You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Let’s get physical! It’s ‘Physical activity for life’ today on World Physiotherapy Day 2017

8 Sep, 17 | by atarazia

The Physical Activity and Population Health BJSM Blog Series 

By Sonia Cheng (@soniawmcheng)

Today, September 8 is none other than World Physiotherapy Day, and this year the World Confederation of Physical Therapy (WCPT) is celebrating the profession with the message ‘Physical activity for life’. This message builds on the World Health Organisation’s call for global efforts to reduce physical inactivity by 10% by 2025, and highlights the critical role played by physiotherapists in keeping people active.

Emma Stokes, President of the World Confederation for Physical Therapy, lends us her thoughts on how the physiotherapy profession can promote physical activity through the years and in the wider community.

Sonia Cheng (SC): Emma, we used to think that increasing physical activity was just a matter of “If you can move more, you will move more”. Then both clinical trials and clinical experience started to show us that you could not simply address pain, dyspnoea, or impairments in strength and mobility in isolation. Physical activity is a behaviour, and it is a complex behaviour. How do physiotherapists start to tackle this issue in everyday practice?

Emma Stokes (ES): Regardless of the reason why a person attends a physiotherapist, it represents an opportunity to have a conversation about physical activity. It’s important to be curious about how that person is meeting physical activity recommendations.

SC: Do you think it should become standard care for physiotherapists to set activity goals with their patients with respect to minutes of moderate-vigorous intensity physical activity per week, for example, or steps per day?

ES: It’s not necessarily about being prescriptive about practice, it’s more about raising awareness and exploring solutions to promote healthy levels of exercise and activity. This is a key responsibility for us as a profession as we respond to the challenges facing our communities in living active and healthy lives.

SC: What are some of the steps we can take as a profession to address physical inactivity on a population scale?

ES: World Physiotherapy Day 2017 is one component of the rich tapestry of solutions needed to promote physical activity across the lifespan and in all communities. As part of this year’s theme, the WCPT has a wonderful range of educational resources about the health benefits of physical activity. We also unpack the concept of metabolic equivalents (METs), and try to give examples of how different activities at different intensities can be combined over the course of a week to reach health-enhancing physical activity levels.

SC: How else can we get involved on our special day?

ES: Physiotherapists around the world can organise events in their workplaces and communities to promote “Physical activity for life”. We also come together on social media – last year, we had a rolling tweetchat across the twenty-four hours and three different time zones. See what celebrations and events have been organised in the past. The challenges of enhancing physical activity are enormous, and the solutions will require multifarious collaboration and coordination. World Physiotherapy Day is just one way the global physiotherapy community can come together to advocate for and celebrate our role in promoting health.

Well, you heard Dr Stokes. Get physical on September 8: discuss the physical activity guidelines with your patients and clients, put up posters in your workplace, check out the WCPT toolkit for some great resources about moving more and moving better.

Happy World Physiotherapy Day to all!

We invite you to share and support the Physical Activity and Population Health BJSM Blog Series. Join the conversation on ‘how change happens’ at #PAblogBJSM and #brightspotsBJSM.

If you have ideas for this series please contact:

Sonia Cheng graduated from The University of Sydney with a Bachelor of Applied Sciences (Physiotherapy) (Honours Class I) in 2014. Sonia is currently employed as a physiotherapist with Royal Prince Alfred Hospital and Westmead Hospital in Sydney. 

One small step for a human, and a giant leap for humankind

16 Aug, 17 | by atarazia

Introducing the Physical Activity and Population Health BJSM Blog Series 

By Sonia Cheng (@soniawmcheng)

As you’ve likely read from these previous posts on the BJSM blog, the case to increase population-wide participation in physical activity is stronger than ever. And, like the unsung space heroes at NASA, who crunched the numbers and successfully launched humans into orbit and to the moon1, we as health professionals, researchers, and students play a pivotal role in developing and implementing strategies to address one of the leading risk factors for chronic disease and disability worldwide.

It is an honour to launch the new ‘Physical Activity and Population Health’  BJSM Blog Series. Throughout this series, we’ll bring to you the latest developments in physical activity research, resources, and policy in the area of public health – a small step to raise awareness, discussion, and action amongst researchers and clinicians to address a major health priority.

Some vital stats

The statistics related to physical inactivity are not new to us, but still shocking. Physical inactivity is a key risk factor for non-communicable disease (NCDs) – including cardiovascular disease, type 2 diabetes, cancers, respiratory disease, dementia, and poor mental health. This places it as the fourth leading cause of global mortality, contributing to over five million preventable deaths each year2.

However, physical inactivity is also one of the key modifiable risk factors for NCDs, and the health benefits of regular physical activityare evident across the lifespan (click here for current PA recommendations). Maintaining regular physical activity levels helps to (1) promote growth and development in children and young adults, (2) prevent weight gain in mid-life, and (3) maintain independence and quality of life in older adults and in those living with chronic disease3.

Yet, despite high-quality evidence to implement effective strategies, global efforts to reduce physical inactivity have not been sufficient. It is estimated that one in three adults and more than 80% of adolescents do not meet current physical activity recommendations4.

The call to action

Increasing physical activity at a population level requires a whole-of-community approach. We need to effectively implement our knowledge through policy and practice changes in healthcare delivery, education, environment, infrastructure and media. We need to support individuals and communities to be physically active every day in ways that are enjoyable, accessible, and safe in this highly urbanised and digitalised world of ours. We need to advocate for the development, financing and implementation of evidence-informed national plans so that all countries can achieve the World Health Organisation global target to reduce physical inactivity in children and adults by 10% by 20255.These key messages have been distilled into a seven-point plan developed by the International Society for Physical Activity and Health (ISPAH) in 2012, ‘Best Investments for Physical Activity – What Works’6 and the infographic is published here7.

