19/02/2015

Health Promotion

HH2602
Lecture 1
February 2014
Jennifer Ryan

@jennifer_m_ryan

Learning Outcomes
• Define health promotion and differentiate between primary
and secondary prevention
• List and describe methods of recognising people at increased
risk of cardiovascular disease
• List modifiable risk factors for noncommunicable diseases
• Describe consequences of physical inactivity, poor diet,
tobacco use and excess alcohol consumption
• Describe current recommendations for physical activity, diet,
smoking and alcohol
• Discuss methods for modifying unhealthy behaviours

Health Promotion
• The process of enabling people to exert control over the
determinants of health and thereby to improve their health.

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Benefits of Health Promotion

• Reducing mortality and morbidity
• Cost savings
• Improving the quality as well as the length of people’s lives

Leading Causes of Mortality

Leading Causes of Mortality

CVD

Cancer

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Leading Causes of Mortality

• Noncommunicable diseases (NCDs) are responsible for ≈ 70%
of deaths worldwide
• 4 main NCDs are cardiovascular diseases, cancers, diabetes
and chronic lung diseases.

CVD and Diabetes Mellitus

• Cardiovascular disease (CVD) is an umbrella term for all
diseases of the heart and circulation including coronary heart
disease, stroke, heart failure and peripheral vascular disease
(British Heart Foundation, 2009)

• Diabetes Mellitus is loss of control of glucose homeostasis

resulting in hyperglycaemia

• Approximately 75-80% of people with diabetes die of

cardiovascular disease
(Alberti et al., 2007)

Activity: Modifiable Risk Factors for NCDs

Cardiovascular Disease
Smoking
Poor diet

Physical
Cancer inactivity
Overweight
/obesity

Type II Diabetes Mellitus Psychosocial

stress

Excess alcohol
Chronic Lung Disease consumption

5 min

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Activity: Modifiable Risk Factors for NCDs

Cardiovascular Disease Cancer

• Poor diet
• Physical inactivity
• Overweight/obesity
• Psychosocial stress
• Excess alcohol consumption
• Tobacco use
(Yusuf et al., 2004)
• Tobacco use - stomach cancer, lung
cancer, liver cancer
• Overweight/obesity - breast,
colorectal, endometrium, kidney,
oesophageal, pancreatic cancers
• Physical inactivity - breast cancer,
colorectal cancer
• Poor diet - colorectal cancer, lung
cancer
• Excess alcohol consumption -breast
cancer, colorectal cancer, liver
cancer

(Vineis and Wild, 2014; Ott et al,. 2011)

Activity: Modifiable Risk Factors for NCDs

Type II Diabetes Mellitus Chronic Lung Disease

• Overweight/obesity • Tobacco use
• Physical inactivity • Poor diet
• Poor diet (Carraro et al., 2014)
(Alberti et al., 2007)

Prevention of NCDs
• Primary prevention: aims to prevent new onset NCDs by
reducing risk factors
- most effective way of fighting NCDs
- avoids death or disability resulting from first events (e.g.
stroke, cancer, heart attack)
- primary prevention that targets modifiable risk factors
has the benefit of preventing all NCDs

• Secondary prevention: aims to prevent recurrent events

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Population versus Individual Approach

• interventions to give people direct encouragement to

change their behaviour
‘Individual’ • involves providing information about the health risks of
their current behaviour, advice and/or prescribing
treatment

• interventions that aim to change the risks from the social,

economic, material and environmental factors that affect
‘Population- the entire population
based’ • can be achieved through regulation, legislation, subsidy
and taxation or rearranging of the physical layout of
communities

ROLE OF THE PHYSIOTHERAPIST IN

PRIMARY PREVENTION

NHS - Five Year Forward View

• “The future health of millions of children, the sustainability of
the NHS, and the economic prosperity of Britain all now
depend on a radical upgrade in prevention and public
health.”

• The NHS will:

- back hard-hitting national action on obesity, smoking,
alcohol and other major health risks
- develop and support new workplace incentives to
promote employee health and cut sickness-related
unemployment
- advocate for stronger health-related powers for local
government and elected mayors

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The Forward View into Action

(2015/16)
1. Actions to improve local health and wellbeing e.g. specify behavioural
interventions for patients and staff in line with NICE guidance with
respect to smoking, alcohol and obesity
2. Implement a national evidence-based diabetes prevention programme
3. Develop proposals for improving services for helping individuals stay in
work or return to employment
4. Potentially extend incentives for employers who provide effective NICE
recommended workplace health programmes for employees
5. All NHS employers should take significant actions to improve the physical
and mental health and wellbeing of their staff
6. Prototype four new care models: multispecialty community providers;
integrated primary and acute care systems; additional approaches to
creating viable smaller hospitals (e.g. specialist franchises); models of
enhanced health in care homes

What does this mean for Physios?

