Tuesday, November 03, 2009

Official Advice on Exercise Pt 1

The example of exercise advice given from the health perspective was randomly chosen: I searched Google, found the recommendations from an NHS website and the job was done. It was the only article I read and as it lived up (or down) to my expectation by advocating a gentle approach that almost suggests you can exercise without any great effort, I looked no further. But this is not good enough because: 1) it goes against the principle of always trying to disprove your own assumptions; 2) it is only fair to look further.

So here is a record of my search for official advice on exercise to see whether it is clearly presented and easy to find. I will do this in two posts. The first will look at the sources of information on the Web; the second will look at the content of the advice and its consistency.

Sources of Information

1) Directgov is designed to be the citizens portal for government information and advice and is the obvious place to start. The front page has a link to a index page on 'health and wellbeing', where there is a section for 'healthy living' but this doesn't have exercise as a subheading so the only option is a click to another index page: 'more about healthy living'. Here again there is nothing about exercise I can go to 'Change4life' but there is also a heading 'sports facilities and events', which seems at first to be unlikely. Strangely it is what is needed as it contains links to:
keeping fit (young peoples section);
staying physically active (pensions and retirement planning section);
fitness advice on NHS Choices.
At last some information!

There was of course no need to go through the linky links, there is a search box. The search term 'exercise' threw up the 'sports facilities and events' page as the first hit but I ignored it because, at the time, I thought the strap line 'Find a local gym or sports facility and look up local and national sporting events' made it seem irrelevant. However I did strike gold because the next hit was a newslink to the 2004 report by the Chief Medical Officer's on exercise, which I was able to download from the DoH site.

(Totally by the way their search engine is a bit weird. The results for 'exercise recommendations' or 'exercise guidelines' offered 'NHS to offer acupuncture for back pain' as the first result)

2) Change4life. Apparently the Government is spending £75m on this campaign to encourage us to eat more healthily and exercise more. So surely this must be the place for good advice. It is aimed at families so presumably it's written to advise parents on what's good for them and their kids, ie its supposed to be read by adults.

Oh the bright colours! Oh the perky language! It makes you feel like you are being talked at by the presenters of Playdays. Here is the introduction to 'Why Change4Life?'
Well done! Visiting this site is your first step in making a Change4Life, and you're not alone. Lots of people like you are already enjoying making a Change4Life! The way we live nowadays means a lot of us, especially our kids, have fallen into unhelpful habits. This means all of us need to make small changes to eat well, move more, and live longer.

There is so much I could say about this but I will restrict myself to one small question. Why 'unhelpful' when the obvious word is unhealthy? Sometimes a single word can show a rottenness of thought behind the writing. Here is how they explain why we should encourage our kids to be more active:
Activity raises kids’ heartbeats and helps pump blood around their bodies. It’s like a mini workout for their lungs and muscles! It also decreases their chances of getting life-threatening diseases.

I am comatose with despair!

3) NHS Choices LiveWell. This fitness section is a proper grown-up site and actually quite good. The information on the why and how of exercise is clearly laid out and there is a good range of side links to supporting information (eg a link to Sustrans to help people get cycling and a video wall of tips from Olympic athletes). This is the place to find the Government's advice but this is not the end of the story because there are always other places to look.

4) More from NHS Choices. Entering the term 'exercise' in the search box brings up many more pages of advice that are not linked-to from the fitness site. A lot of them are plain pages of text and are thus probably excluded for looking a bit dull but they contain good, solid information. This on what type of exercise? is a good example. ( on a side note this page is not only dated it shows when it will next be reviewed. I wish this practice was more common)

5) Department of Health. This has more background information to support the exercise campaigns. From here you can Chief Medical Officers report as well as the NICE guidelines for health professionals on increasing physical activity. There is also the action plan published february this year, which brings together both the advice and plans to increase activity. This has to be done because the shocking statistics found in these documents show that:

Around 65% of men and 76% of women are not physically active enough to meet national guidelines (to be at least moderately active for at least 30 minutes on 5 or more days a week). 30% of boys and 39% of girls aged 2–15 years do not achieve the recommended physical activity levels for their age (at least 60 minutes of at least moderate- intensity physical activity each day).