The Physical Activity and Population Health’ BJSM Blog series supplements the brand new BJSM Editorial articles Bright Spots, Physical Activity Investments that Work Jointly8 that feature exciting and novel physical activity programmes from around the globe. Expect both series to keep you updated on research, policy, education, and practice developments in increasing population levels of physical activity.

We invite you to share and support the Physical Activity and Population Health BJSM Blog Series. Join the conversation on ‘how change happens’ at #PAblogBJSM and #brightspotsBJSM.

If you have ideas for this series please contact:

Sonia Cheng graduated from The University of Sydney with a Bachelor of Applied Sciences (Physiotherapy) (Honours Class I) in 2014. Sonia is currently employed as a physiotherapist with Royal Prince Alfred Hospital and Westmead Hospital in Sydney. 


  1. The True Story of ‘Hidden Figures’ and the Women Who Crunched the Numbers for Nasa
  2. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219-29.
  3. World Health Organisation. Interventions on Diet and Physical Activity What Works? Summary Report Geneva, Switzerland: World Health Organization; 2009.
  4. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. The Lancet 2012;380(9838):247-57.
  5. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020. Geneva, Switzerland: World Health Organization; 2013.
  6. Investments that Work for Physical Activity. Br J Sports Med. 2012;46:709-712.
  7. Best Investments for Physical Activity – What Works
  8. Stamatakis E, Murray A Launch of new series: Bright Spots, Physical Activity Investments that Work Br J Sports Med Published Online First: 29 June 2017. doi: 10.1136/bjsports-2017-098096


Faculty of Sports and Exercise Medicine Annual Scientific Conference, September 2017 “Exercise Medicine and Physical Activity for Health”

9 Aug, 17 | by BJSM


This years Faculty of Sports and Exercise Medicine Annual Scientific Conference promises yet again to be a highlight of the international sports medicine calendar. The conference will focus on “Exercise Medicine and Physical Activity for Health” and takes place on the 15th and 16th of September in the Royal College of Surgeons in Ireland (RCSI), Dublin.

Delegates are welcomed from all healthcare backgrounds to this multidisciplinary conference where the Faculty of Sports and Exercise Medicine teams up with colleagues from the Irish Society of Chartered Physiotherapists (ISCP) and Athletic Rehabilitation Therapy Ireland (ARTI).

The conference which takes place over 2 days will include national and international keynote speakers:

  • Prof Donal O’Shea, Consultant Endocinologist and leading clinican and researcher on obesity will discuss the role of exercise in contemporary medicine and population health.
  • Prof Ulf Ekelund, Professor in Physical Activity Epidemiology from the Norwegian School of Sports Science will discuss if sitting is the new smoking.
  • Prof Paul Thompson, Chief of Cardiology and The Athletes’ Heart Program at Hartford Hospital, professor of medicine at the University of Connecticut (USA) and past president of the American College of Sports Medicine, will debate how we prevent sudden cardiac death in athletes and also if there are deleterious effects of too much exercise.

Experts in the field will lead thematic sessions over the two days. On day 1 themes include exercise in chronic, cardiac and respiratory disease as well as mental health. On day 2, topics include the role of exercise in prehabilitation and rehabilitation as well as innovations in exercise science.

Delegates will also be able to attend a number of dedicated delegate scentific sessions under the following themes:

  • Exercise Medicine
  • Exercise and Population Health
  • Exercise in Rehabilitation and Treatment
  • Sports and Exercise Science

Register online for the conference with discounted rates for full-time post graduate students. The conference is approved by FSEM for 12 external CPD credits.

Log on for further information and registration details:

We look forward to seeing you there!

Dr Nick Mahony (FSEM Vice-Dean), Prof Niall Moyna (FSEM Board Member) and Dr Ronan Kearney (FSEM Associate Member)

New (free, online) course highlights the importance of physical activity in healthcare services

1 Feb, 17 | by BJSM

  • NEW Exercise and Health course by Peoples-uni, pulls together a set of presentations developed by an international team of experts, led by Ann Gates, CEO of Exercise Works
  • The program contains data from different countries and encourages students to perform interventions to increase physical activity locally and/or nationally.

Peoples-uni, the UK-based charity focused on providing affordable education in Public Health, recently debuted its new short online course, Exercise and Health: The course is based on a set of world class presentations prepared by an international team of experts in exercise and health, led by Ann Gates, CEO of Exercise Works and a member of the World Heart Federation Emerging Leaders Programme. This organization is dedicated to leading the global fight against cardiovascular disease (CVD), including heart disease and stroke and other non-communicable diseases (NCDs) with physical activity and exercise.

The course is an inter-disciplinary educational resource designed to help global healthcare professionals and community health advocates understand four important points:

  • The size of the problem of physical inactivity in populations globally
  • The role of physical inactivity in non-communicable diseases
  • The benefits of exercise in treatments and prevention
  • To encourage students and those who access the course to perform and evaluate interventions to increase physical activity in their patients at local and/or national settings.

The course contains presentations and resources made available to all undergraduate medical and health schools to use. These have been endorsed by the United Kingdom Council of Deans of Health. Data from different recognized sources such as Global Observatory for Physical Activity and the World Health Organization are also included. At the end of the course, students can earn a certificate.

Ann Gates: “We are delighted to partner with the Peoples-uni on this exciting leadership initiative to provide low and middle income health care students with access and support to the Movement for Movement campaign and educational resources. We hope that this work inspires health care professionals to help patients, communities and nations to move more, and move well!”

Professor Richard Heller from People’s-uni affirms: “We are proud and delighted to provide access to this excellent set of resources, on a topic of major public health importance, to a global audience of health professionals.”

