RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Health Promotion in General Practice

SC1 General Practice

2018-2019

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LEARNING OUTCOMES

By the end of this module you should be able to:

1. Appreciate the value of brief interventions in General Practice to promote

healthy living, prevent disease, and to detect disease at an early stage

2. Know where to access resources for both you and your patient with regard to
health promotion

3 Be able to counsel patients with regard to lifestyle changes which can have an
impact on their morbidity and mortality
WHAT IS HEALTH PROMOTION?

‘The process of enabling people to increase control over, and to improve, their health. It
moves beyond a focus on individual behaviour towards a wide range of social and
environmental interventions’

Or

‘Prevention is better than cure..’

Interventions leading to improved diet, reduced alcohol intake, regular exercise and
smoking cessation could prevent up to 80% of premature heart disease, stroke and type
2 diabetes and over a third of cancers [WHO 2013], so should be attempted whenever
possible
HEALTH PROMOTION: LOCAL RESOURCES
HEALTH PROMOTION: LOCAL
HEALTH PROMOTION: GLOBAL
WHO 2013
HEALTH PROMOTION: GENERAL PRACTICE

Smoking

Obesity Vaccination

Health
promotion

Screening
Alcohol in general
practice
 CYCLE OF CHANGE: GP INTERVENTION

Recommending Advising &

motivating

Signposting
resources
Reassuring

Prescribing /
encouraging
/referring
Encouraging
 Smoking

Obesity Vaccination

Health
promotion

Screening in
Alcohol general
practice
BMI AND DIAGNOSIS OF OBESITY
Classification BMI
Underweight <18.5kg/m2
Normal 18.5-
24.9kg/m2
Overweight 25-29.9kg/m2

Obese class 1 30-34.9kg/m2

Obese class 2 35-39.9kg/m2
Obese class 3 >40kg/m2

Online BMI calculator:

Safefood.eu

Multiple apps available

 60.3% of adults
OBESITY IN EUROPE in Ireland are
overweight or
obese
 Obesity
Complications
Hypertension
Ischaemic heart Sleep apnoea
Respiratory
disease Cardiovascular Asthma
Stroke
Dyslipidaemia

Gout Type II
Musculoskeletal Endocrine diabetes
Osteoarthritis of the knee
Back pain

Cancer (inc oesophagus, colon,

pancreas) Miscellaneous And more..
Impaired fertility ………
 ICGP WEIGHT MANAGEMENT ALGORITHM

Irish College of General

Practitioners’ quick
reference guide for weight
management in Primary
Care

1. Communication
2. Initial assessment
3. Benefits of weight loss
4. Relevant history
 Nutrition

OBESITY: COMPONENTS

Obesity

Physical
Nutrition
activity
FOOD DIARY / CALORIE INTAKE

Lots of apps..
IRISH NUTRITION AND DIETETIC INSTITUTE
 Nutrition

OBESITY: COMPONENTS

Obesity

Physical
Nutrition
activity
PHYSICAL ACTIVITY

• Insufficient physical activity is 1 of the 10 leading risk factors for death worldwide -
key risk factor for non-communicable diseases (NCDs) such as cardiovascular
diseases, cancer and diabetes.

• Globally, 1 in 4 adults is not active enough

– More than 80% of the world's adolescent population is insufficiently physically
active.

• Inactivity is a cardiovascular risk factor

• Recommend 30 mins activity per day, at least 2.5 hours per week
 WHAT IS PHYSICAL ACTIVITY?!
Moderate

Walking briskly (approx 5km per hour)

Cycling slower than 16 km per hour

Doubles tennis

Ballroom dancing or gardening!

Vigorous

Race walking, jogging or running

Cycling 16 km an hour or faster

Singles tennis

Heavy gardening
PHYSICAL ACTIVITY RESOURCES

http://www.getirelandactive.ie/

Dr Mike Evans 23 1/2 hours

PHYSICAL ACTIVITY & WEIGHT LOSS

Physical activity Comparison Effect on weight loss

Exercise No intervention Small weight losses proven

Exercise and diet Diet Increased weight loss than diet alone

Intense exercise Less intense exercise Increased weight loss than less intense
exercise
Greater reduction in fasting serum glucose than
less intensity exercise
Exercise No intervention Decreased diastolic BP, decreased
triglycerides, decreased fasting glucose

Shaw KA, Gennat HC, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database of
Systematic Reviews 2006, Issue 4. Art. No.: CD003817. DOI: 10.1002/14651858.CD003817.pub3.
 BENEFITS OF PHYSICAL ACTIVITY
• Prevention of weight gain: 150- 250 minutes/wk moderate physical activity (PA)

