RNZCGP conference 2011

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

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!

Whirlwind tour through medicine - acute care advances

- trauma - treatment of injuries

- surgery - infection - hygiene and antimicrobial Rx

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.

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

Health Care Crisis

• Manpower issues• Health Care spending• Chronic health epidemic• Sustainability

Health Care Crisis- ManpowerGorman 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

Health Care Crisis - Financial

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’

Diabetes ‘tsunami’

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

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.)

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.

Diet

• Decreased nutrients - more processed food.

• Increased anti-nutrients. - trans-fats - sugar - fructose - chemicals

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. [email protected]• 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.

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. [email protected]

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.

Sugar

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.

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

Physical activity

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.

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 > 95th centile• But only 1% of children between the 81st and 94th centile

• Met synd was present in 18% of those in lowest 25th centile for fitness• But only 1.8% of children between the 26th and 74th centile and 1.2% of top 25th

centile

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

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

Older Persons HealthCampbell 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 programme of strength and balance retraining exercises in reducing falls and injuries in elderly women > 80 through 17 General practices in DunedinNumber of falls and injuries related to falls and time between falls during one year of follow upResults:After one year there were 152 falls in the control group and 88 falls in the exercise group.

Morris 1953

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

Smoke - its safer than watching TV!

Males and Females Females0

5

10

15

20

25

InactivitySmoking

Fit but a bit podgy

Men 20-22.5 Men

22.5-25 Women 20-22.5 Women

22.5-25

0%

20%

40%

60%

80%

100%

120%

140%

CholesterolHigh Blood PressureDiabetes

Just a thought

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

Breast Cancer Survival

• 24-67% Reduction in all total deaths• 50-53% Reduction breast cancer deaths

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?

Evolution…

2011

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’?

Working on a supply versus demand model….

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

Enrico Coiera Coiera E. 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.

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

NZ: where we’re at

1) What are our guidelines?2) Are they right?3) Are we meeting them?

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

How are we doing?

• The Green ScriptSwinburn 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):288-91Gribben B et al. The early experience of general practitioners using a Green Prescription. NZMJ 2000:113:372-3Elley C, Dean S, Kerse N. Physical activity promotion in general practice: patient attitudes. Aus Fam Phys 2007: 36 (12): 1061-1064Elley 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?

What are the barriers to meeting the guidelines?

• Tools• Knowledge• Patient/doctor relationship and….

• TIME!

Barrier Tools

Barrier - knowledge From http://www.topendsports.com/

List of all Tests (alphabetical) • * 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

http://www.topendsports.com/

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

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

Primary Care: Is there enough time for prevention? Kimberly SH et al. 2003: 93, 4: 635-641

• It would be preferable to pursue solutions that [ ] extend beyond the current model of face-to-face patient care. [ ] patient education through telephone or print or electronic media, should be explored further

Why a new system is needed

To meet guide-lines

Address increasedHealth care

costs

Address medical Manpower

Issues

Address the healthCare budget

crisis

Change of Paradigm

Improve patientswellbeing

This is a design problem• It needs to address our work flows • It needs to fit seamlessly• It needs to be based on evidence• We are also aiming for it to demonstrate- - maintenance of behavioral change - enjoyable experience! For GP and patient - produce better results for more people in less

contact time.

The 5A’s of Behavoral changegives timing, content and delivery agent• Assess - physical activity and fitness levels• Advise - possibly changes/guidelines• Ask - check persons barriers - external and

personal and motivators - internal and external.• Assist - with resources• Arrange - follow-up Estabrooks PA, Glasgow RE. Translating effective clinic-based physical activity interventions into

practice. Am J Prev Med 2006: 31 (4S):S45-S56.

The study itself -RE-AIM to target external validity

• Reach - can it be applied across practices- will it work for the doctors and patients

• Efficacy - compatible with practice values, needs of the practice

• Adoption/promotion - must be simple and renumeration concerns addressed

• Implementation• Maintanence/Sustainability

Why IT?

83.9% of New Zealanders have an internet connection.

Minnwatt’s Marketing Group 2011

• 50% of England is on facebook!• Ipad/Tablet • Need to address the inability to provide

face-to-face prevention.

What would the pathway

look like?

Waiting roomiPad

Physical Activity Questions

Consultation.

Hx, Exam, Risks Stratification

ESTPhysical Capacity

assessment

Exercise Prescription

Next appointment

PMS

Tablet Questions

• Physical activity questionnaire

• Risk stratification questions

• MI questions

• Calculations of METS goes back into PMS with MI numbers

Scoring

• High• A separate category labelled ‘high’ can be computed to

describe higher levels of participation. The two criteria for classification as ‘high’ are:

• a) vigorous-intensity activity on at least 3 days achieving a minimum Total physical activity of at least 1500 MET-minutes/week

• OR• b) 7 or more days of any combination of walking,

moderate-intensity or vigorous-intensity activities achieving a minimum Total physical activity of at least 3000 MET-minutes/week.