Professor Ged Byrne, Health Education England’s Director of Education and Quality for the North confirms: “I support this initiative and look forward to the impact it will have on educating health professionals about the importance of physical activity on health. This is very relevant to Making Every Contact Count “ 

Physical exercise to address cardiovascular and other diseases

The World Health Organization (WHO) and the Institute for Health Metrics and Evaluation, identifies cardiovascular diseases (CVD) such as heart disease or stroke, as the number one cause of death around the world, and 1 in 3 deaths globally are as result of CVD, yet most premature heart disease and stroke is preventable.

Many of these NCDs relate to sedentary and physically inactive lifestyles and physical inactivity is the fourth leading risk factor for global mortality. Regular moderate intensity physical activity (walking, cycling or leisure activities) is proven to provide very significant benefits for health and wellbeing as they can reduce the risk of CVD, type 2 diabetes, colon cancer, breast cancer, and depression (WHO).

That is why physical activity promotion, or the inclusion of exercise and active lifestyles in the designing of active lives is key. Therefore, training of health professionals in the benefits of exercise on their interventions and methods is an essential part in the strategy against CVD and other diseases, and Peoples-uni has joined this initiative to promote and protect individual health through regular physical activity.

How to access the course and about People’s-uni OOC courses

The program is part of People’s-uni short Online Open Courses (OOC), a range of short courses designed for self-study, available for free in an open access site, which also offers the possibility for to earn a certificate. The OOC initiative by Peoples-uni is a simple, quick, an affordable way for health professionals, or anyone interested in, in getting more specialization in certain public health related topics, or going deep into certain areas of general interest. For more information:

About Peoples-uni

Peoples-uni is a UK-based charity dedicated to offer affordable education in Public Health. Its main mission is to contribute to improvements in the health of populations in low- to middle-income countries by building Public Health capacity via e-learning at very low cost. To do that, Peoples-uni initiative offers master-level educative programs and short Open Online Courses (OOC). Individual course module development and delivery teams have involved more than 250 volunteers from more than 40 different countries

For more information visit

About Ann Gates and the team of contributors for the resources

Ann Gates ()is a health care leader, clinical pharmacist, and exercise educationalist. She started her career as a clinical pharmacist in the NHS but quickly became interested in leadership and service planning. Ann is CEO and founder of Exercise Works but has also worked as NHS Director of Strategic Planning and as Head of Health Strategy, for Trent Strategic Health Authority, UK. She is passionate about global health, action on inequalities, and exercise medicine.

The resources were curated and authored by Ann as part of an international, collaborative health project including over 60 expert authors, health care students and educational evaluators.


World Heart Federation, fact sheet –

Not all steps are equal: Changing algorithms in wearable trackers changes outcomes

20 Jan, 17 | by BJSM

By Muaddi Alharbi, Robyn Gallagher, Lis Neubeck, Adrian Bauman, Patrick Gallagher

This blog discusses JM, a female patient recovering from a heart attack. She is just one example of many patients I have encountered who monitor and track their activity using a wearable tracker. JM shared her experiences and her disappointment that her normal walk had less activity recorded from one day to the next. Her friends at cardiac rehabilitation all noticed the same thing and had the same concerns. Fortunately, I was able to let them know that Fitbit had changed its algorithm for tracking minutes of moderate to vigorous activity and that this was the reason for the lower recorded activity levels.

What does this change in algorithm mean?

The algorithm for activity trackers has changed so that increments of moderate to vigorous activity are no longer recorded in single minutes, but in 10-minute bouts. Previously, Fitbit just counted very active minutes when calculating a user’s overall minutes, but from now on it will only count active minutes if a wearer engages in an activity for over 10 minutes. So, in practical terms this doesn’t mean much to an athlete (who believes more in the ‘no pain no gain’ approach), but to someone starting a recovery activity program the sudden change could be the difference between achieving goals and giving up. A patient exercising for 39 minutes for example would now see their activity recorded as three 10-minute bouts, not as four 10-minute bouts. Thus, the 10-minute bout threshold would need to be met with each separate exercise or physical activity session. More importantly, the change to the algorithm is more likely to affect how the device tracks the length of time the wearer spends sitting down (sedentary time). Not standing is linked to many chronic health problems, as is sitting for up to 7 or 8 hours a day – which can increase the risk of death by 5%1, 2.

Wearable activity tracking devices have sparked interest worldwide and provide a novel approach to monitoring physical activity. Data generated by these devices can be used by consumers, researchers, clinicians, and insurers to improve health and wellness. They can also help people to have better discussions with their doctor about their health. These benefits are so valuable that the National Health Service NHS ( in the United Kingdom has even announced that it will provide trackers and apps upon prescription to people with heart disease. Given their important role in managing health and wellbeing, it is not surprising that global wearable tracker sales have dramatically increased. A report showed ( 5a47b) Fitbit, the most popular brand of tracker, has sold almost 21.5 million devices worldwide with the Apple Smartwatch hot on its heels with 12 million sales.

How precise do we need activity trackers to be? This is debatable. Manufacturers can change the algorithm they are using to calculate activity at any time, and from time to time, they have made such changes. But they don’t need to tell users – and that is the problem. This can have marked effects on activity outcomes and monitoring.

Every minute matters

Wearable activity trackers provide innovative ways to monitor your physical activity in real time, with little inconvenience. Importantly activity trackers may also be an activity motivator.  Indeed, they have the potential to motivate wearers to achieve their activity goals through a combination of elements such as self-monitoring, continuous feedback on progress, the ability to set reasonable goals, access to social support, and enhanced self-confidence. But how important is the device’s tracking accuracy and encouragement for the wearer to achieve personal activity goals (e.g. number of step counts or active minutes)? This is the issue we need to debate.

