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RNZCGP conference 2011

RNZCGP conference 2011. Elizabeth Harris 1 , Hamish Osbourne 2 , Elaine Hargreaves 3 (nee Rose) , Jim Reid 4 University of Otago, Dunedin 1 Honorary lectureship Dept General Practice,, 2 Senior lecturer, Sports and Exercise Medicine, 3 Sport and Exercise Scientist, Dept Physed,

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RNZCGP conference 2011

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  1. RNZCGP conference 2011 • Elizabeth Harris1, Hamish Osbourne2, Elaine Hargreaves3 (nee Rose), Jim Reid4 University of Otago, Dunedin • 1Honorary lectureship Dept General Practice,, • 2Senior lecturer, Sports and Exercise Medicine, 3Sport and Exercise Scientist, Dept Physed, • 4Professor of General Practice, Primary prevention in primary practice An innovative concept aimed to support GP’s in providing primary prevention in primary care

  2. Session outline • Where we are in medicine and how we got there • The evidence on physical activity and its influence on health • A concept we’d like to present and discussion!

  3. Whirlwind tour through medicine - acute care advances - trauma - treatment of injuries - surgery - infection - hygiene and antimicrobial Rx

  4. Mortality rates • Figure H2.1 Life expectancy at birth, by sex, 1985–1987 to 2007–2009 • Source: Statistics New Zealand • Note: The period life table data in this graph is from complete life tables for all periods up to 2005–2007 and an abridged life table for 2007–2009.

  5. And now? ‘Today’s younger generation will likely be the first to live shorter lives than their parents’ Glen Berill - Chief of Paediatrics Northern York General Hospital

  6. Health Care Crisis • Manpower issues • Health Care spending • Chronic health epidemic • Sustainability

  7. Health Care Crisis- Manpower Gorman DF and Brooks PM. On solutions to the shortage of doctors in Australia and New Zealand, MJA, 190: 152-156, 2009 New Zealand has only 70% of the average number of doctors per head of population as OECD countries. This with a ‘World Health Organization (WHO) estimates a current global shortage of 4.3 million health workers’ Issues of • migration of doctors • Increasing numbers needed - increasing illness - increasing consult times

  8. Health Care Crisis - Financial

  9. Health Care Crisis -chronic health epidemic • Elliott J, Richards M. Heart attacks and unstable angina (acute coronary syndromes) have doubled in New Zealand since 1989: how do we best manage the epidemic? N Z Med J. 2005;118(1223). ‘In 2002/2003, more than twice as many New Zealanders had a heart attack than in 1989’

  10. Diabetes ‘tsunami’ • 2010: Ministry of Health report predicting 1:10 adults will have diabetes by 2028 and nearly half a million people by 2036

  11. How did we get this way? - Stress • 1970’s studies on the !Kung showed that they worked 20 hours a week (and laughter from a village could often be heard 2 miles away.)

  12. How did we get this way? - Diet Hunter gatherer = produced 2-3 calories for every calories consumed. Now we have 1% of the population farming, who produce 300 calories for every calorie consumed.

  13. Diet • Decreased nutrients - more processed food. • Increased anti-nutrients. - trans-fats - sugar - fructose - chemicals

  14. Increasing consumption of processed foods • Public Health Nutr. 2011 Jan;14(1):5-13. • Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. • Monteiro CA, Levy RB, Claro RM, de Castro IR, Cannon G. • Source • Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde, Universidade de São Paulo, São Paulo, Brasil. carlosam@usp.br • Abstract • OBJECTIVE: • To assess time trends in the contribution of processed foods to food purchases made by Brazilian households and to explore the potential impact on the overall quality of the diet. • DESIGN: • Application of a new classification of foodstuffs based on extent and purpose of food processing to data collected by comparable probabilistic household budget surveys. The classification assigns foodstuffs to the following groups: unprocessed/minimally processed foods (Group 1); processed culinary ingredients (Group 2); or ultra-processed ready-to-eat or ready-to-heat food products (Group 3). • SETTING: • Eleven metropolitan areas of Brazil. • SUBJECTS: • Households; n 13,611 in 1987-8, n 16,014 in 1995-5 and n 13,848 in 2002-3. • RESULTS: • Over the last three decades, the household consumption of Group 1 and Group 2 foods has been steadily replaced by consumption of Group 3 ultra-processed food products, both overall and in lower- and upper-income groups. In the 2002-3 survey, Group 3 items represented more than one-quarter of total energy (more than one-third for higher-income households). The overall nutrient profile of Group 3 items, compared with that of Group 1 and Group 2 items, revealed more added sugar, more saturated fat, more sodium, less fibre and much higher energy density. • CONCLUSIONS: • The high energy density and the unfavourable nutrition profiling of Group 3 food products, and also their potential harmful effects on eating and drinking behaviours, indicate that governments and health authorities should use all possible methods, including legislation and statutory regulation, to halt and reverse the replacement of minimally processed foods and processed culinary ingredients by ultra-processed food products.