• Clinically significant weight loss: >250 minutes/ wk moderate PA

• Physical activity is beneficial in obesity even beyond weight loss

• Aerobic activity improves:
• Serum lipoprotein concentrations
• Body composition
• Aerobic capacity
• Systemic blood pressure (long term aerobic exercise)
• Long-term exercise programs cause a greater decrease in abdominal fat than lower
body fat and help maintain it – important in abdominal obesity

• Weight bearing exercises: prevent bone loss associated with aging

• PA can prevent or reverse almost 1% of bone loss per year in the lumbar spine
and femoral neck in both pre- and postmenopausal women

• Exercise training appears to significantly reduce the risk and number of falls and fractures

1. Donnelly et al Med Sci Sports Exerc. 2009 Feb;41(2):459-71. 2. Uptodate.com 3. Warburton et al CMAJ. 4. The benefits
of physical activity. Centers for Disease Control and Prevention
http://www.cdc.gov/physicalactivity/everyone/health/index.html
EFFECT OF PHYSICAL ACTIVITY ON
INCIDENCE OF MALIGNANT DISEASE

Condition Effect of physical activity

Colorectal cancer 30 to 40 % risk reduction relative to those who are sedentary,
regardless of BMI
Breast cancer Moderate to vigorous activity shown to reduce risk- may be
BMI and age related
Endometrial cancer 20 to 40 % reduction in risk of endometrial cancer, greatest
reduction in risk among those with the highest levels of
physical activity
Lung cancer Inverse association between physical activity and lung cancer
risk

http://www.cancer.gov/cancertopics/factsheet/prevention/physicalactivity
 Smoking

Obesity Vaccination

Health
promotion

Screening in
Alcohol general
practice
SMOKING STATISTICS

• Smoking kills up to half its users

• Long-term smokers have a life expectancy about 10 years less than non-smokers

• In Ireland, almost 5,200 people die of smoking-related illness each year – almost
20% of deaths in the country:
– Cancers (44%)
– Circulatory diseases (30%)
– Respiratory disease (25%)
– Digestive diseases (1%)

• Health expenditure on smoking-related diseases approx Euro 500 million in 2009

 NATIONAL SMOKING POLICY
• Department of Health policy on smoking:
Tobacco Free Ireland: promote and move
towards a tobacco free society by 2025
• Physician advice to quit smoking increases abstinence rates
• National comprehensive cessation services with full or partial cost-coverage are
available to assist tobacco users to quit in only 24 countries, representing 15% of the
world's population

HSE SMOKING CESSATION HELP

Nicotine replacement therapy is free of charge for patients with a medical card

https://www.quit.ie/
EFFECTIVENESS OF SMOKING CESSATION
INTERVENTIONS BASED ON COCHRANE
REVIEWS

Intervention Comparison Increased chance of

quitting* successfully
Self-help No intervention 24%
Doctor advice Brief vs none 24%
Intensive vs none 84%
Intensive vs minimal 37%
Telephone counselling None 41%
Nicotine replacement Placebo 58%
Buproprion Placebo 94%
Varenenicline Placebo 133%

*Quitting here defined as abstinence>/=six months

TIMELINE OF HEALTH BENEFITS OF QUITTING
STOP SMOKING INITIATIVES

2009: Backed by
evidence that smoking in
movies causes youths to
want to light up, the World
Health Organization
called on countries to
severely restrict such
depictions
 Smoking

Obesity Vaccination

Health
promotion

Screening in
Alcohol general
practice
VACCINATION

Click on image to go to www.immunisation.ie

CHILDHOOD IMMUNISATION SCHEDULE

BCG:
Currently not available in
Europe = supply issue

BCG vaccination clinics in

HSE Clinics and Maternity
hospitals have been
postponed until new stock
arrives.
SCHOOL PROGRAMME IMMUNISATIONS

Age Where Vaccination

4-5 years Primary school 4 in 1 (diphtheria, polio, tetanus, pertussis)
MMR

First year Secondary school Tetanus, low dose diphtheria and pertussis

Meningitis C
12-13 year old girls: Human papilloma virus (HPV) –
two doses (if >15 years of age need three doses)
 OTHER VACCINATIONS
Patient Vaccination When?
Pre-pregnancy MMR At least one month before pregnancy