A change in the algorithm will change the results. So, when Fitbit™ announced it was changing the algorithm used to track active minutes it was understandable that the wearer was left feeling very confused about what the new readings may mean. Fitbit™ explained that the new10-minute rule meant that from now on, the wearers’ active minutes may sometimes appear lower than what they were used to.  Highly active people who do a lot of physical activity over the day may regard this as only a small change that requires a relatively simple adjustment in how they monitor their daily activity. For other less active wearers, changing the algorithm may motivate them to set small goals – that is to encourage them to complete the 10-minute bout of activity.

Yet, things are not so simple for researchers and for patients recovering from a disease, where every minute of activity matters for monitoring or motivational purposes. For instance, the severity of disease for patients with heart failure is different than for patients who have not experienced heart damage such as occurs with elective coronary interventions. This can affect the patient’s personal goals for achieving the recommended accumulation of active minutes. It appears the manufacturers are not fully clear about the different ways the devices are used, or can be used. Contributing to the confusion is the fact that the manufacturers are very secretive about the algorithms they use to calculate the active minutes.

Can we trust our trackers?

Before we can trust our trackers we need research that shows the algorithms are good for accurately calculating cumulative moderate/vigorous minutes of activity and steps over the day. This will help to sharpen the accuracy of the trackers, build credibility, and to make sure the tracker algorithm supports the health experts’ recommendations for physical activity.

Studies lose precious time

Research is being undertaken and the evidence is building on the accuracy of the algorithms being used in activity trackers. Some studies have even recommended the use of Fitbit devices in specific clinical settings to measure physical activity. For instance, Alharbi et al.3 revealed Fitbit-Flex is an accurate monitor to measure free living physical activity (i.e., step counts and minutes of moderate to vigorous physical activity) in phase III cardiac rehabilitation participants. This study clearly demonstrated Fitbit-Flex being within 20% of the acceptable validity criteria for clinical purposes to measure step counts and minutes of moderate to vigorous physical activity. However, Fitbit-Flex exceeded the acceptable validity criteria for research purposes which is within 3%3. Similarly, a study conducted in a laboratory setting showed Fitbit-One has high accuracy to measure step counts in healthy young adults, with percent relative error below 1.3% for all tested treadmill walking speeds and for multiple placements (e.g. on the hip or in the pocket)4. Therefore, when manufacturers make changes to the algorithm the evidence from these studies becomes outdated, and so reopens the question of their reliability.

Where to from here?

Change is constant in the world of health and fitness. One such change is that people are gaining more control over their lifestyles, health, and future well-being by using wearable activity monitoring devices. There is no doubt that these trackers help to achieve better health outcomes and disease reduction. But tracker manufacturers need to keep users and researchers up to date about any changes they make to the algorithms. Being informed fosters trust and strengthens connections between users and manufacturers. It also helps researchers, physicians, clinicians, healthcare systems and insurance providers to properly respond the changes and assist people to achieve their health goals.

Take home messages

  • Clinicians, patients and researchers are eager to have accurate trackers to monitor and motivate physical activity. Therefore, tracker manufacturers should ensure that the device algorithm provides a high level of accuracy similar to those of known devices such as a research-grade accelerometer (the Acti-Graph)
  • System developers and designers need to ensure open lines of communication with researchers and consumers when changing algorithms to gain their trust
  • Researchers should be mindful of the possibility that tracker manufactures may change their algorithms in the middle of a longitudinal research study without any notification. Thus, supplementary evidence of field-based performance is crucial to ensure data safety


Muaddi Alharbi is doing his PhD in activity tracking and has worked extensively with cardiac patients. You can find out more on Twitter @muad11


  1. Chau JY, Grunseit AC, Chey T, et al. Daily sitting time and all-cause mortality: a meta-analysis. PLoS One. 2013; 8: 1-14.
  2. Ekelund U, Steene-Johannessen J, Brown WJ, et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. The Lancet. 2016; 388: 1302-10.
  3. Alharbi M, Bauman A, Neubeck L and Gallagher R. Validation of Fitbit-Flex as a measure of free-living physical activity in a community-based phase III cardiac rehabilitation population. Eur J Prev Cardiol. 2016; 23: 1476-85.
  4. Takacs J, Pollock CL, Guenther JR, Bahar M, Napier C and Hunt MA. Validation of the Fitbit One activity monitor device during treadmill walking. J Sci Med Sport. 2014; 17: 496-500.

A Movement for Movement: what’s art got to do with it? A lot.

23 Oct, 16 | by BJSM

By Ann Gates @exerciseworks

The newly published “Movement for Movement” editorial (Gates et al) heralds a new era of framing and dealing with the deeply entrenched life style issues that contribute to the rise in the global burden of diseases (1). It uses physical activity as a case study and identifies areas where the physical activity community must work to build capacity and cultural practices in order to implement sustainable results (2). Overall, the editorial addresses: (i) moving forward as a community of practice, (ii) initiating action by the many, and (iii) synergising the way we work together to achieve the World Health Organization goals for physical activity.



The editorial, together with Figure 1 and the web appendix, highlight positive examples from working as a “community of practice.” They also relate principles from the Impressionist Art Movement.

The Impressionist’s way of working and achievements demonstrate disruptive innovation, and different ways of working in a community of practice to propel bottom-up change. The result, was a legacy of respect for their art and culture

Attributes of the Impressionist movement fit perfectly with the wider community approach necessary to deliver physical activity guidelines and strategies. There are 3 basic elements to a community of practice: the domain, the community,  and the practice (3). These basics deliver the desired operational outcomes. Figure 1 demonstrates concrete examples of how this could, should or would work (3).


How real is a community of practice for physical activity and are we already starting to work in this way?

