Welcome to physical activity an interactive workshop designed to assist GPs and their practice staff

1
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.
2
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
QUIZQuestion 1
A. To prevent one breast cancer over 5 years,
2451 women need to have mammogramsB. GPs need
to advise 102 people about physical activity for
one person to achieve an increase in physical
activity with a 2030 risk reduction in all
cause mortalityC. 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
eventD. To identify one colorectal cancer, 1374
people need to have bowel cancer screening.
3
What proportion of Australians aged 1875 years
do not engage in a healthy amount of physical
activity?
Question 2
A. Three-quartersB. Almost halfC.
One-quarterD. One-fifth.
4
What were the annual direct costs attributable to
physical inactivity in 2000?
Question 3
A. 400 000 B. 4 millionC. 40 millionD. 400
million.
5
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
Question 4
A. Eat a Mediterranean dietB. Drink one glass of
red wine per dayC. Do regular physical
exerciseD. Keep his triglycerides within normal
limits.
6
Which of the following groups of people report
the least physical activity in their leisure
time?
Question 5
A. People in their early 20sB. Indigenous
AustraliansC. People in the highest
socioeconomic groupD. School children.
7
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?
Question 6
A. Bill manages a plumbing company. In his 20s he
was a state hockey mid field legendB. Darren is
a journalist. He hated sport at school, because
of short sightedness, but now cycles to work
every dayC. Chris is a computer engineer. He
keen on tennis and he played regularly in local
competitions until 5 years agoD. 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.
8
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
Question 7
A. Increase his walking distanceB. Reduce his
blood pressureC. Increase his cardiac functional
capacityD. Increase his risk of stroke.
9
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
Question 8
A. Preventing falls B. Reversing X-ray changes
in osteoarthritisC. Pain management in
osteoarthritisD. Reducing the risk of
osteoporosis.
10
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
Question 9
A. ProstateB. BreastC. ColonD. Endometrial.
11
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
Question 10
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 obeseC. Decrease insulin
sensitivityD. Reduce her risk of death or
illness from cardiovascular disease.
12
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
Question 11
A. Take part in regular physical activity (brisk
walking for 30 min/day) B. Commence oral
metformin 500 mg twice per dayC. Include regular
physical activity (brisk walking for 10 min/day)
three times per weekD. Include regular
physical activity (brisk walking for 30 min/day)
once a screening stress ECG excludes silent
cardiac ischaemia.
13
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
Question 12
A. Multivitamin tablets B. Antidepressant
therapy C. Cognitive behavioural
therapyD. Regular physical activity.
14
There are national guidelines on the definitions
of levels of physical activity. Which of the
following is FALSE?
Question 13
A. Low physical activity equals watching
television, reading a book, surfing the
internetB. Medium physical activity is going for
a brisk walk, playing doubles tennisC. Vigorous
activity makes you huff and puffD. Vigorous
activity includes football, netball, soccer,
running, swimming laps or training for sport.
15
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?
Question 14
A. Jogging for 40 minutes, 23 times per
weekB. Two 15 minute brisk walks each day, as
often as possibleC. Normal pace walking for 20
minutes every dayD. A 10 minute fast run every
day.
16
You have gained Clares interest and she wants to
know more about physical activity. Which of the
following is TRUE?
Question 15
A. If Clare buys a pedometer she should aim for
5000 steps per dayB. There is no extra benefit
for Clare of doing further exercise once she has
done two 15 minute brisk walksC. Clare will gain
extra benefit from regular vigorous physical
activity such as playing singles tennisD. Clare
can challenge her sister Vicki to a game of
tennis. Vicki is 7 months pregnant.
17
Clare wants to keep her two sons (aged 7 and 11
years) active. All of the following
recommendations are true EXCEPT
Question 16
A. Limit their time on computer games,
television, the internet to dayB. The boys need at least 60 minutes of
moderate to vigorous physical activity per
dayC. Clare can enrol the family in the local
gym studies show long term impact on physical
activity levelsD. Clare can set up a walking-bus
group to take the children to school.
18
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?
Question 17
A. Playing golf, walking the dog and cycle racing
will all equally help B. Cycle racing is better
than walking the dogC. Playing golf is better
than walking the dogD. Cycle racing is better
than playing golf.
19
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?
Question 18a
A. Ella, aged 24 years, who has moderate aortic
regurgitation following rheumatic
feverB. Chelsea, aged 78 years, who had a
complicated myocardial infarction 4 months
agoC. Josef, aged 67 years, who has uncontrolled
hypertensionD. Denise, aged 84 years, who had
cataract surgery 1 week ago.
20
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?
Question 18b
A. Mini, aged 65 years, who has severe aortic
stenosisB. 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.
21
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
Question 19a
A. If he is asymptomatic he can return to his
prior low and moderate activities within 2
weeksB. He can resume sexual activity when he
can walk two flights of stairs
comfortablyC. Daily walking is encouraged
immediatelyD. He should wait a week to 10 days
before resuming sexual activity.
22
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
Question 19b
A. Begins to feel hotB. Becomes
thirstyC. Notices that his breathing has
increased in frequencyD. Experiences chest
tightness or claudication.
23
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, 810 units with lunch, depending
on the carbohydrates, and 10 units with
dinner).You tell Max all of the following EXCEPT
Question 20a
A. He should test his capillary blood glucose
(BGL) before, during and after exercise until a
safe plan is establishedB. He may need
carbohydrate before, during or after the
exerciseC. He may need more insulin on the days
that he goes runningD. The effect of intense
physical activity on reducing blood sugar levels
may persist for 1224 hours after the exercise.
24
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
Question 20b
A. His good control means that he is safe to go
running on his ownB. He should start slowly and
build up the length and his speed
over weeksC. He should carry a medi-alert or
other identification D. He should stretch before
exercising.
25
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
Question 21
A. Omit her metformin on the days she goes
walkingB. Take chocolate bars on her walks in
case of hypoglycaemiaC. Eat a healthy snack
before going for a walkD. Take a healthy snack
on her walk in case she develops symptomatic
hypoglycaemia.
26
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
Question 22
A. Walking is likely to decrease his respiratory
functionB. Walking with his granddaughter is
dangerous, as he may not be able to cope if
there is an emergencyC. Going out for walks is
not recommended as it will increase his
exposure to viral infectionsD. Going out for
regular walks is likely to increase his
respiratory function.
27
SLIDE PRESENTATION
The impact of physical activity on health
28
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
3050) and management.
29
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.
30
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.
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33
Health impact risk of cardiovascular disease
The risk of fatal and nonfatal cardiovascular
events is 1.52 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.
34
The greatest health benefit of physical activity
is seen in people who change their physical
activity status from sedentary to moderately
active.
35
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.
36
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.
37
Health impact type 2 diabetes prevention and
management
Regular physical activity can improve insulin
sensitivity and reduce the risk of type 2
diabetes by 3050 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.
38
Health impact cancer risk (colon, breast)
reduced
In primary prevention, routine physical activity
is associated with a 3040 relative risk
reduction in the incidence of colon cancer
compared to inactive people 2030 relative
risk reduction in the incidence of breast cancer
compared to inactive women.
39
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.
40
Health impact osteoarthritisWhat 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.
41
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.
42
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.
43
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.
44
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.
45
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.
46
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 complica
ted 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.
47
How much exercise is enough?
A. 1 hour of any activity that raises heart rate
to 120 of resting rate, three times per
weekB. At least 40 minutes vigorous activity, at
least 3 days per weekC. Moderate intensity
physical activity for at least 30 minutes on
most or preferably all days of the week.
48
Promoting physical activity
49
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?
50
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.
51
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?
52
What is the best or most common excuse you have
heard from your patients about why they dont
exercise?
Anticipating patients excuses allows you to be
prepared with an appropriate response that
encourages then to continue exercising.
53
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?
54
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.
55
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 Conside
r referral Set review dates.
56
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
24 months for review.
57
Case study Barry talks to Dr Nancy Huang