Between 1995–97 and 2005, the average distance walked had dropped from 200 to 197 miles per person, per year. The average distance cycled fell from 43 to 36 miles per person per year.

6) Behind the Headlines This is a brilliant NHS site that looks at the actual research findings behind health stories in the news and puts them into context and assess how significant they might be. Although this is not the place for the official government advice it is worth checking So far they have analysed 243 stories related to lifestyle and exercise. If searching for articles about exercise it is important to remember that the search engine covers the whole of the NHS Choices site and so the phrase 'behind the headlines' should be included in the search.

7) NICE. As well as the guidelines for health professionals I mentioned earlier, NICE have produced a report on creating physical environments that support increased levels of physical activity. It can be downloaded from this page, where you can also have access to their background information. This is one of the fundamental issues and shows how any attempt to change peoples pattern of behaviour has far reaching ramification that reach into many other areas of government.

8) NHS Evidence In my rather sad way I got quite excited when I found this search portal for health information that covers published, research, grey literature, guidelines and reports. The results page gives the option of refining by type of publication.

9) Other Bodies. There are all sorts of other bodies that have some sort of stake in physical activity from the well known such as Sports England or slightly more esoteric like the Outdoor Health Forum but I feel that I am wandering away from the core subject of official advice into a thicket of bureaucratic bodies and background information and I know that madness lies there. However I must pass-on my favourite line from the website of the Physical Activity Alliance "Currently, the Alliance has no formal status; there is no legal entity; there are no staff, no premises, no agreed strategy or delivery plan/programme."  Brilliant!


travellinghopefully said...

Behind the Headlines is fantastic, I often have a nosy to reduce Daily Mail/Express induced high blood pressure. NHS Evidence is also fantastic for supporting evidence based practice (thank you for sharing my geekiness) and the DH website is a nightmare to navigate even when you know exactly what you're looking for. Though, occasionally this means that you get something that's pure serendipity.

As for Change4Life, I thought part of the purpose that it was encouraging children to lead their families into healthier ways, hence the "Me Sized Portions" etc and why I was advised how to get 3 of my 5 a day in me my breakfast from a broadly accented scamp whilst on hold at work the other day. That's only my assumption, but the principles and guidelines for the scheme do explain why the language is less than technical "Whilst the target audience is mums (and dads), the movement embraces kids for the simple reason that mums know they have to work with their kids, not against them. The movement therefore speaks in a way that mums know their kids will get. Whilst it falls short of being childish, its language is deliberately written in child accessible ways, using simple hooks like rhyming, 1 – 2 – 3, alliteration, colloquialisms etc.".
As for "unhelpful v unhealthy", the aim is that "It does not look back, or blame, or criticise". My perspective is that labelling people's behaviours as unhealthy has the knock on effect of reinforcing that person's self image as being unhealthy. I'm still shaking off the idea that I 'can't run' (playground conversation aged 9 or 10) and that I'm 'not sporty' (PE lessons aged 5-16). On a bit of a tangent, here was a really interesting programme on Radio 4 about the positive/negative effects of metaphor and language in health last week, just missed it on listen again but this article discusses it (I was more interested in the "crumbling" spine parts, than bluebells curing cancer bit).

A bit further into the Change4Life site, the activity section does get a bit more strident "In fact, kids need to do at least 60 minutes of physical activity that gets their heart beating faster than usual. And they need to do it every day to burn off calories and prevent them storing up excess fat in the body which can lead to cancer, type 2 diabetes and heart disease. It also keeps their bones healthy and encourages muscle strength and flexibility." Still not the BMJ, but I hope that helps to ease the despair!

Highway Kind said...

Excellent, thanks for the thoughtful reply TH but unfortunately I am still in despair.

Part of the reason is that I think it is a good and necessary idea to have a campaign like Change4Life. The information government provides is a bit buried and although the mini website in NHS Choices is good, you have to know where to find it. So something high profile is definitely good.