The concept of a community of practice is not new. Further, examples of ways of working as a community of practice for physical activity are already distinguishing themselves:

  1. Social media is similar to the “Salon” culture of Impressionist artists, painters and patrons, as it serves as a test bed for new ideas and feedback. It provides a conduit for continuous professional development and social interest sharing. This reflects the rapid learning style of the artists and how they adapted they own techniques to create masterpieces that challenged society and the public’s perception of what constituted art. Action by physical activity advocates on social media is no different: one great “retweet or share” is rapidly adapted to real life action and further creativity!
  2. The use of massive open online courses provides the opportunity for all to garner knowledge and skills, but it is only the first step. Increasingly such open online courses can be supported (as opposed to just self-study) and especially by volunteers and enable sharing and caring through discussion forums and which is essential for PA implementation. It provides the platform for “conversations” and generates the community feedback needed to inspire participants to reflect and act differently. Further, it translates knowledge into everyday clinical practice and strategic influence. This mirrors the way in which the Impressionists developed their unique art style and mastery.
  3. By combining these new paradigms and shifting the way in which we share, learn, translate knowledge and apply skills to individuals, patients and communities, we can start to realise something special: a unique way of progressing the physical activity agenda and culture of change. The recent use of national and international infographics to convey a public health message (4) is an example of how organisations and individuals are changing the communication values of health practice.

In summary, the community of practice approach has the currency to transcend the barriers and doubters, ignore the financial politics that have prevented a societal culture of “active lives for all”, and enable a movement for movement that is truly a social, cultural –a rich movement of people who can do (5).

“A Movement for Movement” as a community of practice

So what has the art got to do with communities of practice? Perhaps Monet, describes it well: “It’s on the strength of observation and reflection that one finds a way. So we must dig and delve unceasingly”.

May we aspire to apply these community of practice principles to our own work in SEM, and disease prevention (7) – a physical activity advocacy movement that transcends (8): cultures, politics, and strategic inertia, would indeed be an impressive work of great art.

A movement for movement that can make every contact count and every influence matter for patients, communities and nations.

Let’s start painting the future together! (9)

Read the full editorial HERE.


  1. Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015 Dec;25 Suppl 3:1–72.
  2. Reis RS, Salvo D, Ogilvie D, Lambert EV, Goenka S, Brownson RC. Scaling up physical activity interventions worldwide: stepping up to larger and smarter approaches to get people moving. The Lancet [Internet]. 2016 Jul [cited 2016 Aug 11]; Available from:
  3. Wenger-Trayner E, Wenger-Trayner B. Introduction to communities of practice [Internet]. 2015 [cited 2016 Aug 11]. Available from:
  4. Infographics: Infographic. Make physical activity a part of daily life at all stages in life. Ann B Gates, AD Murray. Br J Sports Med bjsports-2016-096643Published Online First: 29 July 2016doi:10.1136/bjsports-2016-096643
  5. Andersen LB, Mota J, Di Pietro L. Update on the global pandemic of physical inactivity. The Lancet [Internet]. 2016 Jul [cited 2016 Aug 11]; Available from:
  6. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015 Aug;386(9995):743–800.
  7. le May A. Communities of Practice in Health and Social Care. Oxford: John Wiley & Sons; 2009.
  8. Wenger E. Communities of Practice: Learning, Meaning, And Identity. New Ed edition. Cambridge, U.K.; New York, N.Y.: Cambridge University Press; 2000.
  9. Ganz M. In: Nohria N, Khurana R, editors. Handbook of Leadership Theory and Practice: A Harvard Business School Centennial. Boston, Mass: Harvard Business School Press; 2010.


Ann Gates is a Member of the World Heart Federation Emerging Leaders Programme, Associate Editor of The British Journal of Sport and Exercise Medicine, and CEO of Exercise Works! She is passionate and interested in cultures and art.

#MakeYourDayHarder campaign launch: who, what, when, where, and why?

10 Jun, 15 | by BJSM

By Dr. Mike Evans


What: on June 11 we are launching #MakeYourDayHarder campaign where people make their day harder (get off a stop early, park at the back of lot, take stairs, have a walking meeting, ride, walk to lunch, etc..) and then share +/- pic/video on social media (twitter, FB, instagram) with the #MakeYourDayHarder hashtag.

Why: see below (PA=Physical Activity). The black line is sedentary time.

sedentary time

Sitting disease has become an independent risk factor for poor health outcomes. People who are active but sit all day have worse outcomes. Read about the evidence HERE. Also, read the consensus statement and guidelines – recently published in the BJSM – geared at sedentary office workers.

What it’s not: this is not about workouts, sports etc.., its about working activity into your average day. Sidney Crosby is not our hero. The guy/gal who take the stairs while everybody else is escalating.

Who: An Olympian/Doctor (@JaneSThornton), a design agency (@pivoting), a patient engagement star (@emily_Nicholas8) and me (@docmikeevans) (and you). We don’t have any funding. We are just doing this to see if we can start to make a little social nudge towards more activity in our days. Kind of an experiment to see if we can start changing the culture of easy.

Website: Launching this week and will summarize science about both sitting disease and challenges (i have arthritis, i am too tired, too busy, etc..)

Want more info? This less than 4 minute video explains the plan:

Not enough? Here’s theWhiteboard explaining the science:

The launch: You can soft launch anytime (i.e. tweet #MakeYourDayHarder about something today) or join us virtually or in person at hard launch on june 11.  I am giving a speech that day at the YMCA on “The Better Life Experiment at 6 pm to launch.

We need you to help us spread the word, and share your pics, videos, and tweets.


Doctors’ role in physical activity adherence: how can we keep patients on the road to better health?

1 May, 15 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Steffan Griffin (@lifestylemedic)

So your patient saw Mike Evans’ 23.5 hours video and s/he understands that physical activity is the polypill that will maximise their chances of living a healthy life (Also see this blog de-bunking physical activity myths). They even started walking for 10 minute periods three times a day. But that was twelve weeks ago and it’s since started getting dark earlier and their daughter has started another after-school class, which further limits their spare time. Is physical activity still a priority or will the habit gently dissolve?