• The 5YFV will affect how physios work in the NHS and offer
physios outside of the NHS opportunities for business
• Boundaries between primary, community and secondary care
will be changing
• Physios will have to adapt to new models of care
• Physios could become the first point of contact
• Physios may take on additional roles historically held by other
healthcare professionals e.g. increase physical activity

ESTIMATING RISK FOR NCD

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Estimating risk for NCDs for Individuals

• Identify individuals who need urgent intervention
• Focus resources
• Educating a person about their risk may change their beliefs
and/or behaviours

Risk scores
• Metabolic syndrome
• Heartscore
• Framingham Risk Score
• Framingham Stroke Profile

The Metabolic Syndrome

• A clustering of risk factors for cardiovascular disease and type
II diabetes

• People with the metabolic syndrome have:

- a 2-fold increase in risk for developing CVD over the
next 5-10 years
- a 5-fold increase in risk for type II diabetes

The Metabolic Syndrome

Measure (any 3 of 5 indicates the metabolic syndrome) Categorical Cut Points

Elevated waist circumference Population and country specific definitions

Elevated triglycerides (drug treatment for elevated triglycerides is ≥150mg/dL (1.7mmol/L)

an alternate indicator)

Reduced HDL-C (drug treatment for reduced HDL-C is an alternate <40mg/dL (1.0 mmol/L) in males; <50mg/dL (1.3
indicator) mmol/L) in females

Elevated blood pressure (antihypertensive drug treatment in a Systolic ≥130 mmHg and/or diastolic ≥85 mmHg
patient with a history of hypertension is an alternate indicator†)

Elevated fasting glucose (drug treatment of elevated of elevated ≥100 mg/dL

glucose is an alternate indicator)

(Alberti et al., 2009)

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MODIFIABLE RISK FACTORS - WHAT

SHOULD WE BE DOING?

Physical Activity
Physical activity is….

“…any bodily movement produced by skeletal muscle that results

in energy expenditure.”
(Caspersen et al., 1985)

kcalsleep +kcaloccupation+kcalconditioning+kcalhousehold+kcalother=kcaltotal daily physical activity

Physical Activity Quiz!

1. What are the UK Department of Health’s recommendations for physical
activity for healthy adults?
2. What are the UK recommendations for physical activity for children?
3. How many men in England report that they meet the physical activity
guidelines? a) 80% b) 24% c) 66%
4. How many men in England actually meet the physical activity
guidelines? a) 66% b) 6% c) 16%
5. What are the UK Department of Health’s recommendations for
strengthening exercises for healthy adults?
6. It is unsafe for children to perform strengthening exercises: Trueor false
7. How much moderate-to-vigorous activity, on average, do US adults
accumulate daily? a) 12min b) 6 min c) 27 min
8. How much physical activity do the WHO suggest adults and children with
disabilities should perform?
9. Men are more likely to meet physical activity guidelines than women:
True or False

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10. This is the least active state in America. Which state is it?

Tie breaker: What percentage of GPs know the physical activity guidelines?

Physical Activity Quiz - Answers

1. What are the American College of Sports Medicine’s ( and the UK DoH’s) recommendations f or physical activity
f or healthy adults?
150 min of moderate activity per week, 75 minutes of vigorous activity per week, or combination ofMVPA, minimise
sedentary time
2. What are the UK recommendations f or physical activity f or children?
60 min of MVPA daily. Vigorous activity at least 3 days per week. Minimise sedentary time
3. How many men in England reported meeting the physical activity guidelines? 66%
4. How many men in England actually meet the physical activity guidelines? 6%
5. What are the UK Department of Health’s recommendations f or strengthening exercises f or healthy adults?
muscle strengthening exercises at least 2 days per week (8-12 reps involving all major muscle groups on at least 2 days
per week)
6. It is unsaf e f or children to perf orm strengthening exercises: False
7. How much moderate-to-vigorous activity, on average, do US adults accumulate daily? 6 min
8. How much physical activity do the WHO suggest adults and children with disabilities should perf orm?
The recommendations f or adults and children without disabilitiescan be applied to adults and children with disabilities.
However they may need to be adjusted f or each individual based ontheir exercise capacity and specif ic health risks or
limitations.
9. Men are more likely to meet physical activity guidelines than women: True
10. This is the least active state in America. Which state is it? Arkansas
11. What percentage of GPs know the physical activity guidelines? 28%

