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Let’s get physical about public health

In 2012 The Lancet published a paper that highlighted the global challenge of what it worryingly called the “pandemic of physical inactivity”. Ireland is not immune to this trend. In 2016 the Government estimated that seven-out-of-10 Irish adults do not get enough exercise and less than one in every five children are sufficiently active to achieve health benefits.

There is medical consensus around what the principal benefits are – reducing the risk of obesity, heart disease, type 2 diabetes, cancer, stroke, and depression.

Three years ago the Government launched its National Physical Activity Plan (NPAP) with a new progress report expected to be published shortly (see panel).

However, alongside large-scale public health policy documents there are a number of new initiatives to encourage doctors to make personal interventions with patients, such as the HSE’s new Making Every Contact Count programme and the growth of lifestyle medicine.

“You know ‘physician heal thyself’ is one of the most important statements ever made, because we are appalling at it.” So said Dr Robert Kelly, Consultant Cardiologist at the Beacon Hospital, Dublin. Dr Kelly is also Ireland’s Clinical Lead for the European Lifestyle Medicine Organisation.

“We [doctors] get sick, we don’t look after ourselves, we don’t go to see GPs; some do, but a lot of us don’t. So we are the worst example for self-care.”

According to Dr Kelly, this is not just bad for doctors, but patients as well. The evidence from the field of lifestyle medicine shows that if doctors are physically active, so will a majority (approximately 80 per cent) of their patients.

Dr Kelly was one of the main organisers behind the recent ‘Physical Activity is Medicine’ conference in the RCSI, which was held in late January. Tickets for the conference were sold out weeks in advance, and Dr Kelly said similar events may be held in the future.

“Lifestyle medicine is an umbrella term that looks at stress, sleeping habits, physical activity and nutrition. I have been doing this with patients actively probably for the last three or four years,” Dr Kelly told the Medical Independent (MI).

“One of the big things about lifestyle medicine, which really originates out of the US, is that it is evidence-based. So there is clinical data that supports managing these pillars, in addition to stop smoking and over drinking.

“The important point is, it’s evidence-based. So as a practising doctor you should be quite comfortable that this is an acceptable way of treating patients.

“The big mantra around lifestyle medicine as it comes out of the US is the importance that it is doctor-led. So the presence of doctor self-care is also very important. It has been commented that there is very little point having two patients in the room during a consultation.”

Challenge

Dr Kelly admitted promoting lifestyle medicine among doctors is a “challenge”, but that the benefits for public health are significant. 

“I grew up in a time in medicine that I remember working in other hospitals with the sight of the doctor outside between a procedure with a cigarette or a cigar. Or the old tradition that you might walk into an office in the 1970s and 1980s and there might be an ashtray in the corner of the doctor or consultant’s room,” he recalled.

“The reality is we have a doctor-driven initiative [lifestyle medicine] that not only focuses on patients, but focuses on the doctors themselves.

“It is about raising awareness for the medical profession that you need to take on physical activity and look after your own health for obvious reasons in relation to burnout, etc.

“But also if you guys and girls do it, and you have these conversations with your patients, you have the capacity to turn about 80 per cent of your patients to follow your lead.”

Dr Kelly describes the interventions doctors could make by asking patients questions about their physical activity and diet.

“The real message is that you get doctors at every point of contact with their patients, to ask them these sort of questions,” he said.

“In practice I ask every single one of my patients about what they are eating, what their physical activity is, what sort of stress they are under, smoking and drinking as well. I try to work with them around those areas.”

He noted that in the US there are “exercise prescriptions”.

“The idea behind an exercise prescription is giving the patient some instruction on exercising for a certain frequency at a certain intensity for a certain period, then following it up in a couple of weeks trying to increase the frequency etc,” he said.

“It does not have to be a particular exercise. You do not have to go into the gym, walking is a great place to start. The message is being active rather than inactive, using the stairs rather than the lift, all of these things add up. The idea is doing something rather than nothing.”

Beneficial

Dr Kelly argues that the action taken by a doctor with an individual patient all adds up to a wider public health benefit.

“Every doctor, every GP, should be doing it,” said Dr Kelly. 

“Obviously there are lots of politics around GPs not having time, etc. But at a basic level, you should look after yourself. Exercise is hugely beneficial for your health. You live longer, you get less cancers, strokes, heart attacks, less mental health issues, less dementia, less stress. [You are] more mobile and stronger. You get less of everything. So as a profession it makes so much sense. But yet as you can visually see it is so poorly adhered to by many of us.