We all know patients who have a yo-yo relationship with physical activity, but what can we do to try and facilitate a sustainable change? In these individuals, how can we maximise the chances of adherence to a physical activity pledge/programme? This blog adresses the evidence relating to certain interventions and techniques proposed to affect adherence. It also provides some top tips to use in practice.

Why is adherence important?

Long-term adherence to physical activity is essential for the maintenance of health benefits. It has a long-term survival benefit¹, and is linked to greater fitness improvements and disease-specific outcomes as well as increased physical function and quality of life². Yet as you know, around 50% will drop out of a PA programme within a few months³.

Who is most likely to drop-out?

Essentially, exactly the population we want to get and keep active! Demographic risk factors for low adherence include older age, female gender, non-white ethnicity and low socio-economic status. Couple this with pre-existing chronic disease and/or lower physical function and weight issues and you’ve found your perfect recipe⁴ for a yo-yoer.

How can we keep these patients on the straight and narrow?

As Jorgen Jevre stated in relation to lower back pain in his recent fantastic BJSM blog, there is no golden ticket in medicine, and this especially true in trying to get and keep patients being physically active. So after assessing your patient’s activity levels, what can you do in the time you have left with your patients?

Tip 1: Inform,,

  • mamilHow can being active benefit them?
  • What counts as activity?

Physical activity doesn’t have to mean becoming a MAMIL (middle age man in lycra).



What does/did the patient enjoy? Enjoyment is a good indicator of long-term behaviour change.

Tip 2: Be #SMART,,

Goal-setting is a good way to increase adherence. Make goals Specific (Who, What, Where, When, Why?), Measurable, Attainable, Realistic and Temporal (setting subsequent shorter term goals is better than one huge longer-term one).

Tip 3: #SmashThroughBarriers,,

Identify the barriers and strategise on how they can be overcome. Teach the patient how to use this approach by themselves too.

Tip 4: #TeamEffort

Suggest that the patient involves those around them in their goals. Is group activity more suitable/realistic? Social support increases the connectedness to the activity and is more likely to lead to internalised behaviours,,, the ‘golden snitch’ of health psychology.

Tip 5: MI (not the MI you’re thinking about)

Motivational Interviewing is a patient-centred form of discussion used to strengthen an individual’s motivation for a specific goal by exploring the person’s own reasons for change⁷. It may sound a bit hippy, but you can’t argue with the fact that 80% of relevant studies report that MI outperforms traditional advice-giving⁸.


Essentially, instead of adopting an expert position, the goal is to guide the patient towards directing themselves as to why/how they might increase their PA. Whilst you provide information (with permission!), the key objective is to elicit some form of patient-based change-talk.

Step 1: Engage with the patient and establish an agreed focus for the conversation

Step 2: Evoke the patient’s own motivation to change, followed by planning if the person is ready for this.

Dr Brian Johnson provides a great overview and video examples of good practice in the fantastic ‘Motivate 2 Move’ module. This document also provides a fantastic example of using MI to increase PA.

How can I summarise these tips?

The ultimate goal for long term adherence is facilitate the internalization of the desired behaviours in patients. Deci and Ryan’s⁹ self-determination theory essentially deals with this, claiming that our inherent propensity for personal development and wellbeing are governed by a few basic pscychological needs:

  • Autonomy: the degree of personal control/choice in the matter
  • Competence: the degree of proficiency related to a certain behaviour, task or skill
  • Relatedness: the degree to which we feel connected to the behaviour in question

Focusing on each factor¹⁰

Autonomy: take the perspective of the client/patient, support their choices, minimise pressure

Competence: be realistic, limit negative feedback, provide optimally challenging goals

Relatedness: create an empathetic and positive environment

If you use these as the clinical framework to increase and maintain adherence in your patients, be it regarding physical activity or otherwise (diet, smoking, alcohol etc) and utilise the MI techniques, you will hopefully find that your patients are much better at sticking to the right path.


1. Morey MC, Pieper CF, Crowley GM, Sullivan RJ, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults [comment]. J Am Geriatr Soc. 2002;50(12):1929–1933

2. Belza B, Topolski T, Kinne S, Patrick DL, Ramsey SD. Does adherence make a difference? Results from a community-based aquatic exercise program. Nurs Res. 2002;51(5):285–291.

3. Dishman RK. Overview. In: Dishman RK, ed. Exercise adherence: It’s impact on public health. Champaign, IL: Human Kinetics; 1988.

4. Allen, Kelli, and Miriam C. Morey. “Physical activity and adherence.” Improving Patient Treatment Adherence. Springer New York, 2010. 9-38.

5. Rejeski WJ, Brawley LR, Ambrosius WT, et al. Older adults with chronic disease: benefits of group-mediated counseling in the promotion of physically active lifestyles. Health Psychol. 2003;22(4):414–423

6. The Writing Group for the Activity Counseling Trial Research Group. Effects of physical activity counseling in primary care: the activity counseling trial: a randomized controlled trial. JAMA. 2001;286: 677–687.

7. What is motivational interviewing? Motivational Interviewing Network of Trainers (MINT) (Accessed 04/02/2015)

8. Rubak S, Sandback A, Lauritzen T, Chitensen B. Motivational interviewing: a systemic review and meta-analysis. British Journal of General Practitioners. 2005;55(513):305-312.

9. Ryan, R. and Deci, E. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist. 2000; 55, pp. 68-78.

10. Teixeira PJ, Carraca EV, Markland D, Silva MN, Ryan RM. Exercise, physical activity, and self-determination theory: a systematic review. Int J Behav Nutr Phys Act. 2012;9:78.


