Janathon 212 Day 15: Some progress

Janathon 212 Day 15: Run 3.17 miles, Time - slowish, Weather - crisp and cold, bright and blue

A glimmer of hope today: I managed to run most of the way without walking to reduce my heart rate. It was not fast but at least it was a sign that the current discipline might become  becoming manageable; a sign that things are not hopelessly stuck. Huzzah!

Everything I have read about base training emphasises that it is a matter of patience - and so patient is what I will be. I am now looking forward to my next run to see if the progress will be maintained.

But enough of me. I need to return to the subject of exercise and health and the evidence of benefit

The obvious place to start is Cochrane Reviews, which are systematic reviews of the primary literature in health care and health policy. They have done a number of reviews about the effects of exercise. The first I looked at concerned its effect on type 2 diabetes.

The findings were:

Fourteen randomised controlled trials comparing exercise against no exercise in type 2 diabetes were identified involving 377 participants. Trials ranged from eight weeks to twelve months duration. Compared with the control, the exercise intervention significantly improved glycaemic control as indicated by a decrease in glycated haemoglobin levels of 0.6% (-0.6 % HbA1c, 95% confidence interval (CI) -0.9 to -0.3; P < 0.05). This result is both statistically and clinically significant. There was no significant difference between groups in whole body mass, probably due to an increase in fat free mass (muscle) with exercise, as reported in one trial (6.3 kg, 95% CI 0.0 to 12.6). There was a reduction in visceral adipose tissue with exercise (-45.5 cm2, 95% CI -63.8 to -27.3), and subcutaneous adipose tissue also decreased. No study reported adverse effects in the exercise group or diabetic complications. The exercise intervention significantly increased insulin response (131 AUC, 95% CI 20 to 242) (one trial), and decreased plasma triglycerides (-0.25 mmol/L, 95% CI -0.48 to -0.02). No significant difference was found between groups in quality of life (one trial), plasma cholesterol or blood pressure.


So it had a good effect but not as overwhelming as promised in the video especially as it did not seem to improve quality of life.

Janathon 2012 Day 11: Circumspection

Janathon 2012 Day 11: Walk - 3 miles, Time 55min, Weather - clear and mild for time of year

I must make some sort of correction, or rather a reservation, to something I posted a couple of days ago.

I saw an illustrated talk on the benefits of exercise, which had been going round the internet, thought “that’s neat’ and posted it up. OK, up to a point - it is neat - but it is not the full story. I should have thought about it a bit more. 

I posted it because I am a believer in the benefits of exercise and it is a good demonstration but it is not the whole story. The story line is too strong and it seems the evidence is more equivocal than is claimed. 

This posting on the BMJ site is very good about the way we should look at such claims and  treat them with circumspection even if they support our own side - no make that especially when they support our own side.

The thing is that having posted the video clip I feel a sense of responsibility to delve a little deeper and find out what evidence there is about the link between exercise and health.

Janathon 2012 Day 7: Half and hour a day

Janathon 2012 Day 7: Walk - 3.5 miles, Time - 1hr, Weather - blue skies before the grey swept back in

I ought to be feeling shamefaced about the low level of activity in this years Janathon. A three and a half miles walk is more of a holding activity than anything else but it might be doing more good than I think.

This video is a little illustrated talk which proposes that exercise might be the most efficacious public health intervention. The surprising thing to me is how little is needed to have dramatic benefits. Just half an hours walk a day will do the job.

Obviously this is rubbish if you want to train for a marathon but it shows I should not belittle these little outings too much 

2011 Streak 288 (Tuesday Oct 18th): Fearful of drunkenness

2011 Streak 288 (Tuesday Oct 18^th): Cycle 13 miles, Time 1hr 5min, Weather clear and bright

The day was beautiful and I went out for a spin. No specialist cycling gear (apart from shoes), just out for a nice relaxed pootle, breathing deeply and taking-in the fine autumn views. There are some days when it is a privilege just to be able to get out and enjoy these moments.

There is a pleasure in cycling this way - head up instead of down. The only concession I made to the concept of fitness was a hill but apart from that it was all about looking around, not sweat.

The photo is of a pub called Martins Pond, and to show it is appropriately named it is viewed from across the pond. It is in Potton End, a village close to Hemel, which has recently offered a wonderful example of how small scale local government works - or rather doesn't work. (As it is to do with public health and exercise it is relevant to this blog, so I can talk about it).

The parish council put in a bid for funding to buy equipment for an outside gym (newspaper report).

