I remember clearly the day I looked into the eyes of Brian, a 64 year overweight lorry driver with diabetes, and I realised the words that were coming out of my mouth were ending up in every part of the consulting room except his cerebral cortex.
‘You could take up badminton,' I said feebly, ‘or go to the gym.'
But the thought of him driving six miles to the nearest gym, break into a sweat and come back to a bowl of couscous was ludicrous. We were both enthusiastic when we talked about blood pressure and HbA1C and he even showed some interest when I suggested taking fruit instead of a large grab bag of crinkly crisps on his long journeys.
But discussing physical activity was a miserable experience for both of us. That evening in 1994 I took the dog for a walk and went along empty footpaths right past Brian's house – and that was the inspiration for setting up Health Walks from Sonning Common surgery.
There are now 3,500 health walks each week to get inactive people like Brian, more active and we are getting near to the vision that every GP surgery in England will have access to a local walk scheme.
So what is it about physical activity that makes us GPs feel uncomfortable and insecure? Well after 18 years of trying to embed physical activity into clinical care, here are some of the responses I've met from GPs.
‘It's not that important'
When I ask doctors to list the importance of each risk factor, physical activity is usually buried at the very bottom. Looking at your practice population as a whole, the most significant attributable risk factor for cardiovascular death is low fitness.
‘I don't know what activity to recommend'
This is because so many people are unfit and, as an individual risk, it is up there with smoking, cholesterol and blood pressure. For cancer of breast, prostate, bowel and endometrium exercise can reduce the incidence by 30%. It can prevent and reduce symptoms in osteoarthritis, and is as effective as antidepressants for depression. It can reduce the incidence of dementia by up to 60% and is one of the few interventions that will keep an elderly person independent at home. Promoting physical activity is not taught to GPs and is then made to appear more complicated by the use words such as isometric, gluteus maximus, lactate and, scarily, pain threshold, which are aimed at a completely different audience to the likes of Brian. If in doubt, just get the patients walking. It's that easy! Walking covers all the basic benefits of physical activity. The lactate won't accumulate, the gluteus maximus will know what to do and the patient won't need a signed form to walk.
‘It's impossible to get people to become active.'
Yes, it's hard but so is getting someone to give up smoking, and we are better at that. It's all about positive experience. Look at the website www.yourpersonalbestcampaign.co.uk to get patients inspired. There is good evidence that a brief intervention by a GP gives that important ‘permission' to get them started.
‘It's inherently unsafe for many patients'.
If physical activity is dangerous then sitting on a sofa is lethal. Inactivity increases mortality by 30%. The NNT for physical activity to prevent one cardiac death over 5 years is 25 and the numbers needed to harm (NNH) is 1208 for men and 14,600 for women. If unfit just get them to build up slowly and refer those with nasty cardiac problems such as cardiomyopathies and aortic stenosis.
It's not in QOF. No, it's not. It was due to be under hypertension for 2012/2013 recommended strongly by NICE. Unfortunately the BMA rejected it.
This is a real missed opportunity and my guess is that they are not aware of all the evidence. As a major risk factor and as treatment for 23 long term conditions, it is time physical activity came of age and for its effective promotion to be viewed simply as good medicine.
For free walks near you go to www.whi.org.uk
Dr William Bird MBE is a GP in Reading and is currently working part time with NHS London to train London GPs to using physical activity as a treatment (www.yourpersonalbestcampaign.co.uk). He also chairs the physical activity alliance that promotes all non-sport physical activity.
British Journal of Sports Medicine 2009:43:1-2