Steffan Griffin is a third year medical student at the University of Birmingham currently intercalating at Cardiff Metropolitan University in Sports Science. As an ambassador for Move.Eat.Treat and the president of the Birmingham University Sport and Exercise Medicine Society (BUSEMS), he is passionate about the role of exercise as a proactive healthcare tool. He is involved with the Undergraduate Sports & Exercise Medicine Society (USEMS) committee as the Conference Officer. He combines a passion for all things SEM related with an avid interest in sport, and tries to live as active a life as possible.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

The Body Matters: Massive Open Online Course (MOOC) via McGill University, Canada.

3 Mar, 15 | by Karim Khan

MOOCTo all 23,000+ participants in Body Matters, the Massive Open Online Course (MOOC), congratulations on a wise choice and thanks for asking a BJSM opinion. What a great set of lectures to open the course! Kudos to Professor Ian Shrier and McGill University.

For those not privy to the MOOC, the class posed this question. ‘Is there anything to the idea that exercising way over the minimum requirement has harmful effects? Assuming no injuries etc. are people who run ultramarathon distances doing more harm than someone who puts in 150 minutes per week?’

No-one has all the answers so I plan to make 5 comments to stimulate more discussion. And remember, it’s a safe place to disagree.

1. 150 minutes per week is a minimum – it represents 22 minutes a day! These 22 minutes are the most valuable in your day to promote health. Interestingly, a recent BMJ Analysis paper (not open access) and podcast (open access) suggested that this was too much – a ‘stretch goal’ as it were. Really? I was shocked! Isn’t 22 minutes equal to one minute per hour? OK – let’s say you have narcolepsy (no offence) – then 22 minutes is 2 minutes every hour of the 11 hours you are awake. Too much? Wow!! Listen here and make up your own mind. Of course one could argue that public health advice should be based on the data. In that case one wouldn’t negotiate the minutes depending on what might be palatable. You might want to discuss this in your MOOC.

2. Would it be more palatable to call the ‘150 minutes a week’ just 23.5 hours of sitting and lying a day? ‘Look, you can sit around, watch TV, lie on a floating device in a massive Caribbean hotel pool, get hours of massage and spa treatment, sleep, but try to limit that to 23.5 hours a day, OK?’ Seem unrealistic? Impossible? Many of you will be familiar with this idea – as popularized (‘viralized’?) by the indomitable Canadian doctor – Mike Evans (@DocMikeEvans). Is he a guest professor in this MOOC? Watch the 23.5 hours YouTube video here. I would DEMAND that your professor, Ian Shrier, gets Dr Mike on board! When the class has 23,000 votes you should be able to beat a professor into submission. Please don’t take that literally.

3. Doses beyond 150 minutes per week. Is 60 minutes the magic number?

Do you drive the worst car possible? The bare minimum to get from A to B. Do you have the worst possible accommodation and food? Just to survive? Unfortunately, that’s all many people can afford to do. But many others are in a position to upgrade beyond basic food, shelter and transport. They are prepared to pay for what they perceive as value.

The bare minimum of physical activity is 22 minutes a day – 150 minutes per week. That is an appropriate public health guideline and the correct focus for the committees that made these recommendations. The most bang for very little buck. However, the evidence is very clear that an additional 30 minutes a day of physical activity (let’s call it 60 minutes in total for convenience) brings substantial additional benefit. This will prevent cardiac disease, cancers and dementia. My favourite paper capturing this is by the quietly spoken Professor Ken Powell in partnership with – you guessed it – Steven Blair. I’ve reproduced the key graph here.







On the vertical axis, ‘Relative Risk’ of 1.0 represents risk of many chronic conditions in the setting of physical inactivity (first column, 0 minutes of physical activity daily). On the horizontal axis, you can see how various doses of physical activity reduce the risk of diseases. Move one bar to the right, and notice that at 30 minutes of physical activity daily (‘150 minutes a week’) there is a Relative Risk of 0.7 (compared with 1.0) which represents a 30% reduction in risk of disease. Moving further along to the right, 60 minutes of physical activity a day provides a Relative Risk of 0.5, a 50% reduction in major diseases.

Can you imagine the popularity of a drug if one were to provide such benefits? Would you want to take one pill (30% risk reduction – 22 minutes a day?) or would you sneak a 2nd pill when the supervisor was distracted on Facebook (this would give you a 50% reduction in risk of major diseases).

If you were not already aware of this, then you have learned something very practical in this course – you can reduce your risk of the major killers grouped as ‘non-communicable diseases’ by an additional 20% just by building an extra 30 minutes of physical activity into your day. Walking is fine – no lycra required. 10 minute bouts are fine – you learned that on Monday.

Two points to go – what about long distance running/ultramarathons – safe or harmful? I’ll share some thoughts about (4) running and the risk of osteoarthritis, and (5) many many marathons and the heart.

But not today. I’m choosing to boost my physical activity dose from 30 minutes to 60 minutes by riding home from work. I’ll answer the rest of the question tomorrow, all being well.

Karim Khan (@BJSM_BMJ)
One of the 3 lead editors at the BJSM – along with Babette Pluim (@DocPluim) and Jill Cook (@ProfJillCook).

Map of where participants in the MOOC are based

Map of where participants in the MOOC are based


Why Physical Inactivity is the Cinderella of non-communicable diseases: 8 common myths de-bunked

4 Feb, 15 | by BJSM

By Thea Franke and Christina Thiele

Originally published on the Centre for Hip Health and Mobility’s blog (Follow: @Mobility_Health)

Much like Cinderella, physical inactivity goes under-recognized and largely under-appreciated. Bull and Bauman (2011) state that physical inactivity receives a “poverty of policy attention and resourcing proportionate to its importance.”

