Promoting physical activity to patients
BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5230 (Published 17 September 2019) Cite this as: BMJ 2019;366:l5230
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Having read the article and all the responses, may I please say that Mr Jonathan Super, medical student, has, in his rapid response said all one needs to.
Is anyone listening?
Competing interests: Ancient. Multiple morbidities. Thin as a rake ( but I never was a rake). If anyone can restore my ability to walk ( not crawl, as I do now), will have a place reserved in my brand of Heaven.
Dear sirs
I’m very grateful for Dr Haseler replying to my private email re. the use of these relative risk percentages as it seems almost disingenuous to be quoting them to my patients as I can’t provide absolute risk reduction numbers. Though after reading the v interesting article by Marteau Dr Thomas quoted perhaps I shouldn’t hold too much weight that patients will be persuaded by the numbers anyway. I would be v interested to hear people’s views re the fact the data is based on epidemiological studies (with their inherent problems and confounders) and how they might approach this with their patients or do people feel happy to quote these impressive sounding percentages to try to shock them into action.
Competing interests: No competing interests
Whilst reading this article with great interest, it occurred to me, as a final year medical student at Imperial College London, that there is an absence in formal teaching on how to instruct or advise patients with regards to physical activity. I studied an intercalated BSc in Sport and Health Sciences at the University of Exeter, learning in great detail about the benefits associated with increased activity, as well as the topic of clinical exercise prescription, prompting my consideration whether this should be integrated into the medical school syllabus.
It has been long established that regular physical activity has a role in both the primary prevention and treatment of many medical conditions (1). However, knowledge that physical activity is beneficial and the ability to give patients informed advice concerning physical activity are two different entities. There are a number of considerations, including patient limitations and comorbidities, as well as choosing the exercise modality, intensity and duration, that make the task of routinely prescribing physical activity daunting. Thus, exercise is often overlooked, with doctors often opting in favour of medical or surgical interventions without considering physical activity (2).
As healthcare professionals, we are in the privileged position to have conversations with individuals regarding their health or illness as well as discussing potential interventions, including physical activity. In addition, Thornton et al., showed that patients prefer to receive advice about their health and physical activity directly from a doctor (3). Exercise prescription requires assessment of a patient’s fears, misconceptions and motivation relating to exercise (4). Within minutes, a doctor can screen for a patient’s activity/inactivity and offer personalised physical activity advice, taking into consideration any locomotor or comorbid issues.
I hope that, going forward, medical schools will incorporate formal teaching on exercise prescription for patients with different pathologies, using the practical guide outlined in the original article, to aid in the prevention and successful management of various conditions through competent advice regarding physical activity.
1. Pedersen BK, Saltin B. Exercise as medicine - Evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sport. 2015;
2. Persson G, Brorsson A, Ekvall Hansson E, Troein M, Strandberg EL. Physical activity on prescription (PAP) from the general practitioner’s perspective - A qualitative study. BMC Fam Pract. 2013;
3. Thornton JS, Frémont P, Khan K, Poirier P, Fowles J, Wells GD, et al. Physical activity prescription: A critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: A position statement by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med. 2016;
4. Hoffmann TC, Hons B, Maher CG, Phty B, Bphysed TB, Sherrington C, et al. Prescribing ewxercise interventions for patiens with chronic conditions. Cmaj. 2016;
Competing interests: No competing interests
Thank you for this helpful article. I do feel that doctors of all specialities, myself included, ought to be more proactive in encouraging patients to exercise more, eat more healthily, lose weight etc. Every presentation be it to the GP, to A&E, for elective surgery, or a medical ward is an opportunity to promote physical activity. I particularly liked to use of the ask, assess, advise strategy we sometimes use for smoking cessation. The non-judgmental phrasing (e.g. "From what you've told me, being more physically active may help you feel better and improve your health") is particularly helpful, and something I will incorporate into my practice.
However, as I read I discovered my conscience was wittering away in the background, 'you don't do 150 minutes of exercise weekly!' We would not expect a patient to take advice from a person claiming to be a doctor who in fact had no medical qualifications. In like manner, can we really expect a patient to follow this advice if we ourselves are not meeting the mark? I suspect the hypocrisy is part of the reason we doctors often do not offer this advice to our patients. NHS Employers and post-graduate training programmes ought to do more to facilitate healthy lifestyles for staff: A weekly rostered exercise break would show society how seriously the NHS was about physical exercise. I would not be surprised if it also resulted in reduced stress levels and increased staff productivity.
