Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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We need to promote safe walking habits in our communities
- Ediriweera Desapriya, S.Babul, S. Subzwari (9 June 2007)
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Efficacy and effectiveness of interventions to promote walking
- Michel R Odent (10 June 2007)
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Mobile Music: A behavioral intervention to promote walking
- S Kapoor (12 June 2007)
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Incompatibility of cycling and walking.
- Phillip J. Colquitt (12 June 2007)
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The effects of walking on health
- Mark A Tully, Margaret E Cupples, Senior Lecturer, Queen’s University Belfast, Belfast, BT9 7HR (13 June 2007)
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The Emperor's New Clothes
- Matthew RA Smith (14 June 2007)
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Interventions to promote walking: author's reply
- David Ogilvie (29 June 2007)
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Inactivity in Secondary Care Doctors
- Amy L Chue, Kiran C. Patel, Rajai A. Ahmad, Patrick J. Cadigan, Derek L. Connolly, Russell C. Davis (10 October 2007)
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Ediriweera Desapriya, Research Associate Department of Pediatrics, Centre for Community Child Health Research 4480 Oak Street V6H 3V4, S.Babul, S. Subzwari
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Walking is an important mode of active life styles of our communities (1).The consultation document from the Health of the Nation physical activity taskforce more than a decade ago concluded that activities of moderate intensity, such as brisk walking and cycling, offer the greatest potential of health gain for most of the population (2). The benefits of physical activity for public health are widely accepted. Many studies have shown that environmental modifications are important to promote walking and the challenge now is to make policymakers work for an environment that promotes walking (3). However, we have been extremely slow to recognize the impact that decisions about transport, land use and infrastructure have on health. As there are many public health benefits of active life styles and pedestrians safe walking rights should be promoted to increase the pleasure, safety and likeness of walking in our neighborhoods. A recent study explored the question why children don’t walk to school more often and 40% of parents reported traffic danger among the multiple barriers that inhibit walking and biking to school (4). If traffic danger continues to propagate avoidance of walking and cycling among children, youth and older citizens then the disease burden (with inactivity as a risk factor for other diseases) will increase, and the total burden of disease will be much larger than the WHO predicts in 2020 (5). We need to advocate a systematic environmental approach to reduce pedestrian injuries: complete separation of pedestrians and cyclists from traffic and traffic calming in residential areas as well as provision of safe outdoor areas in which people can be both independent and mobile. Benefit of such measures could promote walking and cycling habits of our communities. REFERENCES: (1). Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V, Fitzsimons CF, et al; on behalf of the Scottish Physical Activity Research Collaboration (SPARColl). Interventions to promote walking: systematic review. BMJ 2007 doi: 10.1136/bmj.39198.722720.BE (2). Physical Activity Task Force. The health of the nation. More people, more active, more often: physical activity in England, a consultation paper. London: Department of Health, 1995. (3). Andersen, L. B. Physical activity and health. BMJ 2007; 334: 1173-1173 (4).Barriers to children walking and biking to school—United States. MMWR 2002; 51(32); 701–4. (5). Desapriya E.B., Pike I., Basic A., Subzwari S. Deterrent to healthy lifestyles in our communities. Pediatrics. 2007; 119(5):1040-2 Competing interests: None declared |
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Michel R Odent, Director Primal Health Research Centre, London NW3 2JR
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‘Much of the research currently provides evidence of efficacy rather than effectiveness’. This is the main lesson of the review by David Olgivie et al of studies assessing the effects of interventions to promote walking.(1) The authors and editors should keep in mind that many readers of BMJ use English as a second language and cannot easily digest certain linguistic subtleties. I feel unable to translate the conclusions of this article into French, my mother tongue. 1 - Ogilvie D, Foster CE, Rothnie H, et al. Interventions to promote walking: systematic review. BMJ 2007;334:1204-7 Competing interests: None declared |
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S Kapoor, M.D. UIC, Chicago, IL
