Health secretary urges GPs to be “creative” in prescribing exercise

Dear Sir,

The recently announced renewed government interest in increasing the
nation’s physical activity is to be applauded. The benefits of physical
activity in preventing cardiovascular disease (CVD) have been apparent for
over half a century since the initial observation that physically active
London bus conductors were less likely to develop coronary heart disease
than their sedentary bus driver colleagues (1). Since then evidence has
continued to accumulate demonstrating that physically active men and women
reduce their risk of CVD by between one third and one half compared to
their sedentary counterparts (2). The relative risk of CVD associated
with a sedentary lifestyle is similar to that associated with cigarette
smoking, hypertension or hypercholesterolaemia (2) and clearly represents
an ideal target for CVD risk reduction in the population. However, the
capacity of physical activity interventions to prevent CVD events has yet
to be born out in outcome studies and in addition, a sustained increase in
physical activity following a brief intervention remains the holy grail.

The United Kingdom Health Development Agency in their evidence briefing
for brief interventions aimed at increasing physical activity levels (3),
concluded that at the present time there is some evidence suggesting that
a single episode of brief tailored advice with some follow-up can increase
physical activity but possibly only in the short term. Given this lack of
evidence it is unsurprising that the provision of lifestyle advice yields
few rewards in the Quality and Outcomes Framework (QOF) (4). Previous
government initiatives in primary care to increase physical activity
include ‘exercise on prescription’. A National Institute for Health and
Clinical Excellence (NICE) review found that exercise on prescription
schemes result in only short term increases in exercise levels (<_12 weeks="weeks" _5.="_5." this="this" latest="latest" initiative="initiative" seems="seems" at="at" odds="odds" with="with" the="the" department="department" of="of" healths="healths" previous="previous" advice="advice" to="to" primary="primary" care="care" trusts="trusts" _6="_6" only="only" endorse="endorse" interventions="interventions" when="when" they="they" are="are" part="part" a="a" properly="properly" designed="designed" and="and" controlled="controlled" research="research" study="study" determine="determine" effectiveness="effectiveness" as="as" recommended="recommended" by="by" nice.="nice." p="p"/>Despite much government focus on improving the health of the population in
recent years, public perceptions of what constitutes a healthy lifestyle
and which behaviours are unhealthy remain poor with between a half and two
thirds of the population citing television and magazines as their main
sources of health promotion information (7). Of those who have received
healthy lifestyle advice from primary care services, few are able to
accurately recall what they have been told (8).
Whilst there is convincing epidemiological and physiological evidence of
the cardiovascular protective effects of physical activity in adults,
disappointingly intervention studies have yet to demonstrate that
interventions designed to increase physical activity can result in a
reduction in CVD or an improvement in CVD risk factors or indeed a
sustained increase in physical activity levels. It seems unlikely
therefore, that the recently announced government recommendation to
provide brief physical activity advice in primary care will have any
meaningful benefit on the health of the population.
It may therefore be more appropriate for our elected government ministers
to implement legislative changes that coerce the population into
increasing their activity for example, banning traffic from city centres
and providing more cycle lanes, rather than handing the baton to primary
care to improve performance in European league tables, a mission in which
they will almost certainly fail.

1. Morris J, Heady J, Raffle P, Roberts C, Parks J. Coronary heart-
disease and physical activity of work. Lancet. 1953;265(6795):1053-7.

2. Gill J, Malkova D. Physical activity, fitness and cardiovascular
disease risk in adults: interactions with insulin resistance and obesity.
Clinical Science. 2006;110:409-25.

3. Hillsdon M, Foster C, Cavill N, Crombie H, Naidoo B: The
effectiveness of public health interventions for increasing physical
activity among adults: a review of reviews. 2005:1-40 London, Health
Development Agency [online] Available at;
http://www.nice.org.uk/niceMedia/pdf/physical_activity_adults_eb.pdf
(accessed 31/8/09).

4. Quality and Outcomes Framework guidance for GMS Contract 2009/10
[online] Available at;
http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContra...
(accessed 31/8/09).

5. Four commonly used methods to increase physical activity: brief
interventions in primary care, exercise referral schemes, pedometers and
community-based exercise programmes for walking and cycling. March 2006
[online] Available at; http://www.nice.org.uk/phi002 (accessed 31/8/09).

6. Department of Health statement on Exercise Referral, March 2007
[online] Available at;
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
(accessed 31/8/09).

7. Duaso M, Cheung P. Health promotion and lifestyle advice in a
general practice: what do patients think? Journal of Advanced Nursing.
2002;39(5):472-9.

8. Little P, Slocock L, Griffin S, Pillinger J. Who is targeted for
lifestyle advice? A cross-sectional survey in two general practices.
British Journal of General Practice. 1999;49(447):806-10.

Competing interests:
None declared