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Death in family prompts request for exercise advice

Dr Tanvir Jamil discusses how you might proceed

Dr Tanvir Jamil discusses how you might proceed

Case History

Margaret, 55, has diabetes and is overweight. Her diabetes is well controlled but she had a bit of a shock when her cousin recently 'dropped dead' from a heart attack at the age of 60. This has made Margaret think about her sedentary lifestyle and she would like your advice about taking up exercise.

Where do I start?

If you look at all the literature the basic conclusion you come to is that if you exercise regularly you live longer and healthier. To put it another way – the more you walk the longer you live. There are some studies that have shown only vigorous exercise helps reduce mortality, but that is probably not the right approach for most of your patients who need encouragement about starting slowly.

Many patients make a lot of excuses not to exercise. What can I tell them?

About 30 minutes of exercise daily is good for you. Most patients can spare 20-30 minutes a day. I advise them to go out of their house and take a left turn. Walk fast for 15 minutes. Turn round and come back again. At the end of their walk they should be slightly sweaty and a bit out of breath. That is their daily exercise done for the day.

Joining a gym is good but it costs money, takes more time but does get you out of the house and you have the chance to make new friends – so it's great for people who are lonely and depressed. Exercise, incidentally, is a vastly underused treatment for depression, stress and anxiety.

The Government is putting a lot of effort into helping people stop smoking. Do you think the money would be better spent on encouraging more exercise?

There is a good argument for giving people good access to exercise. Look at the prevalence of risk factors for CHD: smoking 30 per cent; hypertension 15 per cent; hyperlipidaemia 30 per cent; lack of exercise 70 per cent. The level of risk from each of these factors is almost the same but lack of exercise is at least twice as prevalent as the rest.

What are the specific benefits of exercise?

  • Cardiovascular: exercise protects against stroke (50 per cent reduction in men 50-59) and heart attack (60 per cent in same population). One study has suggested the least fit men have eight times the death rate for cardiovascular disease compared with the most fit. Exercise after a myocardial infarction can reduce the risk of further heart attack and death from heart failure by 25 per cent
  • Regular exercise can also reduce blood pressure by up to 5-10mmHg systolic – especially if combined with diet. High-density lipoprotein can rise 4-5 per cent with regular exercise. Some studies have also shown that exercise makes blood less likely to clot, improves the electrical stability of the heart and decreases its response to adrenaline – making arrhythmia less likely
  • Osteoporosis: exercise reduces the risk of hip fractures by almost 50 per cent but the exercise has to be weight-bearing, so swimming and cycling are not as good as walking, jogging and aerobics. People who exercise are more likely to fall over than 'couch potatoes' but improved muscle strength and the ability to 'save a fall' from better balance and flexibility are all additional advantages
  • Psychiatric problems: exercise is at least as good as cognitive behavioural therapy and behavioural therapy in helping mild to moderate depression. Exercise affords primary protection against depression in women and reduces relapse rates in depressed men
  • Osteoarthritis: aerobic exercise and quad-riceps strengthening improves self-reported measures of disability, pain and physical performance in OA of the knee
  • Diabetes: exercise reduces the prevalence of type 2 diabetes with improved glucose tolerance and increased insulin sensitivity. According to the UK Diabetes Prospective Study Group data, three 45-minute moderate intensity aerobic workouts per week can reduce HbA1c to a degree sufficient to reduce risk for MI by 9 per cent and microvascular complications by 24 per cent
  • Cancer: exercise protects against cancer of the colon and probably breast cancer too
  • Getting fitter can help patients to cope much better with their concurrent illnesses – particularly asthma, COPD, angina, intermittent claudication and heart failure.

What kind of checks or questions do patients need before being declared fit for exercise?

A blood pressure check and asking about exertion-related chest pain is all you need to do. Some gyms, health clubs and even GP practices have a 'Physical Activity Readiness Questionnaire' (PAR-Q) to give patients.

PAR-Q

1. Has your doctor ever advised you that you have a heart condition?
2. Do you feel chest pain when exercising?
3. Do you frequently have pains in your heart or chest?
4. Do you often feel faint or have spells of severe dizziness?
5. Has your doctor advised you that you have high blood pressure?
6. Has your doctor ever advised you that you have a bone or joint problem such as arthritis that may be made worse by exercise?
7. Are you over 65 and not used to vigorous exercise?
8. Do you know of any other reason why you should not undertake physical exercise?

Patients answering 'Yes' to any of these questions should see their GP before beginning an exercise regime.

Patients with diabetes need a bit more attention. Blood sugar should be tested before and after exercise and 'sugar' should be carried during exercise in case of hypoglycaemia. Some patients may need a reduction in their dose of oral medication if prolonged exercise is planned. Most patients, however, will be able to exercise without any undue problems. But do advise them to start slowly and build up gradually and always warm up and warm down. No one should exercise during an infection or just after a large meal.

Anything else I can do to encourage patients to exercise?

Yes, set a good example – start jogging and cycling round your practice area, organise a 'practice mini-marathon' and avoid the fish and chip shop.

Tanvir Jamil is a GP trainer in Burnham, Buckinghamshire

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