Knowledge of Physical Activity

Guidelines
50.5%

28.0%

Phy siotherapists General Practitioners

(Barrett et al., 2012)

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Sedentary Behaviour vs Physical Activity

• Sedentary behaviour and physical activity are separate concepts

Aim to:
1. Increase moderate-to-vigorous physical activity
2. Reduce sedentary behaviour
3. Increase breaks in sedentary behaviour

Cardiorespiratory Fitness and Mortality

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16 Men W omen

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Fractions (%)

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Attributable

0
Low CRF Obesit y Smoker Hyper tens ion High Cho les ter ol Diabet es

Attributable fractions (%) for all cause deaths in 40 842 (3333 deaths) men and 12 943
(491 deaths) women in the Aerobics Center Longitudinal Study. The attributable fractions
are adjusted for ages and each other item in the figure. (Taken from Blair, 2009)

Cardiorespiratory fitness vs Physical Activity

“Cardiorespiratory fitness is more important than physical activity in relation

to health outcomes” (Blair et al., 2001)

Is this a valid conclusion?

1. Physical activity is the principal determinant of cardiorespiratory fitness

2. Certain components of physical activity are more strongly associated with
health outcomes
3. Historically, physical activity has been measured by self-report
4. Even objective measures of physical activity can result in misclassification
5. Cardiorespiratory fitness can be measured objectively in a standardised
environment

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Cardiorespiratory fitness vs Physical Activity

• Assessing cardiorespiratory fitness may identify people at risk

of NCDs
• Increasing cardiorespiratory fitness may prevent mortality and
morbidity
• Physical activity, particularly at a vigorous intensity, should be
prescribed to increase cardiorespiratory fitness

Diet and NCDs

Fruit Red meat
Vegetables Processed meat
Whole grain foods
Salt
Fish
Processed foods
Poultry
Nuts and seeds
Garlic
(Eckel et al., 2014; NICE, 2010; World Cancer
(Eckel et al., 2014; NICE, 2010; Eisner
Research Fund, 2007)
et al., 2010; World Cancer Research
Fund, 2007)

Smoking Recommendations
• Smoking cessation support should be offered to all smokers
with the aim of encouraging all people who smoke to quit

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Consequences of Smoking
- Chronic Lung Disease
- Cancer
- Cardiovascular disease

- Stomach and duodenal ulcers

- Erectile dysfunction and infertility
- Osteoporosis
- Cataracts
- Lower survival rates post surgery
- Delayed wound healing
- Post-op respiratory complications

Alcohol Intake - Recommendations

• ≤ 14 units per week for women
• ≤ 21 units per week for men
• Everyone should have 2-3 alcohol free days per week

Consequences of Excess Alcohol Consumption

Approximately 2.5 million deaths per year worldwide (4% of all deaths)

• Cardiovascular disease including stroke, arrhythmias, heart failure,

hypertension
• Type II diabetes mellitus
• Cancer
• Seizures
• Poisonings
• Accidents
• Violence

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What constitutes a drink?

Unit Drink type Specifics
1 unit 1/2 pint beer / larger / cider at 3.5% - 4% ABVa
1 unit 1 glass of wine 125ml at 12% ABV
1 unit 1 pub measure of spirits 25ml spirits at 40% ABV

2 units 1 glass of wine at home 160ml at 12% ABV

2 units Alcopop 400ml at 5% ABV
2 units 1 pint beer / larger/ cider at 3.5 - 4% ABV
2 units 1/2 pint strong beer at 8% ABV
4 units 1 pint strong beer at 8% ABV
5 units 1 cocktail 125 ml alcohol at 40% ABV

aABV, alcohol by volume

Risk of cardiovascular disease

Light to
moderate Abstainers Heavy drinkers
drinkers

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• Maximum protection noted at:

½ to 1 drink daily for women
1 to 2 drinks daily for men

• Increased risk of death noted at:

> 2.5 drinks per day in women
> 4 drinks per day in men

• Increased risk of death associated with binge drinking

i.e. episodic excessive alcohol intake (≥5 drinks within a few
hours) often with intent to become intoxicated
(O’Keefe et al., 2014)

Alcohol Consumption across Europe

HOW CAN WE CHANGE PEOPLE’S

BEHAVIOUR?

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Individual Approach
• Brief advice
• Referral

How can you influence behaviour?