My problem with Change4Life is that it is patronising and badly written. Although the audience is the family most of the advice is aimed at the parent (ie what they should do for their kids), yet they are addressed as if they are 5 year olds. It is possible to write for children and adults (eg Harry Potter) but this is not done by writing down in such an obvious way. If they want to write for younger children they should have a separate section.

My frustration is that could have been really good if it had been a portal to different types of information for younger kids, older kids, adults for themselves and adults for their family. Instead it has homogenised the tone and made not particularly great for anyone.

Which brings me to unhelpful/ unhealthy. Here is the sentence again
" The way we live nowadays means a lot of us, especially our kids, have fallen into unhelpful habits. "

Now if this was about not doing enough for others it would be perfectly fine but it is not, so it leaves open the question of what is not being helped. Our habits are not contributing - but contributing to what? That word either opens up a load of ancillary questions of what ,how and why or it is meaningless. Or perhaps it means vaguely not quite right. In which case there is not much of a problem and no great need to do anything

Your point that we don't want to make people, especially kids, feel bad about themselves is well taken but saying there are health consequences to modern lifestyles does not cross that line and point the finger. It is the whole point of the site.

Changing peoples habits is very difficult but for it to happen there needs to be both an acceptance of the need for change and a belief that it can be achieved. If that change can be seen as also being fun and rewarding then so much the better. For sure the positive messages need to be heavily emphasised but that doesn't mean we should not be clear about what is wrong with the status quo.

(I would also argue that the sentence is wrong when it says 'especially our kids'. The evidence is that far more kids achieve the recommended levels of exercise than adults but that is a completely different issue).

Adele said...

Excellent! I was particularly interested in the fact that: '30% of boys and 39% of girls aged 2–15 years do not achieve the recommended physical activity levels for their age', being a mum. It amazes me how a child in this age category could NOT get enough exercise, they naturally run around all day and seek out opportunities to run, jump, skip, roll, hop...at least my little one does. I suppose this reflects families who are more likely to sit in front of the telly or computer games than go out together for a bike ride, sad to think they might be easing into the majority.

Highway Kind said...

I think the problem hits later on. This can be seen when you watch children going to school. The young ones often skip along whilst many of those going to secondary school seem to drag themselves there.

travellinghopefully said...

I have to admit that I was playing devil's advocate a bit with some of my comments. Certainly the DoH's claim that their language isn't patronising made me go "hmmmmm" when I read it. They do seem to have fallen into that trap of Being Fun, and that Being Fun = exclamation marks. Or writing that feels like it has invisible exclamation marks.

In terms of changing behaviours, I think that it's a stupendously complex challenge trying to change more than one person's behaviour. Where are the parents up to in terms of readiness for change? Where are children? Do the parents have the skills/knowledge/self-efficacy to action change? Are there external factors like the socio-economic situation that affect ability to make changes? How do you reach that stage where the child, parents, other carers etc are ready to change? What if they're at different stages?

I'm not saying that children are incapable of making changes for aspects of their lifestyle, but they lack autonomy. To compare with the age group that I work with, our team might go into a care home and recommend an exercise programme to improve a patient's strength and balance and help prevent her falling. If we don't have the home's staff on board to practise the exercises with her, then regardless of the patient's readiness for change, it aint going to happen.

I completely take your point (and thought the same) that "especially our kids" is off the mark. Personally, it seems to take further responsibility off the parents for their children's behaviour. People don't take enough responsibility for their own health - there's an expectation that the NHS is there to pick up the pieces ("I'm not giving up smoking - I've paid enough in taxes to be entitled to the NHS sorting me out if I get ill", that sort of thing). There is starting to be a change in health service thinking that we need to encourage people to take responsibility for themselves, otherwise there's not going to be enough NHS to go around. The difficulty with that is that it's often perceived as interfering by the state. I shall now get down off my soapbox.

Whether Change4Life works remains to be seen, I assume that there's some kind of outcome measures in place to assess that (hopefully more precise than 'there'll be less fat kids'). I'm just fascinated by the mechanics of health psychology and behaviour change.