Competing interests: No competing interests
In order to facilitate patients to take more exercise we need to make it easier for them. This is not a medical intervention directly, but we can try to motivate local and national governments. In many countries people are put off public transport, even though walking to a bus stop or a railway station would be a convenient way of exercising. Roads and cars are subsidised but public transport isn't. Pavements and cycle routes are afterthoughts and are often diverted to make way for motorised vehicles. We need to convince governments that changing their policies are win / win decisions, by improving health, reducing pollution, and making living environments much more pleasant.
Competing interests: No competing interests
I am delighted to see this article. The benefits of exercise are well known; but how, in practice, to encourage people to take more exercise is less well known.
While building exercise into daily routines is very useful, some people like to go to a gym. Particularly after an illness, people may feel safer exercising in controlled surroundings than they might do coping with, for example, weather and uneven footpaths.
Sadly, many gyms require people - especially if they admit to having been ill, or to common conditions such as hypertension - to obtain a letter from a doctor to absolve the gym of liability in the unfortunate event that the gym-member becomes unwell while exercising. The well-known "get a note from your doctor" (GANFYD) situation.
This puts people in the position of having to ask already-overworked GPs for a note; and possibly (as it clearly isn't NHS work or part of a GP's contractual duties) having to pay for it - which is clearly a barrier to them accessing the benefits of exercise in the gym.
Has a strategy been devised to get around this? Or to prevent gyms from requiring such notes?
Competing interests: No competing interests
More physical activity for the majority of people could well be equivalent to a “wonder drug”, but the best means to achieve that end are uncertain.
Sarah Payne Riches wonders how effective is the personalised advice that physicians give to their patients, and suggests that the authors may be over optimistic in the dividend they expect from a GP’s advice.
GPs who have spent a professional lifetime trying to persuade patients to adopt healthier lifestyles, may share her scepticism.
Our scepticism is supported by the work of Professor Theresa Marteau, whose research suggests that we overestimate how much our behaviour is under intentional control, and underestimate how much is cued by the environment. (1)
If we and the public become more aware of the importance of our environment in shaping our choices, then we are more likely to put pressure on our politicians to increase those health promoting aspects of daily life, which are often sabotaged by the pervasive effects of inequality. Those pervasive effects which were made clear by the work of Wilkinson and Pickett, (2) although no political initiatives have resulted from their work, and our profession continues to be expected to alleviate many increasing problems which follow from political indifference.
1 Theresa M Marteau, The Lancet,January 13, 2018
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33324-X/fulltext
2 RG Wilkinson & K Pickett, The Spirit Level, Allen lane, 2009.
https://www.equalitytrust.org.uk/about-inequality/spirit-level
Competing interests: No competing interests
Dear Authors,
I was delighted to see this article published and commend your efforts to try and encourage more physician advice to increase physical activity. However, I wanted to bring your attention to the statement you make "even a brief discussion can help someone to become more active" supported by the example RCT by Calfas et al 1996.
My initial reaction to your statement was "wow, that is incredible" and it felt a bit too good to be true. On reading the 1996 RCT paper in prev med it seems it is too good to be true. What you fail to mention or encompass in your statement that "even a brief discussion can help" is that in that study only physicians interested in physical activity were recruited and they were then trained in 2 separate visits to their offices. It doesn't state how long this training is but mentions it including role-playing exercises so one would expect it is more than a 15 min chat. I don't think these physicians can be seen as representative of typical GPs.
Furthermore, the physicians delivered what was, effectively, tailored counseling based on the participants' pre-determined stage of change. This was followed up by a 10-minute phone call by a health educator. Participants had also completed a questionnaire encouraging them to reflect on and consider their physical activity. This study had a fantastically positive result but it isn't a fair comparison to typical primary care in the UK. I think it is unreasonable to extrapolate this study to say that "even a brief discussion within a consultation can lead to change".
