30 Dec, 13 | by Toby Hillman
Exercise is good for you – but then we sort of know that already – The Earl of Derby had it right back in 1873 pointing out that
‘Those who think they have not time for bodily exercise will sooner or later have to find time for illness.’
Take a look at this brilliant animation if you are in any doubt:
But, what about when you get a bit older – (over 65 to be precise)? A paper in the January issue of the PMJ (Editor’s Choice so it is free!) has examined the current recommendations for physical activity in older adults (over 65), looks at the measurement of physical activity (in trials self-reported activity doesn’t seem to have the same benefits as objectively measured physical activity) and how to increase participation in exercise.
The conclusion is that yes, there are clear health benefits associated with physical activity in the over 65s, but also that there is a rapid drop-off in participation – 20% of men and 17% of women aged 65-74 managed the recommended amount and in the over 75s this dropped to 9% and 6% respectively . The key barriers to participation in physical activity were ill-health, pain and injury.
The section of this review which caught my eye was the section on the importance of the physician when considering physical activity.
How important is it that physicians give these messages? The review highlights some evidence that GPs can have a positive impact on participation in physical activity – simply giving advice can have an impact. If that advice is tailored to the individual, and backed up with follow up from exercise professionals, then there is a positive benefit on uptake of physical activity – and perhaps more importantly, on hospitalisations in the subsequent 12 months.
Along with dietary modification, medication adherence, and smoking cessation, physical activity is another domain to be added to the growing list of behavioural changes which doctors of all types are now expected to facilitate. But are we any good at it? The evidence presented shows that actually mentioning the subject of concern is important ( for 38% of older adults in one study had no mention of exercise in consultations) but are we equipped to truly impact on the health behaviours of the patients we meet?
Often messages about health are from the perspective of the doctor, and we encourage patients to adopt behaviours which will deliver outcomes we are interested in (this paper examines diabetes care in this light) Perhaps unsurprisingly, patients often don’t appreciate their problems from the point of view of a national audit or a QoF point counter. Patients tend to be more interested in outcomes which directly affect them. Even framing problems correctly may not be enough.
So what to do – simply repeating ourselves doesn’t seem to be that logical, so a different approach is required.
At a recent conference one of my colleagues asked a brief but powerful series of questions:
How many of you advise your patients to stop smoking?
How many of you prescribe smoking cessation medications?
How many of you have had training in motivational interviewing or behavioural change?
The answers were telling – the first two questions revealed a forest of hands – the third could barely summon up a shrubbery of positive responses…
As doctors, we are trained to understand pathological processes, to diagnose diseases, and prescribe drugs. Communication skills have come to the fore in training of late, but tend to be based on how to deliver a traditional message in a more palatable form.
To be truly effective agents of behavioural change, we need to acquire new skills. Our current skills tend to achieve adherence to medication regimes in the order of 50% (see a paper here on this) The precise way forward is still debatable (this review looks at motivational interviewing for physical health) but will undoubtedly draw those of us who care for physical health problems closer and closer to psychological interventions – perhaps it is us physicians who really need to engage in a bit of behaviour change… perhaps a good resolution for the new year?