However the the council later withdrew their bid because councillors later discovered that not many villages wanted it and there were fears that it would be used by drunk people coming out of a nearby pub. In addition several councillors said they were unaware of the original application. (Report here)

It is the last bit that amuses me. The council applies for something and then councillors deny they knew anything about it. It is wonderful how consistent politics is from national down to microscopic local level. if something blows up and becomes unexpectedly contentious, then if you can't blame the last lot you say you weren't there and didn't know anything about it. Brilliant.

It actually has all the hall marks a good idea thwarted by by people playing on general fears of rowdiness and the misbehaviour of drunks. My guess is that the councillors who made the initial application did not see it as at all controversial (in fact thought it was rather a good idea) but people living close to the site thought they might be inconvenienced and took against..

It is wonderfully easy for everybody to agree that we need to  encourage more exercise for the population as a whole. I don't think there are any dissenters. But attempts to actually do something are fraught with difficulties as there are always conflicting interests. This is a small example. 

For me the biggest example is the reluctance to do much to make the roads safer for cyclists and walkers, so that more people can incorporate physical activity into their normal getting about. Getting people to exercise is always difficult if it requires special equipment. clothing and arrangements but if it is something that can be done as part of the day or casually there is a much bigger chance it will happen.

Official Advice on Exercise Pt 2

Official advice on the amount of exercise needed is quite simple:

■ Children and young people should achieve a total of at least 60 minutes of at least moderate intensity physical activity each day. At least twice a week this should include activities to improve bone health (activities that produce high physical stresses on the bones), muscle strength and flexibility.
■ For general health benefit, adults should achieve a total of at least 30 minutes a day of at least moderate intensity physical activity on 5 or more days of the week.
■ The recommended levels of activity can be achieved either by doing all the daily activity in one session, or through several shorter bouts of activity of 10 minutes or more. The activity can be lifestyle activity or structured exercise or sport, or a combination of these.
■ It is likely that for many people, 45-60 minutes of moderate intensity physical activity a day is necessary to prevent obesity. For bone health, activities that produce high physical stresses on the bones are necessary.
■ The recommendations for adults are also appropriate for older adults. Older people should take particular care to keep moving and retain their mobility through daily activity. Additionally, specific activities that promote improved strength, co-ordination and balance are particularly beneficial for older people.

That’s all there is.

When I first read them I thought they were very soft. There is no mention of vigorous, nothing about raising the pulse rate or breathing heavily and nothing about being able to gradually do more with practice. As for breaking it up into 10 minutes units I thought it was the slippery slope to counting any slight movement as exercise.

But I was probably being a bit snooty because I run and know the feeling of wellbeing that sweeps through you after a good session. I therefore know in my bones that exercise is good for you. So my viewpoint is distorted especially as I have little understanding of the general level of inactivity in the population as a whole or how hard it is to start from a low base.

Reading the 2004 report by the Chief Medical Officer changed my mind (it can be downloaded here) as it shows the evidence base for the recommendations, which can be summarised by this quote:

The World Health Organization has reported that physical inactivity is one of the 10 leading causes of death in developed countries, producing 1.9 million deaths worldwide per year.21 It estimates that physical inactivity is responsible for the following proportions of ‘disability-adjusted life years’ in developed countries:

■ 23% of cardiovascular disease for men and 22% for women
■ 16% of colon cancer for men and 17% for women
■ 15% of type 2 diabetes
■ 12% of stroke for men and 13% for women
■ 11% of breast cancer. Becoming more active can bring substantial benefit.

There is a clear dose-response relationship between physical activity and all-cause mortality, and between physical activity and diseases such as coronary heart disease and type 2 diabetes: greater benefits occur with greater activity participation (see Figure 1). From a public health perspective, helping people to move from an inactive level to low to moderately active levels will produce the greatest reduction in risk. A physical activity energy expenditure of 500-1,000kcals per week (about 6-12 miles of walking for an average-weight individual, compatible with the current physical activity recommendations for adults) reduces the risk of premature death by 20-30%. These considerable health benefits hold for both women and men and are evident even up to the age of 80 years.

This is clear. If more people adopted this regime of moderate exercise there would be dramatic change. However in the back of my mind is the quote from Jerry Morris saying that vigorous activity was necessary and his survey of civil servant showed gardening was not enough. I presume later surveys have different results but is vigorous exercise really unnecessary?