If there are other studies which show that a truly brief discussion with a GP or practice nurse can really improve people's physical activity levels then you ought to reference them. If there is no literature more recent than 1996 then that in itself is a concern. I suspect that getting patients to be more physically active would take a lot more than a 3-5 min chat to their GP as you imply. The ask-assess-advise approach would most certainly take longer than that as setting goals with patients about their physical activity and how they might self-monitor this is time consuming. Improving physical activity is a hugely important topic and I agree that clinicians are uniquely positioned to help patients to do so. However, if it advised this is done in routine consultation, which your paper suggests, it is only fair to provide the clinicians with up-to-date evidence of what works in a typical routine primary care context. Otherwise it is just pie in the sky!
Competing interests: No competing interests
Response to the responders
Thank you for your informative comments on this article.
The evidence for brief interventions less than 5 minutes is sparse and dates from the 1990s (1, 2) These two papers which look at a quantifiable brief intervention less than five minutes. It is reported that there is moderate evidence from 15 studies suggesting there is an increase in the self-reported physical activity levels in those participants who received brief advice or who were seen by primary care professionals trained to deliver brief advice (3) but also that there are significant gaps in evidence including accessibility of brief advice if more than a few minutes, effectiveness of differing durations of brief advice, advice that should be provided, infrastructure that should support it, how to measure impact, physician, consultation and patient factors. Clearly more research is needed (4).
The ask – assess – advise model was based on NHS Scotland brief intervention scripts which were evaluated in 2013 (http://www.healthscotland.scot/health-topics/physical-activity/screening...). We find this framework useful and practical in the confines of a ten minute GP consultation.
We acknowledge the lack of robustness in the evidence which is why we used the phrase ‘can help’. However, in this Practice pointer article we proposed a framework for raising the issue of physical activity with the best evidence available for what is possible in the consultation.
We thank you for raising points of discussion and clarification on this.
We agree that the effect of a physician influence is only moderate at best as seen in NICE guidance (3). The effect of environment is clearly outlined in UK government documents, Everybody active every day (5) which includes sections on active society and active environment. The impact of physician advice can be seen in smoking cessation (6) where it is clearly only one element of many interventions and we anticipate that a multiagency approach (5) will be required to support physician efforts in the consultation.
We agree that it is inappropriate for patients to be requesting fitness assessments before attending a gym. The resource of ‘Moving medicine’ ( https://movingmedicine.ac.uk/) gives information about specific conditions and also other options for appropriately increasing physical activity. It is not all gyms, by any means, that do this and there are usually options which are tailored for all people. In the UK ‘social prescribing’ and active lifestyle coordinators help patients to access physical activity that is suitable.
We agree that making physical activity more accessible is key as stated in ‘Everybody active every day’ and NICE guidance (5, 7, 8).
We agree that a healthy workforce is an integral part of a physical activity strategy. This is reflected in ‘Everybody active every day’, although not the Moving professional section! NICE guidance clearly outlines physical activity in the work environment which includes the NHS (9).
We thank you for your comments on the need for more undergraduate teaching on physical activity. In the UK this has been a topic of discussion between governing bodies for many years. The article focuses on promoting physical activity rather than exercise prescription as this is more specialised and involves different training. More undergraduate training would equip doctors to integrate physical activity as the ‘miracle cure’ it is.
1. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med. 1996;25(3):225-33.
2. Bull FC, Jamrozik K. Advice on exercise from a family physician can help sedentary patients to become active. Am J Prev Med. 1998;15(2):85-94.
3. NICE. Physical activity: brief advice for adults in primary care PH44. National Institute for Health and Care Excellence; 2013.
4. Lamming L, Pears S, Mason D, Morton K, Bijker M, Sutton S, et al. What do we know about brief interventions for physical activity that could be delivered in primary care consultations? A systematic review of reviews. Prev Med. 2017;99:152-63.
5. Varney J BM, Aaltonin G. Everybody active, every day. PHE publications: Public Health England; 2014. Contract No.: 2014432.
6. Physicians RL-RCo, Studies UCfTC. Fifty years since smoking and health: Progress, lessons and priorities for a smoke-free UK. 2012. p. https://www.rcplondon.ac.uk/projects/outputs/fifty-years-smoking-and-health.
7. NICE. Physical activity; walking and cycling PH41. 2012. p. https://www.nice.org.uk/guidance/ph41.
8. NICE. Physical activity:Encouraging activity in the community QS 183. 2019. p. https://www.nice.org.uk/guidance/qs183/chapter/Quality-statement-2-Activ....
9. NICE. Physical activity in the workplace PH13. 2008. p. https://www.nice.org.uk/guidance/ph13.
Competing interests: No competing interests