Heart Disease as One of the Leading Causes of Mortality - Essay Example

Critically analyse whether there is any short term and/or long term benefit in running an exercise referral scheme to modify risk factors for heart disease Introduction: Heart disease is one of the leading causes of morbidity and mortality among the developed countries. Atheromatous disease of coronary arteries is the most important single cause of death in the western world and Atheroma is the commonest cause of angina pectoris leading to myocardial infarction and its complications. The risk factors in aetiology of heart disease are complex and much of its understanding is based on epidemiological evidence. It has been seen that geographical difference between countries in the manifestation of all aspects of heart disease is evident but immigration studies conducted in the West suggest that cultural factors such as smoking and improper diet outweigh genetic and environmental factors in their effects. Arterial hypertension, stress, hypercholesterolemia and obesity are all contributory factors in the genesis of heart disease. Conditions like hyperlipidemia and diabetes also contribute to the morbidity associated with this disease. Though all these factors are varied in nature yet a sedentary lifestyle is generally associated with the development of obesity, high blood pressure, atherosclerosis etc which are again related to the high incidence of cardiovascular problems prevalent in the developed countries. Obesity in itself is a weak risk factor for heart disease but in Britain, it is closely associated with the most common form of hypercholesterolemia which in turn is crucial in the genesis of heart   disease. It is proved beyond doubt that sedentary behavior has a detrimental effect on health which can only be reversed through physical activities. All communities showing low physical activity have a higher prevalence of heart diseases. Hence the need to encourage the communities to adopt a healthy lifestyle in which regular physical exercise is a part of the daily routine, has been adopted by the governments of Europe and USA. Taking a serious view of problems associated with sedentary existence, this subject has become a public health priority in many countries. Hundreds of community based exercise referral schemes have been established to increase physical activities. The government policy in England has developed a system to support exercise referral scheme or ‘exercise on prescription’ to increase the uptake of healthy lifestyle behaviour in the general population. It aims to encourage people to engage in regular physical activity working in partnership with primary care and local leisure services. Exercise officers are deployed who closely supervise the physical activities of people sent to them under this scheme. The role of physical activity in mitigating the ill effects of cardiovascular disease has been known for a long time and some guidelines are also available for its prevention through a proper regimen of exercise yet modern lifestyle has only propelled the population towards rising incidence of heart disease and its attendant problems. For prevention of cardiovascular diseases adults should undertake at least 30 minutes of moderate intensity aerobic physical activity, i.e. expenditure of 5 – 7.5 calories per min of energy, five times a week. This is where the exercise referral scheme assumes Page1 of 6 significance and can be aptly defined as referral by a primary care clinician to a tailored programme of increased physical activity with an initial assessment, monitoring and supervision throughout. The broad framework of this scheme is the same but minor variations exist in different places. Warwickshire exercise referral scheme called PACE is designed around 24 exercise sessions over 12 weeks in local leisure centers where there are provisions for gym activities, swimming, aerobics, water aerobics etc. Some schemes have also included gardening, walking, yoga and meditation. The basic structure remains the same in which trained exercise officers encourage people to increase the level of physical activity within a supportive environment, helped by experienced and qualified leisure centre staff that are aware of the best exercise for the patient and will design a personal training programme for each individual. It is recommended that this scheme should be available to people who meet certain specific criteria. Though we are dealing with heart disease it is important to note that these schemes are also being popularized for conditions like mental diseases, diabetes, prevention of falls, low back pain, osteoporosis and also to combat psychosomatic problems like anxiety, asthma and to improve the general health of individuals in a community. Scope of exercise referral schemes: As this scheme is a community based programme, its outreach and impact should be tremendous. Local medical practitioners are in the best position to influence the lifestyle of their patients positively. A family practitioner working in tandem with committed people who can teach and supervise patients in their daily exercise regime can go a long way in decreasing the incidence of heart disease in a community. Yet, the scheme has not achieved the desired results and several studies have been conducted to ascertain the reasons for its success or failure and also to understand its benefits in modifying risk factors for heart disease in both short and long term.     Studies to Assess the Effectiveness of this Scheme: Many research scholars and analysts from department of primary care and public health institute have conducted studies to assess the effectiveness of this scheme. In the journal of public health, 2005 a population based analysis report was published which assessed the access to exercise referral scheme which is the first step to ensure the success of any project. Their approach was to conduct a register based study in which the number of patients referred to the scheme and their characteristics was quantified. It was a five year long study in which data were collected prospectively from patients register for referrals made to the exercise referral scheme in north- West England within a geographically defined population. It concluded that the commonest cause of referrals was cardiovascular risk factors and musculoskeletal disorders. In the cardiovascular category, the number of females referred for exercise was 23.8% as compared to 39.4% males and the three main reasons for referral were found to be high blood pressure, angina and previous episode of heart attack. Overall, the largest number of patients referred to this scheme was found to be between 55- 64 years of age. The average age of referrals for Page 2 of 6 males and females was almost the same, i.e. 52.8 years for males [SD 12.2] and 51.3 years for females [SD 12.6]. Among the total number of patients referred 60.8% of the cases were females. As this was a comprehensive study spread over a period of five years, it was found that only 4% of the at risk population was referred to this scheme and among the adults referred more than half were between the age group of 45- 64 years. Based on all the data collected this study concluded that the interventions had a modest impact on increased physical activity but the gain was not sustained for even a period of one year. All general practitioners were not referring cases to the exercise referral scheme. Majority of patients were referred by a small number of doctors who were