Addressing physical inactivity needs to be a global public health top-priority. Physical inactivity is the fourth leading risk factor for preventable non-communicable diseases, “preceded only by tobacco use, hypertension, and high blood glucose levels, and accounting for more than 3 million preventable deaths globally in 2010.” (Bull & Bauman, 2011)

ABauman_CHHM-cReturning to the Cinderella analogy, who in the public health realm are the ugly stepsisters keeping Cinderella out of the limelight? How can we enable everyone to play a role as physical activity’s Prince Charming?

Stemming from an engaging recent talk with Professor Adrian Bauman at the Centre for Hip Health and Mobility, we highlight the common myths that contribute to physical inactivity’s treatment as the Cinderella of non-communicable diseases.

Myth #1
The strength of evidence of physical inactivity’s impact on health outcomes is relatively new and not fully accepted.

We’ve had epidemiologic evidence on physical activity, inactivity and health since 1953 (Morris, Lancet). Not only that but 20 years ago Morris described physical activity as the “best buy in public health”.

Myth #2
There is a lack of consensus-based guidelines on how much activity is needed for disease prevention.

We’ve had excellent physical activity guidelines for 13 years (Australia 1999, rev 2012); elsewhere, Global PA guidelines, WHO 2010.

Myth #3
Physical activity is not understood or identified as a discrete risk, because it is a behaviour embedded within everyday life.

In reality physical activity is defined as all large muscle-related bodily movement” (Caspersen, Powell, & Christenson, 1985) and can take on different meanings depending on your cultural and socioeconomic context. In low- and middle-income countries it can mean your daily activities, in other settings it can mean “sports activity”. Clearer communications about “physical activity for health” can be helpful here.

Myth #4
Physical inactivity cannot be measured reliably to provide valid estimates of risk.

Physical activity measures are well established in research (and have been for some time). (Taylor, 2014).

Myth #5
Physical inactivity is not recognized as a problem for low- and middle-income countries.

Low and middle income countries are increasingly affected by inactivity especially due to urbanization and economic growth.

Myth #6
Population-wide levels of participation in physical activity cannot be changed.

Emerging evidence shows that physical inactivity is difficult to change but not impossible as emerging evidence has shown (Pratt et al., 2014). Although complex, multi-sectoral approaches are needed and possible, plus we cannot afford to NOT fix it.

The physical activity community must communicate consistently that there is sufficient evidence to act. In 2011 an economic review of physical activity NCD Prevention: Investments That Work for Physical Activity identifies specific interventions, which are supported by evidence, and is available here.

Myth #7
Lack of “ownership” of the problem and control of the relevant solutions by any single government ministry requires integrated action and partnerships beyond the health sector.

At the individual, societal and political levels we share a responsibility for advocating for change and promoting physical activity as a way to prevent death.

Myth #8
There are insufficient use of advocacy and communications strategies to make a strong and convincing case for the importance of physical activity.

Understanding of the overwhelming burden physical inactivity has on population health is increasing. In accordance, NGO advocacy and improved strategic communication has been on the rise in the past 3 – 4 years.

In Conclusion
Sure, the causes of physical inactivity are more complex than just two ugly stepsisters. But with increased advocacy and support from national and provincial governments to create tailored on-the-ground, evidence-based strategies, action from professionals across disciplines, and individuals that serve as examples and daily champions, there are many opportunities for us to collectively save Cinderella so she can live an active life in good health.

Read Bauman’s article: Physical Inactivity: The “Cinderella” Risk Factor for Non-communicable Disease Prevention

Or this related BJSM Material

*NEW* Gates A. 2015. Training tomorrow’s doctors, in exercise medicine, for tomorrow’s patients (Online only) bjsports-2014-094442.

Bull F. 2012. NON COMMUNICABLE DISEASE PREVENTION: Investments that work for physical activity. BJSM 46:709-712.

 Bauman A, Titze S, Rissel Cand Oja P. 2011. Changing gears: bicycling as the panacea for physical inactivity? BJSM 45:761-762. (Free online!)

Hellenius M, Sundberg C. 2011. Physical activity as medicine: time to translate evidence into clinical practice. BJSM, 45:158.

Blair SN. 2009. Physical inactivity: the biggest public health problem of the 21st century. 43:1-2.

Owen N, Salmon J, Koohsari M. 2014 Sedentary behaviour and health: mapping environmental and social contexts to underpin chronic disease prevention. BJSM 48:174-177.

BJSM Podcast: Fit vs fat with Steven Blair

BJSM Podcast: Bob Sallis on Exericise as Medicine

About the authors

Thea Franke is a PhD student in the Interdisciplinary Program at the University of British Columbia. Her doctoral work focuses on the intersections between the built and social environment, older adults’ mobility and health. Her recent publication in The Journal of Aging Studies examined key factors that facilitated physical activity in highly active community dwelling older adults.

Christina Thiele is the award winning Communications and Community Relations Manager at the Centre for Hip Health and Mobility. She develops and implements strategic communications and community relations plans that support CHHM’s health promotion mandate.


Bull, F. C., & Bauman, A. E. (2011). Physical inactivity: the “Cinderella” risk factor for noncommunicable disease prevention. Journal of health communication, 16(sup2), 13-26.

Caspersen , C. J. , Powell , K. E. , & Christenson , G. M. ( 1985 ). Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports , 100 ( 2 ), 126 – 131.

Pratt, M., Perez, L. G., Goenka, S., Brownson, R. C., Bauman, A., Sarmiento, O. L., & Hallal, P. C. (2014). Can Population Levels of Physical Activity Be Increased? Global Evidence and Experience. Prog Cardiovasc Dis. doi: 10.1016/j.pcad.2014.09.002

Taylor, D. (2014). Physical activity is medicine for older adults. Postgraduate medical journal, 90(1059), 26-32.

BJSM blog homepage


A peer review journal for health professionals and researchers in sport and exercise medicine. Visit site

Creative Comms logo

Latest from British Journal of Sports Medicine

Latest from British Journal of Sports Medicine