It makes sense to focus on interventions that make the most difference by using the number needed to treat (NNT). All of

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. QUIZQuestion 1 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: 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 20–30% 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. Question 2 What proportion of Australians aged 18–75 years do not engage in a healthy amount of physical activity? A. Three-quartersB. Almost halfC. One-quarterD. One-fifth.

4. Question 3 What were the annual direct costs attributable to physical inactivity in 2000? A. $400 000 B. $4 millionC. $40 millionD. $400 million.

5. Question 4 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: A. Eat a Mediterranean dietB. Drink one glass of red wine per dayC. Do regular physical exerciseD. Keep his triglycerides within normal limits.

6. Question 5 Which of the following groups of people report the least physical activity in their leisure time? A. People in their early 20sB. Indigenous AustraliansC. People in the highest socioeconomic groupD. School children.

7. Question 6 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? 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. Question 7 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: A. Increase his walking distanceB. Reduce his blood pressureC. Increase his cardiac functional capacityD. Increase his risk of stroke.

9. Question 8 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: A. Preventing falls B. Reversing X-ray changes in osteoarthritisC. Pain management in osteoarthritisD. Reducing the risk of osteoporosis.

10. Question 9 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: A. ProstateB. BreastC. ColonD. Endometrial.

11. Question 10 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: 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. Question 11 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: 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. Question 12 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: A. Multivitamin tablets B. Antidepressant therapy C. Cognitive behavioural therapyD. Regular physical activity.

14. Question 13 There are national guidelines on the definitions of levels of physical activity. Which of the following is FALSE? 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 puff’D. Vigorous activity includes football, netball, soccer, running, swimming laps or training for sport.

15. Question 14 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? A. Jogging for 40 minutes, 2–3 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. Question 15 You have gained Clare’s interest and she wants to know more about physical activity. Which of the following is TRUE? 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. Question 16 Clare wants to keep her two sons (aged 7 and 11 years) active. All of the following recommendations are true EXCEPT: A. Limit their time on computer games, television, the internet to <2 hours per 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. Question 17 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? 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. Question 18a 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? 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. Question 18b 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? 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. Question 19a 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: 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. Question 19b 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: A. Begins to feel hotB. Becomes thirstyC. Notices that his breathing has increased in frequencyD. Experiences chest tightness or claudication.

23. Question 20a 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, 8–10 units with lunch, depending on the carbohydrates, and 10 units with dinner).You tell Max all of the following EXCEPT: 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 12–24 hours after the exercise.

24. Question 20b 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: 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. Question 21 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: 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. Question 22 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: 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 30–50%) 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.

33. Health impact – risk of cardiovascular disease The risk of fatal and nonfatal cardiovascular events is 1.5–2 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 30–50%•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:• 30–40 % relative risk reduction in the incidence of colon cancer compared to inactive people•20–30 % 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• complicated 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.