Scoring• Moderate• The pattern of activity to be classified as ‘moderate’ is

either of the following criteria: • a) 3 or more days of vigorous-intensity activity of at least

20 minutes per day• OR• b) 5 or more days of moderate-intensity activity and/or

walking of at least 30 minutes per day • OR• c) 5 or more days of any combination of walking,

moderate-intensity or vigorous intensity activities achieving a minimum Total physical activity of at least 600 MET-minutes/week.

Scoring

• Low• This is the lowest level of physical activity. Those

individuals who not meet criteria for Categories 2 or 3 are considered to have a ‘low’ physical activity level.

Waiting roomiPad


Consultation.



assessment


Next appointment

PMS

Waiting roomiPad


Consultation.

Hx, Exam, Risk Stratification


assessment


Next appointment

PMS

Waiting roomiPad


Consultation.



assessment


Next appointment

PMS

Physical Capacity Assessment

• Strength/Power• Aerobic Capacity• Flexibility• Balance

• Sit Stand Test• 4m sit stand sit• 10m shuttle• 6 min walk• 12 min run• Sit reach• Grip strength

Waiting roomiPad


Consultation.



assessment


Next appointment

PMS


• PA guidelines based

• Doesn’t seem to be a plateau of effect– So it’s for everyone

• Use available resources

Waiting roomiPad


Consultation.



assessment


Next appointment

PMS

(R)Evolution…

2011

Waiting room assessment

• Medical validityGoodyear-Smith F, et al, Case finding of lifestyle and mental health disorders in primary care: validation of the ‘CHAT’ tool. Br J Gen Pract. 2008 January 1; 58(546): 26–31

• Medical tools - questionnaires• Technology - tablets that can run flash• Security/ Data storage.

Needs to be intuitive - no education sessions!

Brief intervention

• Clickable resources - info on patient, info on norms and info on tests.

• Automatic generation of intervention - 1) if safety issues - appointment request flash’s to front

desk. 2) If no safety issues - doctor over-ride - can refer as

though is issue. Appointment made. a)willing to do fitness test - appoint. request. (rest f/u by

nurse for plan) b)not willing to do fitness test - 2 sentence brief interven

and connect to support if willing.

Mediated exercise assessment

Mediated support - instruments

Sleep Cycle – Turn Your iPhone Into a Sleep-tracking Device.

http://www.fitbit.com/ the ‘fitbit’

http://www.fitbit.com/

What’s been found• If its individually tailored • Assesses patients barriers • If GP initiating gives credibility• Elley C, Dean S, Kerse N. Physical activity promotion in general practice: patient

attitudes. Aus Fam Phys 2007: 36 (12): 1061-1064

• If there are support forums (IT research)• Needs to be sensitive to personal issues• Needs to take the patient into account - - socially acceptable - psychologically acceptable - physically acceptable.

Other support

• Personal trainer• Community resources Can be covered and offered in an e-mail.

How we can personalize it

• ‘Walk around person’ • Culturally - we can have a choice of

people presenting. This person can continue on other side on e-mail support.

Would it be cost effective?• Muller-Riemenschneider F, Reinhold T, Willich SN. Cost-

effectiveness of interventions promoting physical activit. Br J Sports Med 2009 Jan: 43(1) 70-76

• Cobiac LJ, Vos T, Barendregt JJ. Cost-effectiveness of interventions to promote physical activity: a modelling study. PLoS Med 2009 Jul 14: 8(7):e1000110

• Elley R, et al. Cost-effeciveness of physical activity counselling in general practice. NZMJ 2004: 117, 1207:U12167 Programme-cost per patient was NZ170 dollars from a funder's perspective. The monthly cost-effectiveness ratio for total energy expenditure achieved was 11 dollars per kcal/kg/day. The incremental cost of converting one additional 'sedentary' adult to an 'active' state over a twelve-month period was

NZ1,756 dollars in programme costs.

Solutions for..

3)Knowledge - Contains the

knowledge

Barriers…1)Time - runs in the

Patients time

2)Tools - contains The tools

Assessment, Prescription and

support

4)Doctor/patient Relationship -notAs threatening?

Shifting paradigms - Both for patients and for

doctors

Bring scientific Track-able measures

To lifestyle factors

Designed to Address long term

maintenance

Supply side (demand)Solution for health care

crisis

Meeting guidelines by addressing the barriers 1-4, plus…

Why talk about it if we haven’t got it running yet?

• Example of gambling intervention• This is translational - to build a system for

the end users - the GP’s and their patients!

The issues! - On the patient side

• Confidentiality• Security of the data• Safety issues - during testing, and

prescribing• Medicalizing lifestyle factors.• Human face of medicine• Insurance companies - issues

The Issues - on the doctor side

• Looking after equipment (? Tablet walking out the door!)

• Our own wellness/comfort issues• Funding! - for IT ( tablets) and for program

running. • Renumeration!

The Issues - on the doctors side

• Time! - Green script = 4 patients /practice per day. We would be aiming at ?10 initially but of those needing more than 2 sentence intervention may be one - an appointment made for that.

Exercise PrescriptionWorkshop

Documents

RNZCGP conference 2011