convinced of the merit of this scheme. After a careful analysis of all aspects of the exercise referral scheme it was concluded that the scheme was unlikely to contribute significantly to increased physical activity which could mould or arrest the progress of cardiovascular disease as desired. This study mooted the idea of neighborhood or area based interventions as its effectiveness potential was likely to be much more. A larger number of people living in the locality could be motivated to make healthy changes in their lifestyle thus modifying the risk factors of heart disease in both long and short term. A neighborhood group could be encouraged to lessen the intake of saturated fats and incorporate polyunsaturated fatty acids in their diet thus gradually decreasing the risk of hyperlipidemia and its progression to heart attack if left unchecked. A smaller group hailing from the same area was more likely to carry on with their exercise regimen and accrue the benefits of increased physical activity over a period of time. Traditional exercise referral scheme is best suited for those in need of strictly supervised exercise activity like patients recovering from a recent attack of stroke or myocardial infarction. Nefyn H Williams, PhD, Maggie Hendry, A, Research Fellow and others from department of primary care and public health school of medicine, Cardiff University North Wales clinical school Wrescam conducted a systematic review of the effectiveness of exercise referral scheme in adults and some enlightening results were obtained. The method of study adopted was randomised controlled trials, observational studies, process evaluation and qualitative studies of all exercise referral schemes encouraging physical activities. Randomised control trial results were combined in a Meta analysis where there was sufficient homogeneity thus negating the impact of diverse factors which could affect the patients under study in different ways. After a careful study and analysis of the results obtained it was concluded that 17 sedentary adults would need to be referred for 1 person to become moderately active. The small effect may be partly due to poor rates of uptake and non adherence to exercise schemes. This clearly proves the ineffectiveness of this scheme in motivating patients to come forward and follow an exercise schedule. Thus, it underlines the truth that exercise referral scheme has a small effect on increasing the physical activity in sedentary people making it an ineffective   tool for effectively modifying risk factors associated with  heart disease. The study included some randomized controlled trials and the meta analysis of exercise referral scheme compared with controls had some anthropometric, physiological and Page 3 of 6 biochemical outcomes .The analysis of these outcomes could be used to improve future exercise schemes taking a more realistic view of the possible benefits and cost effectiveness of the entire exercise. In three randomized controlled trials and one non randomized controlled trial study outcomes such as BMI, waist-hip ratio, percentage of body fat, BP, blood cholesterol etc were measured. There was no statistically significant difference in the outcomes between exercise and control groups. Just one parameter i.e. skin fold thickness was reduced by 8% in the exercise group at the completion of 16 weeks of   regular exercise. One startling revelation was that the change in physical self profile of patients with change in their skin fold thickness prodded them to adhere to the exercise scheme but changes in the cardiovascular fitness did not produce the desired result of continuing with the increased physical activity schedule offered by the exercise referral scheme. This study also assessed the cost effectiveness of the scheme together with the barriers encountered by patients in following this regime. They have concluded that exercise referral scheme was more costly than the usual care provided by health professionals and owing to its poor attendance was not an efficient use of resources. They suggested that if future exercise referral schemes were to be commissioned by NHS, the main challenge would be measures to increase uptake and improve adherence by addressing the barriers detected in the study. Some of the reasons of adherence as gauged by the study were found to be professional, supportive, encouraging and friendly services provided by the staff in leisure centers. This could be further strengthened to create a congenial environment where people felt free to come and follow the exercise schedule tailored to their individual needs. The reasons for non adherence were found to be lack of self efficacy, poor body image, poor time management and poor organization of scheme, to list a few. The five days a week, thirty minute schedule proposed by guidelines on prevention of cardiovascular disease could be too high a target for many patients at risk of   heart disease. This could be toned down to suit the individual patient threshold for exercise. It is important to take a serious note of these barriers and devise a scheme which is more acceptable and encourages people to gradually uptake a healthy lifestyle. The importance of exercise referral scheme cannot be minimized by the initial failures encountered in its initial years. The study conducted by the department of primary care also included some process evaluations which found sustained increase in physical activity among people adhering to the programme with improvement in physiological outcomes like fall in blood pressure, pulse, resting heart rate, BMI and weight. Positive life style changes were also reported. The results drawn by this study are in agreement with NICE public intervention guidance on increased physical activity which states that exercise referral scheme should only be recommended if they are part of a properly designed and controlled research study to determine effectiveness. The scheme also has a vital role in conducting exercise for rehabilitation of cardiovascular patients. The rehabilitation programme for such patients is vital as it will strengthen their heart muscles and reduce the risk of suffering from further attacks. Page 4 of 6 Conclusion: It can be concluded that in the present day scenario the role of exercise referral scheme to modify the risk factors of heart disease and serve a positive role in giving short and long term benefits is neither feasible nor practically sustainable. Yet, from the various studies conducted on its effectiveness, it can be assumed that if properly designed and implemented, such community based schemes can play a major role in modifying the risk factors of heart disease and providing a healthy life to all people who come under its purview. Page 5 of 6 Work Cited 1. Dept. Of Health. Saving Lives: Our Healthier Nation. London. The Stationery Office.1999 2. MMWR weekly. Prevalence of physical activities including lifestyle activities among adults. United States. 2000-2001. MMWr weekly 2003; 52:764-769 3. Harrison RA, Roberts C, Elton PJ. Does primary care referral to an exercise programme increase physical activity one year later? Public Health 2005; 27:25-32 4. Lord JC, Green F. Exercise on prescription: Does it Work? Health Educ J1995; 54:453-464   5. www.extend.org.uk 6. www.bhf.org.uk 7. www.bcs.com 8. Nefyn H Williams, Maggie Hendry, Barbara France, Ruth Lewis, Clare Wilkinson. 2007. Effectiveness of Exercise- Referral Schemes to Promote Physical Activity in Adults: Systematic Review. Page 6 of 6 Read More