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The article by Ogilvie et al provided conclusive evidence that tailor made and targeted interventions are most effective in promoting walking and that new behavioral interventions are needed to promote walking. (1) One intervention that has universal appeal irrespective of age, gender, culture or socio-economic status is music. Nearly every one has a passion for music of some sort or the other. Music has been shown to improve functional performance, decrease the perception of dyspnea and increase adherence to walking regimens. (2) Soft, slow, easy listening music has also been shown to increase endurance. (3) The fact that musical motor feedback has resulted in increased walking speeds in patients with strokes clearly illustrates the subtle yet concrete affects of music. (4) The increasing popularity and easy availability of portable music devices such as iPods is clearly a big advantage that healthcare professionals should take advantage of in promoting “mobile music for walking”. Undoubtedly, promoting walking while listening to music or an audio book is something that can go a long way in making a community wide change in walking patterns. 1. Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V, Fitzsimons CF, et al. Interventions to promote walking: systematic review. BMJ 2007; Jun 9;334(7605):1204. 2. Bauldoff GS, Hoffman LA, Zullo TG, Sciurba FC. Exercise maintenance following pulmonary rehabilitation: effect of distractive stimuli. Chest 2002; Sep;122(3):948-54. 3. Copeland BL, Franks BD. Effects of types and intensities of background music on treadmill endurance. J Sports Med Phys Fitness 1991; Mar;31(1):100-3. 4. Schauer M, Mauritz KH. Musical motor feedback (MMF) in walking hemiparetic stroke patients: randomized trials of gait improvement. Clin Rehabil 2003; Nov;17(7):713-22. Competing interests: None declared |
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Phillip J. Colquitt, Technician/RN Independent Comment
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I would never choose to have cyclists on the same track/road/way as pedestrians. A cycle with a say 80 kgs person aboard, and travelling at the relatively fast speed needed to counteract the cycle’s efficiency yet raise the heart rate, is in fact a missile. I’ve seen several cases of cyclists crashing both into each other, and into pedestrians, and causing hospital stays of several months. Pedestrians need to have an environment relatively free of threat. Otherwise it just becomes another stress. Competing interests: None declared |
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Mark A Tully, Research Assistant University of Ulster, Jordanstown, BT37 0QB, Margaret E Cupples, Senior Lecturer, Queen’s University Belfast, Belfast, BT9 7HR
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We read with interest the recent review of walking interventions by Ogilvie et al1 and wholeheartedly support their efforts in further eliciting the “compelling reasons to encourage people to walk more”.1 Whilst there is indeed a need for further studies, we wish to highlight current evidence of positive health benefits which we have found in randomised controlled trials of home-based walking programmes among populations with low levels of physical activity. The authors conclude that few studies found unequivocal improvements in health and risk factors for disease.1 Though not clear from the text, further investigation of the search strategy on http://sparcoll.org.uk/images/bmjsupp.pdf indicated that studies were excluded if their aim was to “evaluate the effects of a prescribed walking regime on clinical or physiological outcomes” which may explain their failing to find a relationship between walking and health outcomes. Due to the strategy employed by Ogilvie et al,1 our study of the effects of brisk walking on fitness and cardiovascular fitness was excluded from the review. We found that an increase in walking of 30 minutes 5 days per week led to significant improvements in blood pressure, reduction in Framingham risk and increase in functional capacity in primary care patients.2 In a more recent study (in press), we have found improvements in blood pressure and functional capacity from walking for 30 minutes on either three of five days per week, in a group of 106 healthy, sedentary adults.3 The results of these studies and others demonstrate clear improvements in health and cardiovascular risk factors which we feel should not be ignored. 1. Ogilvie D, Foster CE, Rothnie H, et al. Interventions to promote walking: systematic review. BMJ 2007;334:1204-7. 2. Tully MA, Cupples M, Chan W, McGlade K, Young I. Brisk walking, fitness, and cardiovascular risk: a randomized controlled trial in primary care. Prev Med 2005;41:622-8. 3. Tully MA, Cupples M, Hart ND et al. Randomised controlled trial of home based walking programmes at and below current recommended levels of exercise in sedentary adults. J Epidemiol Community Health 2007;000:1–6. doi: 10.1136/jech.2006.053058 Competing interests: None declared |
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Matthew RA Smith, SpR Public Health Public Health Sciences and Medical Statistics, Southampton General Hospital, SO16 6YD
