Physical Activity and CVD

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Physical Activity and CVD

• Katherine Thompson
• Physical Activity for Health Lead
• London Regional Public Health Group

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OVERVIEW

• Setting the scene
• Risks of being physically inactive
• Benefits of being physically active
• Activity Levels in London
• Physical Activity Recommendations
• Physical Activity in Primary Care
• Behaviour Change
• Motivational interviewing

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SETTING THE SCENE

• So what has physical activity done for me lately?

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Headlines

• Physical inactivity has been linked to 1.9
  Million deaths Annually (WHO 2002)

Physically active adults have a 20 30 reduced
risk of premature mortality (CMO report 2004)
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Physical Inactivity, disease and the lifecourse
Premature mortality

Disease and disorders
Risk
Risk factors
Growth and development
Adolescence
Old
Middle
Young
Childhood
Adulthood
The upper line represents risk for individuals
with an inactive lifestyle The lower line
represents risk for individuals with an active
lifestyle CMO Report At least five a week -
2004
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The wider benefits of PA

• Prevention and management of stress, anxiety and
  depression
• Improved psychological well-being (self-esteem)
• Improved functional capacity
• Reduced risk of osteoporosis
• Reduced risk of colon cancer
• Prolonged independence in older adults
• Reduced risk of developing lower back pain

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CHD Risk Factors
Blair, S.N et al.(1996) Influences of
cardiorespiratory fitness and other precursors on
cardiovascular disease and all-cause mortality in
men and women JAMA 276(3)205-210
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Prevalence of CHD risk factors
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Hypertension

• Can be prevented and treated by physical activity
• Systolic BP reduction of 3.8mmHg (Whelton et al.
  2002)
• Diastolic BP reduction of 2.6mmHg (Whelton et al.
  2002)
• BP reduction can be elicited in both normal and
  overweight populations.
• Resistance and aerobic activity

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Lipids

• Increases level of HDLs
• Decreases triglicerides
• Doesnt impact on LDLs or total cholesterol
• EE 1200 2000 Kcal 0.051 0.077
  mm/L increase in HDL and a decrease of 0.09
  0.22mol/L in triglicerides
• Volume and frequency of activity, not intensity
  is important.

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Insulin Resistance

• Resistance and aerobic exercise prevent and
  modify insulin resistance
• Elicit 11 36 improvement in glucose metabolism
• Those at high risk who are physically active can
  reduce the risk of developing diabetes by up to
  64
• Diet and exercise are significantly more
  effective than metformin in the prevention of
  diabetes in glucose intolerant patients (Knowler
  2002)

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Post Event

• HR BP Myocardial Oxygen
• Demand
• Therefore Ischaemic threshold is improved and
  angina threshold is improved
• Also
• Period of diastole giving greater time
  for blood to flow through coronary arteries

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Cardiovascular health benefits of PA

• There is substantial evidence identifying the
  benefits of physical activity
• Prevention and management of obesity
• Prevention and management of diabetes
• Reduced risk of CHD, stroke and hypertension
• Improved blood lipid profile
• It is estimated that 33 of all CHD , 25 of
  strokes and Type 2 diabetes could be avoided with
  regular physical activity (HEA 1995)

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Small Changes

• Kohl 2001
• CMO Report At least five a week - 2004

High
CHD RISK
Low
Inactive or Very Unfit
Very Active Or Fit
PHYSICAL ACTIVITY OR FITNESS LEVELS
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ACTIVITY LEVELS

• How active are Londons residents?

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Physical Activity Levels London
Percentage of residents achieving 5 x 30 minutes
moderate intensity physical Activity
London average 11.6
http//www.sportengland.org/eastmidlands_index/eas
tmidlands_get_resources/homepage-ap/apd.htm
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Physical Inactivity Levels London

• Percentage of Adults doing zero 30 minute
  moderate intensity physical activity / sports
  sessions a week (Active People 2006)

London Average 49.5
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Recommended Levels of Physical Activity with Age
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National Travel Survey 2006
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Physical Activity is disappearing from everyday
life

• Labour-saving devices
• Travel patterns
• Concerns over safety in public spaces
• Sport as entertainment
• The impact of information technology
• Leading to an increase in sedentary and
  physically less demanding lifestyles

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How Active should we be ?

• Physical Activity Recommendations
• Key Principles

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The Challenge of Maintaining Good Health!
CMO Recommendation 30 Minutes moderate intensity
physical activity on at least 5 days of the week
(CMO 2004)

• 11.6 of Londoners achieve 30 minutes of moderate
  intensity physical activity on 5 days of the week
  (Active People 2006)
• 80 of people believe that they are doing enough
  physical activity (Health Survey England 1998)

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Types of Physical Activity
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Types of Physical Activity

• NICE recommendations for types of activities
• Activities that can be incorporated into everyday
  life
• Supervised exercise programmes
• Leisure time activities such as swimming,
  cycling.