58
Case study Barry talks to Dr Nancy Huang
Ask and Assess What was the impact of the
waiting room material on Barrys willingness to
talk about physical activity?
59
Case study Barry talks to Dr Nancy Huang
Ask and Assess Barrys height is 180 cm and his
weight is 95 kg Identify the risk factors for
cardiovascular and other diseases that Barry
has.
60
Case study Barry talks to Dr Nancy Huang
Barrys 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.
61
Case study Barry talks to Dr Nancy Huang
Ask and Assess Name three diseases or
conditions for which Barrys risk is increased.
62
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.
63
Case study Barry talks to Dr Nancy Huang
Ask and AssessUsing 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?
64
Case study Barry talks to Dr Nancy Huang
Barrys total score is 2 (he does two lots of
30 min or more moderate intensity physical
exercise) Barrys 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).
65
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 youre not moving enough to stay
healthy. Your activity level is below the
recommended minimum.
66
Case study Barry talks to Dr Nancy Huang
Advise How would you summarise the benefits of
physical activity to Barry?
67
Case study Barry talks to Dr Nancy Huang
A possible response may include Barry, if you
increase your physical activity its likely that
you will have a better quality and longer
life youll 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.
68
Case study Barry talks to Dr Nancy Huang
Advise What do you see as the potential
barriers to increased physical activity for
Barry?
69
Case study Barry talks to Dr Nancy Huang
The most likely barriers for Barry are time
family pressures financial pressures.
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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 15
mmol/L) severe aortic stenosis acute
infection or fever resting heart rate 100
bpm/resting arrhythmia recent complicated acute
MI ( 71
Case study Barry talks to Dr Nancy Huang
Barry has no contraindications to increasing
physical activity.
72
Case study Barry talks to Dr Nancy Huang
Your prescription for an active lifestyle

• Document Barrys 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).