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The paper by Ogilvie et al(1) is a good example of the challenges faced by Public Health when trying to implement the health improvement agenda (encouraging the uptake of healthy lifestyles) from within the NHS. The problems faced by health service commissioners is neatly summarised in the last sentence of this paper “we still have much to learn about exactly who will benefit from what type of intervention and by how much”. However, the authors do not feel this uncertainty should delay implementation of interventions because it is a major public health problem. Decisions about health policy are based on a combination of three factors: evidence, values and resources(2). The weights placed on these components differ by individual and organisation. In recent years there has been a cultural shift within the NHS to focus on evidence based medicine(3); any new intervention or service should have good evidence of clinical effectiveness and cost-effectiveness before implementation. As a commissioner of health services it would be very difficult to prioritise this lifestyle intervention against other medical interventions where there is extremely good evidence of what one will achieve with scarce resources. If the health improvement agenda was located within local authorities, as suggested recently by Blackman(4), this would not be so critical. The evidence required and values held by these organisations when setting priorities are different; the process is also overseen by democratically elected members who represent the views of their local populations (i.e. the funders). To affect population health requires a balanced approach between helping the individual and changing the environment(5). Local authorities are the organisations with direct responsibility for the implementation of environmental interventions. There is also no reason why they can not provide many of the interventions aimed at individuals as these do not need highly skilled health professionals to be successful(6). I do agree that something should be done but mass implementation because it is a “big problem” is not enough justification when the evidence is weak. This fallacy was exposed by Normand(7). However, if schemes are adopted by PCTs (or local authorities) there needs to be ongoing evaluation to add to the evidence base. As a matter of urgency a national evaluation programme needs to be developed. A key aim should be the development of a practical evaluation framework, which can be modified to fit most health improvement schemes. The programme will ensure consistency and comparability of results and aid dissemination of findings. Resources are scarce and we need to ensure that there are not more effective ways of achieving the health outcomes we want. References: 1.) Ogilvie D, Foster C, Rothnie H, Cavill N, Hamilton V, Fitzsimons C, Mutrie N; on behalf of the Scottish Physical Activity Research Collaboration (SPARColl). Interventions to promote walking: systematic review. BMJ 2007 doi: 10.1136/bmj.39198.722720.BE 2.) Gray J. Evidenced-based healthcare. Edinburgh: Churchill Livingstone 2nd ed, 2001. 3.) Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312: 71-2. 4.) Blackman T. Statins, saving lives, and shibboleths. BMJ 2007;334:902. 5.) Rose G. Sick individuals and sick populations. International Journal of Epidemiology 1985; 14: 32-38. 6.) Truby H, Baic S, deLooy A, Fox KR, Livingstone MBE, Logan CM, et al. Randomised controlled trial of four commercial weight loss programmes in the UK: initial findings from the BBC "diet trials". BMJ 2006; 332:1309 -11. 7.) Normand C. Ten popular health economic fallacies. Journal of Public Health Medicine. 1998; 20: 2:129-132. Competing interests: None declared |
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David Ogilvie, MRC fellow MRC Social and Public Health Sciences Unit, Glasgow G12 8RZ
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Trials such as those of Tully and colleagues [1] form part of a body of evidence concerned with quantifying the health benefits of walking, some of which has been synthesised in other recent systematic reviews such as that of Murphy and colleagues [2] and all of which contributes to 'the epidemiological evidence for the health benefits of moderate intensity physical activity' we referred to in the discussion section of the full version of our paper. Evidence of this kind forms part of the justification for our decision to investigate a related but different question: how best to promote walking. The focus of our systematic review was clearly stated in the abstract as being on 'studies of the effects of any type of intervention on how much people walk'. As Tully and Cupples point out, their published trial [1] does not address this question. We did not 'fail' to find a relationship between walking and health outcomes because we were not primarily seeking to establish such a relationship; our review was focused on a point further upstream in the putative causal chain. We are sorry that Odent had difficulty translating one of our conclusions into