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What are the most popular activities?
Top 10 sports by participant numbers (m) Active
People 2006
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Physical Activity in Primary Care

• NICE Guidance
• Screening
• Behaviour Modification

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GUIDANCE

• NICE 2006 Primary care practitioners should take
  the opportunity, whenever possible, to identify
  inactive adults using a validated tool, such as
  the DH GPPAQ

DH NSF CHD 2000 Physical activity should be
assessed and entered on to a clinical record for
all patients over 16 and updated every 5 years
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PHYSICAL ACTIVITY SCREENING

• Research into a short measure of physical
  activity - GPPAQ
• Validated with 16 74 year olds
• 4 level index, self completed in 1 min.
• Can be used within diatetic and hypertensive
  clinics
• Is predictive of all cause mortality and CVD
  mortality in men and women
• Cross referenced to read codes
• Further guidance www.dh.gov.uk
• PAI

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PHYSICAL ACTIVITY INDEX
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ASSIGNING READ CODES
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GPPAQ RECOMMENDATIONS

• Any intervention should be consistent with the
  agenda on patient led consultations and choice.
  One way to do this is to base behaviour-change
  negotiations on the principles of motivational
  interviewing (MI). Although developed in the
  field of addictions, brief versions of MI have
  been adapted and applied to a wide variety of
  behaviours and conditions such as smoking, diet,
  physical activity, medical adherence and
  diabetes, with evidence of effectiveness (DH
  GPPAQ report 2007)

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NICE 2006

• RECOMMENDATION 2 When providing physical
  activity advice, primary care practitioners
  should take into account the patients needs,
  preferences and circumstances. They should agree
  goals with them.

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Behaviour Change

• Fixing the Problem
• Motivational Interviewing

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FRUSTRATIONS OF CHANGING BEHAVIOUR

• Motivation to change a behaviour is complex and
  perplexing, people will change when they are
  ready and able.
• However sometimes the assumption is made that
  there is something wrong with the patient..
• Patients dont see the problem
• Patients dont understand the problem
• Patients dont know how to change
• Patients just dont care

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FIX THE PROBLEM

• Problem
• Patients dont see the problem
• Solution
• Give them Insight if you can just make people
  see then they will change

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FIX THE PROBLEM

• Problem
• Patients dont understand the problem
• Solution
• Give them knowledge if people just know enough
  then they will change

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FIX THE PROBLEM

• Problem
• Patients dont know how to change
• Solution
• Give them Skills if you can just teach people
  how to change, then they will do it

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FIX THE PROBLEM

• Problem
• Patients just dont care
• Solution
• Give them Hell if you can just make people feel
  bad or afraid enough, then they will change

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The Righting Reflex

• Human beings have a built in desire to set
  things rightWhen we se things go awry we want to
  fix itSee someone go astray and the reflex kicks
  in to set them back on the right path (Miller
  and Rollnick 2002)

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What is missing?

• What makes the client behave as they do?
• What beliefs and values influence their current
  behaviour?
• What beliefs and values influence our practice
  behaviour?

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Definition

• Motivational interviewing is a client-centred,
  directive method for enhancing intrinsic
  motivation to change by exploring and resolving
  ambivalence (Rollnick Miller 2002)

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What is Motivational Interviewing

• Based on the transtheoretical model of behaviour
  change developed by Prochaska and Diclemente
  (1984)
• Developed as a method to assist working through
  ambivalence and eliciting a commitment to change
• Has been widely used in the field of substance
  abuse and behaviour change.

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Motivational Interviewing

• McHugh et al (2001) Patients awaiting coronary
  artery bypass surgery.
• Wollard et al (1995) Patients with hypertension
• Scales (1998) Coronary artery disease patients
  awaiting cardiac rehabilitation

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In Summary

• Wide range of physiological and psychological
  benefits to being physically active
• Patients physical activity levels need to be
  identified and if appropriate given advice
• Motivational Interviewing is an effective tool
  for supporting long-term behaviour change

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Support and Resources

• Further Information

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What's out there?

• Activities of Daily Living
• Gardening / Allotments
• Active Travel
• Walking the way to health Initiative
  www.whi.org.uk
• Everyday Swim www.everydayswim.org
• Everyday Cycling www.everydaycycling.com
• Physical Activity Clinics
• Exercise on Referral Programmes
• Sport and Physical Activity Development Units

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Physical Activity support Resources

• HealthEx
• Physical Activity Advice Leaflets
  www.healthex.net
• BHF
• Physical Activity Primary Care Toolkit
• Physical Activity leaflets
• http//www.bhfactive.org.uk/information-centre/phy
  sicalactivityandyou.html
• NHS Choices
• General web based advice and support
  www.nhs.uk/LiveWell