It seems that there is might be some debate. In 2007 the American Heart Association modified its advice by incorporating vigorous exercise and resistance training. The base recommendation was still 30 minutes of moderate activity 5 times a week, but 3 sessions of vigorous exercise could be substituted, if preferred, or moderate and vigorous sessions could be mixed. The Guardian report of this change was exaggerated and had the headline “The era of gentle exercise is over: it’s official you’ve got to work up a sweat”, which is a complete misrepresentation (the NHS Behind the Headlines response is here). Although the American report was merely an enhancement of the existing recommendations, it did acknowledge that there were still some people who believed that only vigorous exercise had a health effect and that recent evidence gives some indication that vigorous exercise is more beneficial for cardiac disease.

However in terms of a public health message the last thing you want is debate. It is important to stand firm with advice and only change it when counter evidence is very clear. Any sign of confusion is an excuse for people to do nothing. You need only look at diet, where there is a perception of scientists always changing their minds (even if this is not the case) to see how that works.

Additionally getting people to move from nothing to something is very difficult and you do not want to make the task seem daunting. (Again diet is the example ‘5 a day’ for fruit and vegetables was chosen as a target that would not be too off-putting; it is not necessarily the optimum).

So I can now see why the current advice is good. It has a the maximum chance of making an impact but it needs to seep into the general consciousness in the same way as '5 a day'. If we walk on average only half a mile a day and 38% of adults have less than 30 minutes of moderate activity a week. There is a long, long way to go.

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!

More Jerry Morris

I have been thinking more about the article about Jerry Morris I linked-to recently and realise that I need to explain why I found it both interesting and uplifting.

The main reason is a straightforward admiration for anybody who has spent his life trying to make things better for others. Such people, who try to solve problems practically, based on knowledge and understanding, are the backbone of the country (compared to most of the people in the media who seem to float on clouds of opinion). Jerry Morris was a high level example and, from the evidence of the article, it looks as if he led a virtuous life.

Times Past

Another reason is probably nostalgia. When I read it I could almost imagine a black and white film of the forties with the central character calmly displaying determination in the face of adversity, moral strength, and practical intelligence (he would probably have to be played by John Laurie because I think it was the law at the time that all Scotsmen had to be played by John Laurie). But deeper than an internal cinema is the attraction of looking back at what has changed and what is still the same.

He worked when we were changing from a physically demanding life to the more domesticated, sedentary world we now inhabit. To be able to compare bus drivers to bus conductors was a wonderful opportunity because class, background, lifestyle, diet of both was very similar and it was possible to isolate the differences caused by exercise. This is no longer the case: there are very few conductors; there are far more differences between those who take exercise and those who don't and there are far more confounding factors.

I also found his regret at the passing of the can-do attitude of the 40s to be poignant. i am sure that it is not that we are any less practical or enterprising now but rather we have lost faith in the idea that national plans and initiatives can make things better. Our default position is cynicism and it is a shame that it is so. The post war period, up until the mid 70s, was probably the high point of optimistic thinking, ie a belief that life could be made better, planning could improve the lot of everybody and the application of science would be beneficial. It is not easy to recapture that mood but I still think there is a lot to recommend in the idea of rounding-up all the experts on a subject, sending them away to the Hebrides and not letting them back until they come up with a workable plan.

Applying the Lessons

Although he made is discovery a lifetime ago, there is now a general understanding of the importance of exercise, I am not sure the full message has been accepted. He is very clear that there needs to be vigorous exercise (gardening by itself is not enough) but a lot of the health advice offered today tones that down. We pussyfoot.

I looked at the exercise recommendations on the NHS Choices. Although it contains some sensible advice, nowhere does it mention the need to raise the pulse rate. Vigorous? The word is shunned as we cannot make even the tiniest suggestion of effort in case we scare people off. I understand the motive, and we certainly don’t want to make things seem overly forbidding, but our bodies were evolved for exercise; there is pleasure in breathing heavily. More to the point vigorous exercise is necessary and we are diluting what we know to be true in an effort to make it more palatable. That does nobody any good.

“Exercise normalises the working of the body”. I like that quote. I think it should be at the head of all the health advice.

The Necessity of Exercise

This quote says it all:

“For the first time in history,” says Morris, “the mass of the population has deliberately got to take exercise. It’s a new phenomenon, which is not appreciated.” For decades he has tried to persuade governments to make exercise easier. He was involved in the pioneering English National Fitness Survey of 1990, which found that half of women aged 55 to 64 could not comfortably walk a mile. These people were in effect disabled. The government ignored the report. Since then, British exercise levels haven’t changed much. His voice becomes high-pitched with outrage: “Just imagine, what historians in the future are going to say about the way we’ve allowed this epidemic of childhood obesity. ‘Disgrace’ is a sort of mild word.”