  15. Even what unprocessed food that is eaten… has lower mineral content Nutr Health. 2003;17(2):85-115. A study on the mineral depletion of the foods available to us as a nation over the period 1940 to 1991. Thomas D. Source Mineral Resources International (UK) Limited Silverdale, Lower Road, Forest Row, East Sussex, RH18 5HE, UK. david@mineralresourcesint.co.uk Abstract In 1927 a study at King's College, University of London, of the chemical composition of foods was initiated by Dr McCance to assist with diabetic dietary guidance. The study evolved and was then broadened to determine all the important organic and mineral constituents of foods, it was financed by the Medical Research Council and eventually published in 1940. Over the next 51 years subsequent editions reflected changing national dietary habits and food laws as well as advances in analytical procedures. The most recent (5th Edition) published in 1991 has comprehensively analysed 14 different categories of foods and beverages. In order to provide some insight into any variation in the quality of the foods available to us as a nation between 1940 and 1991 it was possible to compare and contrast the mineral content of 27 varieties of vegetable, 17 varieties of fruit, 10 cuts of meat and some milk and cheese products. The results demonstrate that there has been a significant loss of minerals and trace elements in these foods over that period of time. It is suggested that the results of this study cannot be taken in isolation from recent dietary, environmental and disease trends. These trends are briefly mentioned and suggestions are made as to how the deterioration in the micronutrient quality of our food intake may be arrested and reversed.

  16. Sugar

  17. Chemicals • Ann Allergy. 1994 May;72(5):462-8. • Foods and additives are common causes of the attention deficit hyperactive disorder in children. • Boris M, Mandel FS. • Source • North Shore Hospital-Cornell Medical Center, Manhasset, New York. • Abstract • The attention deficit hyperactive disorder (ADHD) is a neurophysiologic problem that is detrimental to children and their parents. Despite previous studies on the role of foods, preservatives and artificial colorings in ADHD this issue remains controversial. This investigation evaluated 26 children who meet the criteria for ADHD. Treatment with a multiple item elimination diet showed 19 children (73%) responded favorably, P < .001. On open challenge, all 19 children reacted to many foods, dyes, and/or preservatives. A double-blind placebo controlled food challenge (DBPCFC) was completed in 16 children. There was a significant improvement on placebo days compared with challenge days (P = .003). Atopic children with ADHD had a significantly higher response rate than the nonatopic group. This study demonstrates a beneficial effect of eliminating reactive foods and artificial colors in children with ADHD. Dietary factors may play a significant role in the etiology of the majority of children with ADHD.

  18. Sleep • Advent of electric light bulb - sleep debt if less than 6 hours of sleep - linked to metabolic, psychiatric and neurobiological effects Padilha HG, et al A link between sleep loss, glucose metabolism and adipokines. Braz J Med Biol Res. 2011 Sep 2 . Brand S, Kirov R.Sleep and its importance in adolescence and in common adolescent somatic and psychiatric conditions. .Int J Gen Med. 2011;4:425-42. Epub 2011 Jun 7 Hans P.A.The Cumulative Cost of Additional Wakefulness: Dose-Response Effects on Neurobehavioral Functions and Sleep Physiology From Chronic Sleep Restriction and Total Sleep Deprivation SLEEP2003;2:117-126

  19. Physical activity

  20. Chakravarty EF, Hubert HB, Lingala VB, et al. Long Distance Running and Knee Osteoarthritis: A Prospective Study. American Journal of Preventive Medicine 2008;35(2):133-38. • 45 runners and 53 controls, mean age 58, 1984 • Serial x-rays and OA knee scores till 2002 • Higher initial BMI, initial radiographic damage, and greater time from initial radiograph associated with worse radiographic OA at the final assessment; • No significant associations were seen with gender, education, previous knee injury, or mean exercise time.

