Intended for healthcare professionals


Promotion of exercise in primary care

BMJ 2008; 337 doi: (Published 12 December 2008) Cite this as: BMJ 2008;337:a2430
  1. Steve Iliffe, professor of primary care for older people1,
  2. Tahir Masud, consultant physician 2,
  3. Dawn Skelton, reader in ageing and health3,
  4. Denise Kendrick, professor of primary care research4
  1. 1University College London, London NW3 2PF
  2. 2Nottingham University Hospitals NHS Trust, Nottingham NG5 1PB
  3. 3Glasgow Caledonian University, Glasgow G4 0BA
  4. 4University of Nottingham, Nottingham NG7 2RD
  1. s.iliffe{at}

    Concerted efforts can improve patients’ health

    The health benefits of exercise are so great that it is probably the most important self help treatment available. Regular exercise reduces the risk of cardiovascular and respiratory disease, type 2 diabetes, some cancers,1 and death from all causes.2 3 Regular physical activity and structured exercise can also reduce falls and injuries, and it is a key factor in the prevention and management of osteopenia and osteoporosis.4 It also promotes mental wellbeing and helps people to manage their weight.4

    Effective promotion of exercise could result in substantial healthcare savings, but this is hampered by our limited knowledge of how to achieve sustained increases in physical activity. The linked study by Lawton and colleagues (doi:10.1136/bmj.a2509) assesses the effectiveness of an “exercise on prescription” programme in less active women in primary care over two years.5

    Current recommendations are that people do at least 30 minutes of physical activity of moderate intensity on at least five days of the week.2 However, recent estimates indicate that around six out of 10 men and seven out of 10 women are not active enough to benefit their health, and activity levels vary with age, sex, class, and ethnic origin.4 In the United Kingdom, physical activity is being promoted in a variety of ways—for example, exercise referral schemes in primary care.6 7 General practitioners recommend exercise for several indications,8 and all probably have access to some form of local exercise promotion programme for their patients’ use.6

    Such referral schemes have not been particularly effective in increasing physical activity beyond 12 weeks (the normal period of support within an intervention), however, and certainly not over years.7 Lawton and colleagues show that exercise promotion in primary care can significantly increase activity and that this increase is sustained for up to two years.5 However, more falls (P=0.004) and injuries (P=0.03) occurred in the intervention group.

    We now have a sense of which types of exercise promotion are likely to produce sustained improvement in physical activity. EXERT (Exercise Evaluation Randomised Trial), based in the UK—which compared leisure centre based exercise on prescription, home based walking, and usual advice in primary care—provides four important lessons.9 Firstly, for most people over 65 (except perhaps those who fall) walking is as effective as leisure centre classes and is cheaper. Secondly, efforts should be directed towards maintenance of increased activity, using proven reinforcement methods like telephone support, follow-up of absences, and working with peer activity mentors. Thirdly, on cost effectiveness grounds, assessment and advice alone from an exercise specialist (for example, in a leisure centre) may be appropriate to initiate physical activity. Finally, subsidised schemes may be most effective for patients at higher absolute risk of falls, or with specific conditions for which particular exercise programmes may be beneficial.

    A randomised controlled trial in the United States of exercise counselling in primary care with a prescription for walking at either a “hard intensity” or a “high frequency” significantly improved long term cardiorespiratory fitness.10 However, overly optimistic expectations of patients who are inexperienced at exercising may cause disappointment and attrition. Interventions by primary care practitioners to ensure realistic expectations might increase the success of exercise promotion schemes and prevent the potential negative effects of failure.11

    The dialogue between the general practitioner or practice nurse and the underactive patient may be crucial to the success of exercise promotion. A randomised controlled trial in New Zealand included the negotiation of activity goals and the writing of a “green prescription” for exercise. Trained exercise specialists from a regional sports foundation gave follow-up telephone support over three months The results of this study indicated that including a green prescription in routine primary health care would significantly improve health, particularly for older people,12 and would provide better value for money than “usual care.”

    Lawton and colleagues’ study shows that exercise promotion through general practice can change behaviour if it is embedded in routine care, based on continuing contact and dialogue, and tailored to individual needs.5 We now have grounds for being optimistic that serious attention to exercise promotion could improve health and reduce costs, but much developmental work still needs to be done. One problem that Lawton and colleagues’ study reveals is the increased risk of falls (especially those resulting in injury) in women in the exercise group. Increasing exercise generally without specifically targeting muscle strength and balance may increase exposure to falls but not reduce the risk. Because encouraging brisk walking and other general physical activity can increase the risk of falls (particularly in people with a history of falls), we need a pragmatic approach. The next round of research and development needs to look at managing this risk.


    Cite this as: BMJ 2008;337:a2430



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