“It’s as simple as turning around on some occasions and saying to the patient ‘You are a bit overweight or you don’t do that much exercise. I, as your doctor, find that the way I manage that is going for a walk when I get home in the evening, or I go to the gym and I do a little bit of this or that.’”

Dr Kelly said it is not just doctors, but also other professionals, such as nurses and physiotherapists, who need to get involved “as much for themselves as the patients”.

“If a patient walks into a hospital and sees staff looking unhealthy, you can’t expect the patient to listen to them. It’s not to suggest that everyone is overweight, but if we can’t live the right message, how can we expect the patients to change their habits.”

Global

A paper in The Lancet entitled ‘The pandemic of physical inactivity: Global action for public health’ was published almost seven years ago.

“There has not been much change,” said Prof Harold W Kohl, Professor of Epidemiology and Kinesiology, University of Texas at Austin, US, who co-authored the 2012 paper.

But looking at the situation now is there any particular effective public health policy or initiative that stands out for Prof Kohl?

“I believe the best way for us to make progress in physical activity and public health is to develop and implement policies that help to reduce motor car use and increase mass transit,” he told MI.

“The physical activity associated with such modes of transit, in addition to the benefits on the environment and sustainability, can go a long way to improve public health.”

Given the alarming title of his 2012 paper, is Prof Kohl hopeful about the future in terms of physical activity?

“I am optimistic that physical activity and public health has emerged as a recognisable public health problem,” he said.

“Recent leadership by the World Health Organisation (WHO) has helped to bring it to the forefront.  Estimates are that as many people die of NCDs [non-communicable diseases] due to physical inactivity throughout the world as due to tobacco use. 

“That is a remarkable acknowledgment and one that should be amplified as loudly as possible.”

However, Prof Kohl warned that he is “less optimistic that we have gotten through to policy makers who can help make a difference at the population level”.

Changes

Back in Ireland, Dr Kelly said he is “optimistic” about the impact that lifestyle medicine could have.

“I have tons of patients who I work with through [their] lifestyle trying to get them off tablets. I have tons of young patients who come in here with chest pains, come in here unwell, because they are drinking too much, they are totally burnt out at work. 

“There are ways of managing those issues, like giving them resilience. Physical activity is a huge one,” he said.

“There is extremely good evidence to show you can reverse some conditions. For example, if you lose a ton of weight, you can reverse diabetes. If you can do the same for obesity as well, that will have a greater impact on longevity and morbidity than any other intervention.

“I’ve seen the data that it works. Yes, a lot of people would be critical about the sample size. But I’m firmly behind it. I’ve seen it work with patients, and I know the evidence stacks up.”

He added that he knows there is “a challenge in the health system, with funding and Sláintecare,” but he said this is an area where progress could be made. 

Training programme

Separately, the HSE is in the process of rolling out a new training programme for all healthcare professionals, including doctors, to help raise lifestyle factors with patients.

Making Every Contact Count (MECC) was established by the HSE in 2016 to support the implementation of Healthy Ireland.

Under MECC during routine consultations, health professionals are encouraged to ask patients about lifestyle behaviour related to chronic disease. The goal of these ‘contacts’ is to address risk factors for chronic disease.

“The programme consists of e-learning modules, and there is a follow-up skills workshop as well,” according to Dr Maria O’Brien who is the Project Manager of the HSE’s MECC programme and holds a PhD in Nutritional Science.

“The programme went officially live in the second half of 2018 and we are having a focused targeted roll-out of the training programme this year. So it has been available to [HSE] staff to start completing it for the last couple of months. The skills workshops are coming online now as well,” she told MI.

“The training programme is seen as a key enabler in implementing the programme across the health services. In terms of the implementation we are looking at all healthcare professionals. So obviously doctors are a very key group of people we want to target and focus on. It is also aimed at nurses and allied healthcare professionals within the HSE.”

Dr O’Brien noted that “obviously GPs are a very important group as well, in terms of their role”.

“We have been linking with the ICGP in terms of promoting the programme for their members.  We are just kind of starting the process with the ICGP.”

So what is the central focus of the MECC programme?

“It’s on the four core lifestyle risk factors that are risk factors for chronic disease,” she said.

“Healthy diet, being physically active, not consuming or minimising your consumption of alcohol and obviously not smoking. There is the opportunity to focus on others at a later stage.