French. Efficacy and effectiveness are standard terms in medical research. The difference between them has been neatly encapsulated in English as that between 'Can it work?' and 'Will it work?' [3] and in French as that between 'résultats dans un contexte expérimental contrôlé en conditions "idéales", sur un échantillon donné' and 'résultats de l'application réelle dans la population générale'. [4] As we explained with illustrations in our discussion section, much of the available evidence is of the former kind. We did not argue, as Smith implies, for the 'mass implementation' of any particular intervention in the NHS in the absence of credible evidence. We agree that more, and more rigorous, evaluation of interventions is needed to populate an evidence base sufficient to satisfy health care commissioners, and also that much of what needs to be done lies outside the realm of health care; that is why we argued for (and some of us are applying) more effort to investigate the effects of large scale community level interventions, including changes to the built environment. However, accumulating 'good evidence of clinical effectiveness and cost- effectiveness' in this field is extremely challenging. [5] If Smith agrees that 'something should be done' in the meantime, it is surely better that that 'something' should be informed by knowledge of what approaches appear most likely to be effective -- even if it is simply an opportunistic encounter in primary care. [1] Tully M, Cupples M, Chan W, McGlade K, Young I. Brisk walking, fitness, and cardiovascular risk: a randomized controlled trial in primary care. Prev Med 2005;41:622-8. [2] Murphy M, Nevill A, Murtagh E, Holder R. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med 2007;44:377-385. [3] http://www.euro.who.int/observatory/Glossary/TopPage?phrase=E [4] http://www.proz.com/kudoz/1153744 [5] http://guidance.nice.org.uk/page.aspx?o=PhysicalActivityandEnv Competing interests: None declared |
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Amy L Chue, Foundation Year Two Sandwell Hospital, West Bromwich, Kiran C. Patel, Rajai A. Ahmad, Patrick J. Cadigan, Derek L. Connolly, Russell C. Davis
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The interventions suggested by Ogilvie et al to increase the amount of walking by individuals can, and perhaps should, be applied to secondary care doctors.(1) The epidemic of obesity driven by inactivity is accentuated by obstacles in the workplace such as calorie-saving lifts and escalators. Hospitals are not exempt from such temptations and doctors as a profession face challenges to maintain adequate levels of physical activity. Physical activity is essential for long-term weight control and avoiding the phenomenon of ‘middle-aged spread.’(2) Even the suggested daily thirty minutes of moderate physical activity recommended may be inadequate to control body weight in some cases. Thirty minutes of moderate physical activity uses approximately two-hundred kilocalories and equates to approximately 3000-4000 steps.(3) We assessed whether all members of a hospital Cardiology team experienced similar levels of physical activity in the workplace, or whether seniority, which brings with it higher levels of sedentary sessions, predisposes to physical inactivity. Pedometers of the same brand and type were given to each member of the Cardiology team, comprising the House Officer, Senior House Officer, Clinical Fellow, Specialist Registrar and Consultant, in a Teaching Hospital, to be worn during the working day, for five days. In order of seniority, the most junior team member (39354 steps) amassed the greatest number of steps each day, and over the five day period was found to walk more than the senior house officer (21148), who walked more than the Clinical Fellow (18567), who walked more than the Registrar (14393), who walked more than the Consultant (7291). In conclusion, there is a clear and significant trend towards decreased levels of activity with increasing seniority within the Cardiology team. Some would argue that it is not the role of the workplace to offer physical activity, yet many would argue that the workplace should encourage physical activity in all its members for the well-being of its workforce. Extra activities, where provided, should be encouraged, such as fitness classes and on-site recreational clubs, and more senior doctors should be encouraged to avoid lifts and use stairs. This may be one of the effective means of intervention in an attempt to increase physical activity amongst doctors, which will provide a leading example to the remainder of the population. (1) Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V, Fitzsimons CF, et al. Interventions to promote walking: systematic review. BMJ 2007; Jun 9;334(7605):1204. (2) Jakicic, J. M. & Otto, A. D. Physical activity considerations for the treatment and prevention of obesity. American Journal Of Clinical Nutrition 2005, 82(1), Supplement, S226-S229 (3) British Heart Foundation – Think Fit! Be Active! www.bhf.org.uk Competing interests: None declared |
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