• Numerous theories of behaviour change to help us
understand why a person is physically inactive, e.g. social
cognitive theory, theory of planned behaviour, health belief
model, transtheoretical model

• Taxonomy of behaviour change techniques provides a “tool

kit”

• Techniques extracted from training manuals and reviews of

intervention
(Abraham and Michie, 2008)

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Activity

Can you identify any of the behaviour change

techniques used in this project?

https://www.youtube.com/watch?v=vBnv1cCWBCg

10 min

Activity – Techniques Used

• Provide information on consequences e.g. poor diet and no
exercise
• Goal setting
• Model or demonstrate the behaviour
• Prompt practice
• Provide instruction on how to perform a behaviour
• Prompt self-monitoring of behaviour

GUIDELINES ON MODIFYING RISK

FACTORS

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Physical Activity Pathway

• Methods to get adults physically active:
– Brief advice
– Exercise referral schemes
– Pedometers
– Walking and cycling schemes

(NICE, 2006)

Physical Activity Pathway

• Methods to get adults physically active:
– Brief advice
– Exercise referral schemes
– Pedometers
– Walking and cycling schemes

(NICE, 2006)

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Brief Advice
Includes:
• Verbal advice
• Discussion
• Negotiation or encouragement
• May include written support
• Follow-up

• Can be opportunistic
• Varies from basic advice to a more extended, individually focused
discussion
• Can typically take from <1 minute to 20 minutes

Brief Advice - Implementation

1. Identify inactive adults
• Measure physical activity e.g. GPPAQ
• Identify the most appropriate time to discuss physical activity
with people not meeting the guidelines
• Record the outcomes of the physical activity assessment
• Encourage people who meet the guidelines to continue

(Nice, 2013)

Brief Advice - Implementation

2. Delivering and following up on brief advice
• Emphasise the benefits of physical activity.
• Advise adults to increase physical activity with the aim of achieving the
guidelines
• Tailor advice to the person’s motivations and goals, current level of activity
and ability, circumstances, preferences and barriers, and health status.
• Provide information about local opportunities
• Consider giving a written outline of advice and goals
• Record the outcomes of the discussion
• Follow-up

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Exercise Referral Schemes

• Recommended for people who are inactive and have existing
health conditions or risk factors

Components of exercise referral schemes:

1. An assessment to determine that someone is not meeting the
physical activity guidelines
2. A referral to a physical activity specialist or service
3. An assessment to determine what programme of activity to
recommend for their needs
4. An opportunity to participate in a physical activity programme

Smoking cessation
• Opportunistic, brief advice to encourage all smokers to quit
and to point them to effective treatments that can help
• Referral to an intensive support service (e.g. NHS Stop
Smoking Services)
- Prescription of pharmacotherapy
- Behavioural counselling
- Group Therapy
• Record and review smoking status once a year
(NICE, 2006)

Excess Alcohol Consumption

• Screen for alcohol intake
- Particularly people that may be at an increased risk of
harm from alcohol and those with an alcohol-related
condition
• Brief advice
• Refer for specialist treatment
(NICE, 2010)

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Influences on Behaviour
Interpersonal
• Friends, family, employer, physiotherapist, sports coach
Organisational/environmental
• Work hours, initiatives, layout, accessibility
Community
• Establishing networks, involving all members of the
community
Policy
• Guidelines, inclusion (e.g. considerations for different
ethnicities, people with disabilities)

Activity

List the important interpersonal, organisational, community and

policy considerations for this intervention

https://www.youtube.com/watch?v=apLQqKN-Lx8

10 min

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Activity – Influences on Behaviour

Public policy – policy of physical activity being good for health
prompted initiation of this project, availability of funding
Community – Relationships built within this project, different
groups/organisations working together to deliver e.g. the
Mosque, University, Physiotherapist, Kinesiologists
Organisational/Environmental – Location of intervention
(importance of religious institution), the exercise space itself,
suitability of surrounding neighbourhood, access by public
transport
Interpersonal – Importance of families to Asian women, link of
physical activity to religion (about the body)

Sample Exam Questions

Q. Identify the risk factors which indicate Malcolm’s at risk of
developing cardiovascular disease
Q. Is physical activity an important rehabilitation tool in
Malcom’s case? Justify your answer
Q. Describe the UK Department of Health’s physical activity
recommendations for adults to reduce the risk of cardiovascular
disease and premature death
Q. Anna does not see why she should make any changes to her
lifestyle. What can you do to help her to increase her physical
activity?

Recommended Reading
• Heyward, V.H. and Gibson, A.L. (2014) “Physical activity,
health, and disease: an overview,” in Heyward, V.H. and
Gibson, A.L. (eds.) Advanced Fitness Assessment and Exercise
Prescription. 7th edition. USA: Human Kinetics, pp. 1-20.
• Reference list on BBL

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