“It’s about having these conversations on lifestyle change and for it to happen in a consistent way. Because it is not to say that medical professionals are not doing this already. They are. They are having conversations about some issues, but maybe not about others.

“But it’s about giving medical professionals the information and ability to signpost patients to local and other supports that could help them make the changes and do that in a consistent way.”

Positive

This is still early days for MECC. What kind of reaction has there been from doctors?

“Quite a positive one,” Dr O’Brien reported. “From across all healthcare professionals I think there is a positive response that this is something that is very valuable to do, the evidence very much supports that any healthcare professional, including doctors, doing this can have a profound impact on a patient making positive lifestyle changes.

“So it’s been very positive, the whole chronic disease prevention agenda and supporting the implementation of Healthy Ireland, people see it as a key programme to how do that. I think people have bought into that and see the value in it.”

Although the HSE’s MECC training programme is not focused on health workers’ own health, she added there may be some positive benefits in that direction.

“The evidence does show that healthcare professionals who take the time and actually raise these issues with their patients, it has a knock-on effect on themselves and their own self-reflection on their behaviour,” she stated.

The HSE’s MECC programme is connected to the Government’s wider Healthy Ireland public health strategy.

“Chronic disease is a huge priority and the evidence overwhelmingly supports that if we make lifestyle behaviour change to being more active, etc, that it has huge impact on the development of chronic disease. Even for those who already have chronic diseases.

“It [MECC] really is quite a simple concept that really tries to underpin what Healthy Ireland wants to do.”

Activity plan up and running for three years

In January 2016, the Government launched Ireland’s first ever National Physical Activity Plan (NPAP). With its lofty aims to get at least half a million more Irish people taking regular exercise within 10 years, cross-departmental structure and the formation of a implementation group, the plan got up and running with €5.5 million ring fenced for funding in 2016.

Since then there has been a NPAP Summary Progress Report published in November 2017 which found that “the plan [NPAP] has already achieved much in the intervening two years”.

The Department of Health told MI that the next summary report is due to be published before the end of March this year.

The Department said that “significant progress has been made on the implementation of the NPAP since its publication in 2016”.

However, there are some more critical voices on the progress of the plan to date. The Irish Heart Foundation (IHF) has made physical inactivity a major part of its recent public health publicity with its ‘chairs can kill’ campaign.

“Unfortunately, the delay in progress with the implementation of the…[NPAP] is not isolated in the overall Healthy Ireland agenda,” Ms Kathryn Reilly, Policy Manager, IHF, told MI.

“While a summary progress report and a full implementation report were published in 2017, we believe that there must be a greater push and accountability in implementing all of the recommendations. We hope that the updated summary and implementation report planned to be published online in the first three months of this year will not be delayed and that there will be significant stakeholder engagement on how to advance progress.

“There are 60 actions in the plan, many of which the Irish Heart Foundation are involved with, but it is frustrating that action on many of the actions has been slow.

“Indeed, we have seen through a recent parliamentary question [reference 3416/19] that implementation to date has only concentrated on nine areas. This is not good enough. These actions are critical as the health benefits of increasing levels of physical activity across our population are well proven and the plan itself must be monitored for efficacy”.

Sedentary

The IHF also said it “strongly believes” that the national guidelines on physical activity should be updated to include a guideline “on sedentary behaviour”.

“A survey last year by the IHF as part of our ‘chairs can kill’ campaign revealed that the average person in Ireland sits down for 7.3 hours a day. We believe that in order to seriously reduce the risk of heart disease and stroke, this must be addressed.”

Progress of the NPAP is overseen by an implementation group, which is co-chaired by the Departments of Health and Transport, Tourism and Sport.  The NPAP implementation group includes representation from the Departments of Education and Skills, Children and Youth Affairs, Housing, Planning and Local Government, Sport Ireland, the Federation of Irish Sport, the HSE and researchers.

In terms of spending on the NPAP the Department of Health spokesperson told MI that there is “no single dedicated budget for the NPAP per se, the total spend on sport and physical activity across Government departments, agencies, local authorities and others is very significant across different sectors”.

As a result of enquiries from the WHO regarding compilation of physical activity factsheets in 2018, the Department estimated the total spend on sport, physical activity and related facilities across Government departments, agencies and local authorities at approximately €325 million in 2017.

“However, this figure represents a minimum estimate of national spend; for example, an additional proportion of the HSE health promotion budget is spent on promotion of physical activity.”

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