u00E2\u0080\u0093 2,419 participants from (54 RCTs) \u00E2\u0080\u00A2 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. \u00E2\u0080\u009CFLIP\u00E2\u0080\u009D Facilitated Lifestyle Intervention Prescriptions Prof Martin Dawes and Diana Dawes and colleagues Depts Family Practice and Physical Therapy, UBC Intensive Lifestyle Prescription ILRx \u00E2\u0080\u00A2 Completed by patient and family physician \u00E2\u0080\u00A2 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\u00C2\u00B0 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 \u00E2\u0080\u0093 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? "@en . "Presentation"@en . "10.14288/1.0074726"@en . "eng"@en . "Unreviewed"@en . "Vancouver : University of British Columbia Library"@en . "Attribution-NonCommercial-NoDerivatives 4.0 International"@en . "http://creativecommons.org/licenses/by-nc-nd/4.0/"@en . "Faculty"@en . "Addressing the pandemic of physical inactivity one patient at a time"@en . "Text"@en . "Sound"@en . "http://hdl.handle.net/2429/43618"@en .