  21. Adolescent Health • Fletcher E, Visich P, Saltarelli W. Prevalence of the Metabolic Syndrome in Children and its Relationship to Overweight and Physical Fitness: 753: May 29 2:30 PM - 2:45 PM. Medicine & Science in Sports & Exercise 2008;40(5):S55-S56 10.1249/01.mss.0000321687.92638.9e. • 2867 children aged 11-13 - 3 or more of these components for Dx MS: • Elevated waist circumference: male >=102 cm. female >=88 cm • Elevated triglycerides, BP> 130/85, fasting bsl • Reduced HDL • 6.5% Females 5.3% of males met the adult criteria for MS • Met synd was present in 21% of those with BMI > 95thcentile • But only 1% of children between the 81st and 94thcentile • Met synd was present in 18% of those in lowest 25thcentile for fitness • But only 1.8% of children between the 26th and 74thcentile and 1.2% of top 25thcentile

  22. Leitzmann Blair et al Arch Intern Med 167 (22): 2453-2460, 2007. • A quarter of a million men and women aged 50-71 followed for 1 265 347 person years of follow up • 7900 deaths during that time – 3% • All cause mortality for smokers relative risk compared with smoking non exercising subjects risk factor was 0.48 • Interesting that for non smokers the all cause mortality risk reduction is less at 0.54

  23. Neurological • Laurin D, Verreault R, Lindsay J, et al. Physical Activity and Risk of Cognitive Impairment and Dementia in Elderly Persons. Arch Neurol 2001;58(3):498-504. • 9000 men and women >65 followed for 5 years. • 4615 completed the follow up • High levels of physical activity were associated with reduced risks of • cognitive impairment 0.58 • Alzheimers disease 0.50 • dementia of any type 0.63

  24. Older Persons Health Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. RCT of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997 Objective:To assess the effectiveness of a home exercise programmeof strength and balance retraining exercises in reducing fallsand injuries in elderly women > 80 through 17 General practices in Dunedin 
Number of falls and injuries related tofalls and time between falls during one year of follow up Results:After one year there were 152 falls in the control groupand 88 falls in the exercise group.

  25. Morris 1953

  26. Lam TH, Ho SY, Hedley AJ, et al. Leisure time physical activity and mortality in Hong Kong: case-control study of all adult deaths in 1998. Ann Epidemiol 2004;14(6):391-8. • Leisure Time Physical Activity and Mortality in Hong Kong: Case-control Study of All Adult Deaths in 1998 • One fifth of 31349 registered deaths attributed to physical inactivity • More than the deaths related to smoking

  27. Smoke - its safer than watching TV!

  28. Fit but a bit podgy

  29. Just a thought • The risk of sudden death while exercising is less than the risk of death by accident while driving somewhere to exercise.

  30. Breast Cancer Survival • 24-67% Reduction in all total deaths • 50-53% Reduction breast cancer deaths

  31. NY Marathon • From age 19 get faster • Peak running speed 27 • Then times start declining till end up running at speed of 19 year old. • How fast is that decline?

  32. Evolution… 2011

  33. Does modern medicine contribute to this epidemic? • What we focus on, and the actions that we take…. is the message that we are sending. • Are we sending too strong a message - ‘live any old way and come and see us when a problem arises - and we’ll give you a pill or an operation’?

  34. Working on a supply versus demand model….

  35. Is prevention part of the answer and is it in our “in-box” as GP’s? • (1) Stephen J. Genuis. An ounce of prevention. A pound of cure for an ailing health care system, Canadian Family Physician, 53 April: 597-599, 2007 • Within the many dimensions of health care provision and public education, a concerted focus on health promotion is urgently required. In order to move preventive medicine from the realm of academic discourse into the sphere of routine medical practice, however, pronounced efforts in medical education, physician remuneration, and public policy are essential • (2) Chakravarthy MV, Joyner, MJ, and Booth FW. An obligation for primary care physicians to prescribe physical activity to sedentary patients to reduce the risk of chronic health conditions. Mayo Clinic Proceedings, 77(2) :165-173, 2002

  36. Enrico CoieraCoieraE. Four rules for the reinvention of health care, BMJ, 328: 1197-1199 • Prevention needs to be designed into the health system’s core, eliminating many of the determinants of ill health that generate the current demand for services.