Pregnant Pertussis Between 27-36 weeks gestation Leaflet

Influenza Any time during pregnancy
High risk patients – chronic Influenza Annually
heart conditions, chronic
respiratory disease, diabetes
mellitus, immunosupression
>65 years of age, or >65 Pneumococcal Pneumococcal vaccination details
years with risk condition vaccination
Overseas travel Dependent on origin Travel vaccination information
and destination of
traveller
Healthcare workers Influenza Annually
Hepatitis B Pre-employment
Laceration/injuries Tetanus immune Post-exposure prophylaxis of tetanus-
globulin prone wounds in pts with
inadequate/unknown tetanus
immunisation status
 Smoking

Obesity Vaccination

Health
promotion

Screening in
Alcohol general
practice
SCREENING

• ‘The presumptive identification of an unrecognised disease or defect by the

application of tests, examinations, or other procedures which can be applied rapidly’

• Screening tests are carried out on ASYMPTOMMATIC patients

• Details of screening tests and programmes carried out in Ireland are contained in the
EBM screening module

• Screening in General Practice includes national screening programmes, as well as

case finding in patients who attend, sometimes for other reasons
– ie Opportunistic blood pressure testing, blood glucose testing, lipid etc.
 SCREENING IN IRELAND AND IN GP

Disease Test Common presentations in General Practice:

• A 47 year old man attends asking for a PSA
Cervical cancer Cervical smear test. Do you do it?
(CervicalCheck)
• A 22 year old footballer says that his mum
Breast cancer Mammography wants him to have a ‘heart check-up’ because
(BreastCheck) a team-mate collapsed and died during a
match last year. What do you do?
Bowel cancer Faecal occult blood
• Do you encourage your female patients to
(BowelChecK)
attend for cervical screening?
Diabetic Digital retinal • Do you encourage your older female patients
retinopathy photography to attend BreastCheck when they get an
screening (RetinaCheck) appointment?

Inborn errors of Heel prick test

metabolism
‘HEALTH CHECKS’ IN GENERAL PRACTICE

Debate regarding value of ‘health checks’ in general practice:

Cochrane review 2012 (Krogsboll et al.)

‘General health checks did not reduce morbidity or mortality, neither overall nor for
cardiovascular or cancer causes, although the number of new diagnoses was increased.’

Systematic review BJGP 2014 (Si et al.)

‘General practice-based health checks are associated with statistically significant, albeit
clinically small, improvements in surrogate outcome control, especially among high-risk
patients. Most studies were not originally designed to assess mortality.’

In practice, most GPs will use the opportunity to check blood pressure and discuss
concerns with the patient, offering advice about lifestyle / BMI / smoking etc.
 Smoking

Obesity Vaccination

Health
promotion

Screening in
Alcohol general
practice
ALCOHOL IN IRELAND: STATISTICS

• 2013:
– >50% of Irish people who drink alcohol do so in a harmful manner
• Too much in 1 sitting or
• More than the recommended number of standard drinks/ week
– Alcohol-related discharges accounted for 160,211 bed days in public hospitals,
that is 3.6% of all bed days that year – a cost of €1.5 billion (this does not include
cost of emergency charges, GP visits, psychiatric admissions or alcohol
treatment services)
– Over 5,000 unemployed people in 2013 had lost their job due to alcohol use
– The estimated cost of alcohol-related absenteeism from work was over €41
million

• 20% of the population do not drink alcohol

• Alcoholic liver disease:
– Rate trebled between 1995 and 2013 in 15-34 year olds
– Makes up >80% of all chronic alcohol-related disease
SUMMARY

• Health promotion is a vital daily activity in General Practice

• Potential for huge impact on health and wellbeing of patients
• Abundant resources online for patients, doctors and students
• Cycle of change crucial (slide 8)
• Ongoing relationship with patient allows for opportunistic intervention / motivational
interviewing etc.
• Interventions leading to improved diet, reduced alcohol intake, regular exercise and
smoking cessation could prevent up to 80% of premature heart disease, stroke and
type 2 diabetes and over a third of cancers [WHO 2013], so should be included
whenever possible in GP consultations
REFERENCES: CLICK ON IMAGES FOR LINKS

Shaw KA, Gennat HC, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database of
Systematic Reviews 2006, Issue 4. Art. No.: CD003817. DOI: 10.1002/14651858.CD003817.pub3

Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing
morbidity and mortality from disease. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.:
CD009009. DOI: 10.1002/14651858.CD009009.pub

Si S, Moss JR, Sullivan TR, Newton SS, Stocks NP. Effectiveness of general practice-based health checks: a
systematic review and meta-analysis. Br J Gen Pract. 2014 Jan;64(618):e47-53.