73
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.
74
Case study Barry talks to Dr Nancy Huang
AssistPut the following activities in increasing
order of their kilojoule expenditurea) Walking
the dog for 30 minb) Walking up three flights of
stairsc) Shopping at a mall, walking for 1
hourd) Getting off the bus and walking 5 min to
worke) Ironing and vacuuming for 1.5
hoursf) Taking the escalator or lift up three
flightsg) Getting off the bus early and walking
15 min 2x/dayh) Gardening and mowing for 1
houri) Shopping online for 1 hourj) Cooking for
30 min.
75
Case study Barry talks to Dr Nancy Huang
AssistPut the following activities in increasing
order of their kilojoule expenditurea) Walking
the dog for 30 min 7b) Walking up three
flights of stairs 3c) Shopping at a mall,
walking for 1 hour 8d) Getting off the bus and
walking 5 min to work 2e) Ironing and
vacuuming for 1.5 hours 9f) Taking the
escalator or lift up three flights 1g) Getting
off the bus early and walking 15 min
2x/day 6h) Gardening and mowing for 1
hour 10i) Shopping online for 1
hour 5j) Cooking for 30 min. 4
76
Case study Barry talks to Dr Nancy Huang
AssistMatch each food intake to the energy
expenditure of each activity for a person
weighing 70 kg.
77
Case study Barry talks to Dr Nancy Huang
78
Heart Foundation sedentary and active energy
comparisons
79
Heart Foundation sedentary and active energy
comparisons
80
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).
81
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).
82
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 50170 kJ.
83
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 24 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.
84
Recommending physical activity in different
patient groups
The elderly population The least physically
active people have the most to gain from
exercising its 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.
85
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).
86
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.
87
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.
88
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 aimto stay at home?
89
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.
90
Case study Sylvia Kong
What special advice would you give to Sylvia
about increasing physical activity?
91
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.
92
Case study Sylvia Kong
A typical walking program for patients with CVD
including survivors of acute MI involves
93
Case study Sylvia Kong
Before Sylvia starts exercising, a pre-activity
evaluation is required, ie medication
review physical examination history of prior
physical activity.
94
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 Im 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?
95
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.
96
Case study Eddie Pocklington
Exercise can also improve Eddies 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?
97
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 34 times per week Start slowly,
gradually increasing speed Walk for a shorter
duration initially (eg. 2 min/day), gradually
increasing duration, until walking for 1520
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.
98
Case study Eddie Pocklington
What symptoms should you tell Eddie to look for
and stop his physical activity if he develops
them?
99
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 uncha
racteristic excessive sweating palpitations
associated with feeling unwell undue fatigue.
100
Summary
In this presentation youve 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.
101
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.
102

Exercise, emotions and the 5As
103
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.
104
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.
105
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
dont understand and with reduced confidence in
their ability to cope with it. Roger Neighbour,
The Inner Consultation
106
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.
107
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 3050) and management.
108
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.
109
The best medicine
No pharmaceutical intervention can match physical
activity Benefits wide range of
problems Minimal side effects.
110
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
111
Role of general practice
Systematic review evidence of effectiveness Targ
eted 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.
112
The 5As
Ask Assess Advise Assist Arrange.
113
Human behaviour change

• Change can be exciting or daunting.
• How can we put the 5As into practice to encourage
  change?

114
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?
115
Findings
Combination of emotion information
see value in change belief that change is
possible. Overcoming barriers to change.
116
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117
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.
118
Maslows hierarchy of needs
119
Permission to speak
The 5As in the GP consult Timing is
important A salutary tale from Yorkshire.
120
Consultation models
The medical model Stott and Davis the
exceptional potential in every consultation for
health promotion Neighbour.
121
Scott and Davis model
A BManagement of presenting Modification of
health-seeking problems behaviourC DMana
gement of continuing Opportunistic health
promotionproblems
122
Neighbours consultation model
123
The 5As in a consult
The 5As in a consult Ask connect
summarise Assess handing over Advise Assi
st Arrange safety netting Advise
housekeeping.
124
Cognitive dissonance
125
Cycle of change
126
Precontemplation
AimHelp 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.
127
Contemplation
AimHelp 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.
128
Preparation
AimAssist commitment to regular physical
activity. Set a start date.
129
Action
AimReinforce behaviour change through
encouragement and support. Reinforce health
benefits of physical activity Feedback any
improvement in risk factors Congratulate person
on achievements.
130
Maintenance
AimSupport 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.
131
Relapse
AimHelp 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.
132
Dealing with fall out
Patients perspective cognitive
emotional Health professionals perspective
133
Dealing with fall out
Health professional advise patients
decide Be honest Be active Be open with
colleagues Be realistic Be responsible
delegate
134
Summary
Physical activity the best medicine Equip
patients to live their lives Target the
sedentary Tailor information to individual
avoid reactance meet patients agenda first
create cognitive dissonance use emotions
positively look after yourself too.