  37. Research contributions • 1998 - Writing it down helps Swinburn B, et al. The Green Prescription study: a randomised controlled trial of written exercise advice provided by general practitioners. Am J Pub Health 1998 Feb: 88(2):288-91 • 2002 US Prev Services Task Force (USPSTF) - inconclusive support for physician counseling as the channel for physical activity promotion. Eden KB, et al. Does counseling by clinicians improve physical activity? A summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 202; 137;208-215 • 2002 Community programs - individually tailored and including social support do increase PA. Kahn EB, et al. The effectiveness of interventions to increase physical activity: a systematic review. Am J Prev Med 202;22(4s) 73-107 • 2003 STEP test - 5A’s assess, advice, ask, assist, arrange does lead to +ve outcomes. Petrella RJ, et al. Can primary care doctors prescribe exercise to improve fitness? The Step Test Exercise Prescription (STEP) project. Am J Prev Med 2003 May: 24(4): 316-322 • 2005 GP plus health educator - increases activity by 1 hour Pinto et al • 2005 Research assistant assessment - GP gives advice - community support contacts given

  38. NZ: where we’re at • What are our guidelines? • Are they right? • Are we meeting them?

  39. Are our guidelines a good guide?! • Baldi, JC. How much exercise is enough? Are we sending the right message? NZMJ202;115:111-113 3-6 MET’s is not the cut off for benefit • Kokkinos P, et al. Exercise capacity and mortality in black and white men. Circulation 2008:117: 614-622 in fact mortality rates reduced by 70% for those achieving >10 METS P<0.001

  40. How are we doing? • The Green Script Swinburn B, et al. The Green Prescription study: a randomised controlled trial of written exercise advice provided by general practitioners. Am J Pub Health 1998 Feb: 88(2):288-91 Gribben B et al. The early experience of general practitioners using a Green Prescription. NZMJ 2000:113:372-3 Elley C, Dean S, Kerse N. Physical activity promotion in general practice: patient attitudes. Aus Fam Phys 2007: 36 (12): 1061-1064 Elley C, et al. Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial. BMJ 2003: 326: 796-798 • 1999 Newcastle Kerse report - 51% GP’s prescribing Green Script but • 2006 - 13% and only 3% Rx’ing • How are we as a group doing?

  41. What are the barriers to meeting the guidelines? • Tools • Knowledge • Patient/doctor relationship and…. • TIME!

  42. Barrier Tools

  43. * 1-RM Tests * 1RM Bench Press * 1 km Run (IPFT) * 1 Mile Walk Test * 10m Beep Test * 1.6 km (1 mile) Run * 1.5 mile run test (PRT) * 2 Hop Jump * 2-Mile Run (APFT) * 3 km Run * 3-Mile Run (PFT) * 5 km Run * 3/4 court sprint * 3-Cone Drill (NFL) * 3 Hop test * 6 minute run * 20 meter Shuttle Run Test (beep, bleep) * 20m Miller Run Test * 20 Yard Agility * 30-15 Intermittent Fitness Test * 30-second Wingate test * 300 meter run * 20 Yard Agility * 30-15 Intermittent Fitness Test * 30-second Wingate test * 300 meter run * 30-second Wingate test * 300 meter run * 400m run test * 300-yard Shuttle * 505 Agility Test * 800m Run Test * 90/90 (AKE) hamstring test * Abalakov Jump (ABK) - Bosco * Abdominal Curl - NCF * Abdominal Endurance Tests * Abdominal Strength Test (7 Stage) * Abdominal Strength Test (4 Level) * Ab Strength Test - straight leg * Aero Test * Agility - AAHPERD for seniors * Agility Test for AFL * Air-Displacement Plethysmography * Allergy Testing * Alternate hand wall toss test Barrier - knowledgeFrom http://www.topendsports.com/List of all Tests (alphabetical)

  44. Barrier - knowledge, basic concepts • Met • VO2 Max • PA testing - subjective/patient report -eg validated questionnaires - objective - pedometers, accelerometers • Fitness testing - Assessments of MET/ VO2 max - many tests available • Heart rate recovery, heart rate variability

  45. Barriers- Time • Calculation on time to implement GP exercise prescriptions. • Swinburn B, et al. Green Prescriptions: attitudes and perceptions of general practitioners towards prescribing exercise. Brit J of Gen Prac 1997:47,567-569

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