Here is a pre-publication script (version 3) of an article published in the BMJ (version 4) where David Nunan argues closer scrutiny of the evidence base will improve belief in exercise as a medicine and help doctors (and all health care professionals) prescribe exercise as they would a drug.
David Nunan, Senior Research Fellow
“Exercise is medicine” (EIM); it’s a catchy sound bite. Surely we all know about the huge benefits on our health from physical activity and exercise (Table 1); we don’t need to think of it as “medicine”? Well, perhaps we do.
Despite the many known benefits on physical and mental well-being, there remains a physical inactivity pandemic that is prematurely killing around 5.3 million people a year globally.
As a result, the EIM initiative emerged in 2007. Supported by the American Medical Association and the American College of Sports Medicine, their initial goal was to “make the scientifically proven benefits of physical activity [Table 1] the standard in the U.S. healthcare system.” Since then, EIM has expanded into an international collaboration consisting of some 43 national centers globally.
Table 1. Commonly cited health benefits of physical activity
The UK perspective
Currently around 25% men and 32% women in the UK class themselves as physically inactive and these numbers dramatically increase with age. As a result there have been numerous attempts to rouse the UK healthcare force to embody physical activity and EIM. “Make every contact count” was put forward in 2012 by the NHS Future Forum as a measure to reduce the costs associated with poor lifestyles. They recommended that health care professionals “…question patients about their lifestyle, including smoking, diet, exercise, and alcohol consumption, at every meeting.”
The Academy of Royal Colleges has gone even further, extoling exercise as “The Miracle Cure” for non-communicable disease. In particular, the academy sees GPs in the prime position to administer it; a stance supported by the Royal College of Physicians..
Physical activity and current practice
When asked, 92% of GPs and 99% of nurses agree or strongly agree that promoting physical activity is important. However, only 32% of health care professionals felt their brief advice would be successful in changing patient behaviour. This may be what’s reflected when looking at some of the evidence for health care professionals’ engagement with physical activity interventions.
In their review of evidence for exercise referral schemes, NICE point out that brief physical activity interventions were instigated on an opportunistic basis in only 25% of appropriate instances (e.g. inactive adults presenting at general practice). A 2008 NHS Next Stage review highlighted how 54% of patients said their GP had not provided advice on diet and exercise. This despite one in four people saying they would become more active if advised to do so by a doctor or nurse.
So it would appear that there is a discourse between practitioners’ belief in promotion of physical activity and their actual engagement with it in clinical encounters. I believe there are at least three factors underpinning this.
“The best evidence must also include methods to support implementation.”
First, there is probably a lack of broad awareness amongst clinicians and health professionals about the role and benefits of physical activity. This deficiency begins early on in clinical training with medical students demonstrating poor knowledge of physical activity guidelines compared to other health guidelines; reflective no doubt of the current miserly provision of teaching content in UK medical school curricula. This may be impacting on working practice, evidenced by none of 167 GPs from 67 practices across London knowing the current physical activity guidelines.
Second is that there is little incentive for GPs to engage. The one attempt to introduce an indicator of physical activity level (General Practice Physical Activity Questionnaire or GPPAQ) was removed from QOF within 6 months, due largely to the fact it was wholly inadequate and poorly thought out. The EIM initiative offers a simpler, time efficient assessment based on some evidence of validity.
Third, is the belief of practitioners (and their patients) that physical activity interventions (brief or otherwise) equate to medicine. And for this to happen, we need closer scrutiny of the evidence-base. Much of the current evidence underpinning brief interventions relates to their effectiveness in increasing physical activity uptake and participation. Few relate to outcomes relevant to clinical practice.
Improving (belief in) the evidence base for true evidence-based health care
Of the evidence that does provide information on clinical outcomes, most is underpinned by data from observational studies that are undoubtedly confounded in their estimated effects and might not be replicated in randomized clinical trials. In addition, information on optimal ‘formulation’ and ‘dosage’ of physical activity is scarce, as is information on whom best to prescribe physical activity to and where more evidence is needed. This most likely has a negative impact on the ‘belief’ in exercise as medicine, if not its application in practice.
These points were once again highlighted in a recent paper assessing the quality of reporting and replication in trials of exercise-based cardiac rehabilitation. Calling for much needed improvements in research methodology and reporting in order to facilitate the delivery of true evidence-based care, where clinical practice is genuinely based on the “best” evidence.
But the best evidence must also include methods to support implementation. An accompanying editorial offers viewpoints that echo my own, stating that “…effective translation of exercise as medicine goes beyond simply telling patients to “exercise” or “exercise several days a week” and, “…proper implementation of exercise guidelines in clinical practice requires that exercise be prescribed for patients in a manner analogous to a drug prescription.”
So should we have a national formulary for physical activity and exercise, analogous to the BNF for drug prescriptions? For this to happen we would need to have a systematic overview of the highest quality available evidence for physical activity for the prevention and treatment of major chronic disease, and so that’s what we are doing. To date we have assessed 54 reviews within the Cochrane Database of Systematic reviews across 20 medical conditions including 1168 RCTs; 107,706 participants and more than 500 outcomes.
The goal is to provide a much needed taxonomy of interventions that ultimately produce a “BNF” for physical activity, that is underpinned by the highest quality evidence assessed using the most rigorously available methods. The strength of such scrutiny lies not only in the improved information of treatment benefit (and harms) but also to demonstrate where evidence may be lacking, and what information is still needed.
Healthcare professionals acknowledge their important role in promoting physical activity to patients but there is a lack of engagement in practice. Reasons cited by clinicians include time constraints, a lack of tools, and skepticism about whether such counselling actually works.
For health professionals to believe in exercise as medicine, and thus better engage with it, closer scrutiny of the evidence-base in the same way as that for drug interventions is needed. Evidence underpinning the health benefits of physical activity is largely based on observational studies with little relevance to clinical practice despite a significant body of clinically relevant trials.
We are conducting a systematic overview of the clinical trial evidence, assessing the quality of physical activity interventions for the prevention and treatment of diseases commonly seen in clinical practice. The aim is to provide a taxonomy to aid prescription of physical activity interventions with proven benefit.
By applying the same standards of critical analysis and evidence-based medicine to the evidence underpinning physical activity as that given to drug treatments (i.e. the predominant mode of treatment in medicine), health care practitioners will be more inclined to engage with the ethos and practice of physical activity and “exercise is medicine”.
Cite as: Nunan D. Doctors should be able to prescribe exercise like a drug. BMJ 2016;353:i2468
DN is supported through the NIHR School or Primary Care Research.
I am grateful for helpful comments from Kamal R Mahtani.
The views expressed are those of the author and not necessarily of any of the NHS, the NIHR or the Department of Health.
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