Encouraging exercise Part 1
‘If your dog is fat, you’re not getting enough exercise.’ Anon.
Every study of exercise behaviour confirms that the level of physical activity in the population is lamentably low. The only question is just how low. When exercise performance is estimated from questionnaires, the level does not look too bad. About 50 per cent of the adult population believe that they reach the current government recommendation for physical activity. (Later in life, the taking of exercise falls off badly – by the age of 75 the level is 8 per cent for men and 3 per cent for women).
As I often emphasise, however, when exercise level is actually measured, the figures are startlingly different. The 2008 HSE report, which did make measurements, found that just 6 per cent of men and 4 per cent of women achieved the government’s recommended physical activity level – only one sixth of the level of compliance indicated by individuals’ own questionnaire response.
Another study indicated that there is some relationship between people’s assessment of how much exercise people think they take and how much they really take – though the relationship is skewed towards overestimation. When it came to physical fitness however, there is absolutely no relationship between how fit people think they are and how fit they really are – none at all!
As a society, we certainly need to put a great deal more money and effort into promoting exercise to a reluctant general public.
My blogs are primarily aimed at grown-ups – but the business of developing a national culture of exercise must begin in childhood. Unfortunately, children are as bad as adults in their reluctance to exercise. The Chief Medical Officer’s guidelines recommend that all children and young people aged 5–17 should engage in at least 60 minutes of physical activity a day, of which 30 minutes should be in school. In reality, less than 20 per cent of kids meet this target and as they reach adolescence even this low figure plummets. Schemes to reverse the trend have nearly always been unsuccessful. For instance a fun exercise programme aimed at maintaining physical activity into adolescence, GoActive, was trialled with over 1,500 youngsters in eight schools. At the end of the study, there was no difference in activity between the children in the GoActive arm compared with the controls.
The government does not help. The figures on school sports grounds are shocking. Since the London Olympics in 2012 the equivalent of one playing field per fortnight has been sold off and that rate has recently risen. In 2016, 21 schools sold their playing fields to developers, the highest number since 2013. Sales of school playing fields hit a three-year high last year, on the same day Boris Johnson pledged tens of millions for new football pitches across England. Permission to sell school playing fields is often denied by local authorities, who are then overruled by the Department of Education.
Schoolteachers, even if lacking their sports grounds, can play a big part in encouraging children to exercise outside school hours. One recent initiative has been the ‘Daily Mile’. Participating primary schools – and at the time of writing there are more than 3,500 in the UK, with many more in other countries – get their charges to run for 15 minutes each morning before the start of lessons. Another promising area is the recruitment of internet technology. Over recent years there has been a surge of new online apps, blogs and videos specifically targeting young people with messages about personal improvement in their health and lifestyle. These technologies offer opportunities for young people, including collecting, tracking and sharing data – for instance about how far they walk or run. Despite their proliferation, there is currently no official assessment nor recommendation for their use, but there are great opportunities for applying IT in this field.
The most important people in promoting children’s exercise, however, must be parents – maybe you, dear reader. The country is amazingly well endowed with altruistic adults, mostly parents, who supervise children’s sporting activities – football, rugby, tennis, athletics – bravo to all of them. Parents may be helped by members of community groups who, in return, are allowed to use school playing fields (where these have been retained) in the holidays.
In adult life the main bar to exercise is the lack of time resulting from gainful employment and/or bringing up kids. For you, the working person/parent, the most important incentive to exercise must be an understanding of just how vital this is to your future health, happiness and longevity. If you have not cottoned on to that by now, you have not been concentrating – start again and read more thoroughly!
Encouraging people to take more exercise is a difficult task. Healthcare professionals should target appropriate patients, but seldom do so. A US study of consultations for diabetes or hypertension showed that exercise was recommended on only one sixth of occasions. Even when advice is given it is largely ineffective. A recent meta-analysis of trials of physical-activity promotion in primary care did find a slight increase in self-reported physical activity at 12 months, but those trials which also measured physical fitness showed no significant increase.
There are many schemes that encourage GPs to prescribe exercise and most local authorities have systems for ‘exercise on prescription’ at their local sports centres. The idea is that the GP ‘prescribes’ a course of exercise and the individual has an initial assessment at the sports centre, followed by a course of exercise of around 10 weeks at a cost somewhat lower than that charged to the general public. At the end of the course the individual is encouraged to continue to attend the sports centre at the usual rate. Exercise training and physical activity are not part of the usual medical student’s curriculum, however, and this may explain why the level of referral to such schemes is extremely low. The uptake and completion of prescribed exercise programmes is even lower. Analysis of a number of these schemes shows that they do not lead to an increase in physical fitness, health-related quality of life or exercise habit in the longer term. The UK National Referral Database analysed 13 exercise referral schemes lasting between six weeks and three months involving 24,000 people. They found small improvements in the health and well-being of most participants, but these changes were too small to be clinically significant.
The idea of exercise on prescription is a sound one, but more attention needs to be paid to barriers to attendance and continued adherence. Some of the factors that have been identified include poor organisation of the scheme, inconvenient opening hours, poor social support and exercise leaders lacking motivational skills. However, regular telephone support and follow-up of absences for those who have been prescribed exercise programmes can be both effective and cost-effective in increasing long-term compliance.
Quality and Outcomes Framework
Prescribing exercise may not be part of the thinking of most general practitioners. However, GPs are extremely good at taking up opportunities to increase their income and this is the basis of the Quality and Outcomes Framework (QOF) through which they are paid to achieve a number of clinical targets. If you think that your GP is taking more notice of his/her computer screen than of you, you are quite right. They are checking that they have made as much money as possible from you, depending on your problems. They will be rewarded for including you on their obesity register, for getting your blood pressure or blood sugar to an acceptable level and for prescribing all the drugs that the NHS wants them to. They may be paid to refer you to various agencies for support and education – but there is no incentive at all for them to encourage you to take exercise. Perhaps if referral to an exercise programme were included in the QOF we might see a benefit for both the individual and the nation as a whole? I will have more to say about this on a future occasion.
Encouraging the population to take exercise needs the commitment of doctors, who should regard exercise as a medicine, as effective a weapon against disease as any drug. The time may be coming for the lifestyle approach. As the BMJ put it, ‘Is lifestyle medicine emerging as a new medical specialty?’ The British Society of Lifestyle Medicine was founded in 2016 and this approach is now being adopted by some medical schools, including Cambridge University. Ideally, lifestyle medicine should not need a label of its own but should become integral to the delivery of health care. In its delivery, the medical profession needs to be backed up by political action to make physical-activity promotion and facilitation key goals in their public-health strategy. It is also the duty of all health professionals to set a good example. Doctors don’t smoke – they should also be seen to take exercise.
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