As defined in the most recent report106 supporting Australia’s physical activity and sedentary guidelines for adults, six terms apply to this section.
Physical activity – Any bodily movement produced by skeletal muscles that expends energy. This includes activities that use one or more large muscle groups for movement in the following domains:
- Occupation (eg. paid and unpaid work)
- Leisure (eg. organised activities such as sports, as well as exercise and recreational activities)
- School (eg. physical education and active play during recess and lunch breaks)
- Domestic (eg. house work, shopping and gardening)
- Transport (eg. walking, cycling or skating to get to or from places).
Sedentary behaviours – Any waking activity that involves sitting or lying down, with little energy expenditure (ie. <1.5 metabolic equivalent), including in the following domains:
- Occupational or educational (eg. sitting at work or school)
- Leisure (eg. watching TV, reading, sewing, computer use, social networking)
- Transport (eg. sitting in a car).
Metabolic equivalent (MET) – The unit used to define levels of activity, in multiples of resting metabolic rate. One MET is defined as energy expenditure at rest, usually equivalent to 3.5 mL of oxygen uptake per kilogram per minute.
Intensity –The rate of energy expenditure required for an activity, usually measured in METs. Physical activities are often divided into ‘light’, ‘moderate’ and ‘vigorous’ levels of intensity. Light activities include those that require standing up and moving around, with an energy expenditure of 1.6–2.9 METs. Moderate activities require some effort, but allow a conversation to be held (eg. brisk walking, gentle swimming, social tennis), with energy expenditure of 3.0–5.9 METs. Vigorous activities make you breathe harder or puff and pant, depending on fitness (eg. aerobics, jogging and some competitive sports), with energy expenditure equal to or greater than 6 METs.
Frequency – The number of times a behaviour (eg. walking, running, sitting) is carried out per day or per week.
Duration – The time spent in each session of a behaviour (eg. minutes of walking or sitting per session), or the total time spent in a behaviour in a specific period (eg. minutes of walking per week). Accumulation describes ‘collecting’ short bouts of a behaviour (eg. walking or sitting) to achieve a total amount of that behaviour over a specified time (eg. a day or a week).
Ask and assess
In assessing physical activity and sedentary behaviour, it is important to judge a patient’s level of activity against appropriate population recommendations. Australia’s physical activity and sedentary behaviour guidelines provide age-specific recommendations for both physical activity and sedentary behaviour. These are summarised in Table 15 in Section 3.5.2.
Physical activity: when, how and who to assess
Methods of assessment
The optimal method of assessing physical activity and sedentary behaviour in general practice is unclear. Options include taking a history, brief questionnaires or structured verbal questioning and the use of objective measures of physical activity, such as pedometers.
History-taking should include the type, intensity, frequency and duration of bouts of physical activity. In addition, physical activity in all domains (occupation, domestic, leisure and transport) should be assessed, as well as the extent of sedentary behaviours. History-taking should also address barriers to, and facilitators of, physical activity in order to facilitate behavioural change.
Brief questionnaires/questions are not recommended as they appear to be less effective than history-taking for identifying adults at risk of not meeting physical activity guidelines.108 A brief questionnaire tested in adolescents against an accelerometer determined physical activity levels had sub-optimal diagnostic performance with low sensitivity.109
Pedometers are an option for measuring steps per day, with 10,000 steps suggested as a reasonable target for healthy adults.110 This may be higher in children (13,000–15,000 for boys, 11,000–12,000 for girls) and adolescents (10,000–11,700),111 but somewhat lower in older adults (7000–10,000).112 However, these estimates may be higher than necessary to be equivalent to physical activity recommendations and health benefits appear to accrue at lower levels of steps per day.113 It should also be noted that pedometers do not measure non-ambulatory physical activity, such as cycling or swimming.
Advise and assist
Provide age-specific advice on meeting recommended levels of physical activity and avoiding exceeding recommended levels of sedentary behaviour (refer to Table 15). The message that any physical activity is better than none is important. If a patient does not already engage in regular physical activity, they can be encouraged to start by doing some, and then gradually build up to the recommended amount.
Australia’s physical activity and sedentary behaviour guidelines for children, young people and adults
Several interventions for improving physical activity in sedentary adults have been shown to be effective in primary care,123 resulting in a higher likelihood of achieving recommended levels of physical activity, or increasing physical activity (odds ratio 1.42 [95% confidence interval, 1.17–1.73], number needed to treat for one additional sedentary adult to meet guideline recommended levels of physical activity = 12). Most interventions included written materials and two or more sessions of physical activity advice or counselling, delivered face-to-face. Other intervention components included the use of written exercise prescriptions and supplementary advice or counselling by telephone. Exercise prescription has demonstrated effectiveness and using pedometers as part of exercise prescription may have additional benefits.124
Interventions targeting sedentary behaviour have not been tested in the general practice setting, but evidence suggests substantial reductions are possible when it is done in workplaces (eg. through use of sit–stand desks).125 Advice about reducing sedentary time at work should therefore be considered in relevant patients.
The health risks of moderate intensity physical activity are low. However, there are certain conditions that place patients at higher risk and require clinical assessment and supervision, including:
- unstable angina
- recent complicated myocardial infarction (within three months)
- untreated heart failure or cardiomyopathy
- resting heart rate >100
- symptoms such as chest discomfort or shortness of breath on low exertion
- severe aortic stenosis
- uncontrolled diabetes
- unstable respiratory disease.
Sedentary individuals should be discouraged from undertaking sudden vigorous physical activity in favour of starting with moderate activity to reduce any transient increased risk of cardiovascular events.126
Patients may be referred to cardiac rehabilitation or physical activity programs, or classes run by local community organisations. Some patient groups may particularly benefit from referral to group programs such as those for socioeconomically disadvantaged women.127
Examples of exercise programs for referring your patients:
- Heartmoves is the Heart Foundation’s gentle physical activity program run by accredited exercise professionals and suitable for people with stable long-term health conditions such as heart disease, diabetes or obesity.
- Heartline (1300 36 27 87) is a telephone service staffed by trained healthcare professionals who provide information on CVD management, nutrition and healthy eating, blood pressure, smoking cessation and physical activity. Information on relevant support programs and information booklets on a range of topics is also available.
- HEAL program is a lifestyle modification program designed to improve nutrition and physical activity and promote self-management for people who are overweight or obese with, or who are at risk of developing, a chronic disease.
Information on local physical activity programs may also be available from your local council. State government departments of sport or recreation have databases of local sport and recreation organisations in each state/territory:
These should be included in a practice directory (refer to Section 4.5.4)
Refer to Chapter 5 for information on other exercise programs and resources.
Patients who are insufficiently active and who have a chronic medical condition and complex needs may benefit from referral to an accredited exercise physiologist or physiotherapist. For referral to an exercise physiologist, you can use the ‘find an exercise physiologist’ feature of the Exercise and Sports Science Australia (ESSA) website.
It should be noted that there is limited research examining the effectiveness of exercise referral. Moreover, adherence to such referrals is frequently poor (<50%).128 For a summary of the evidence and physical activity recommendations for multiple conditions, refer to ESSA’s position statements
Patients who are insufficiently active and who have a chronic medical condition and complex needs may also benefit from a GP Management Plan and Team Care Arrangement under Medicare’s CDM GP services (formerly Enhanced Primary Care). Refer to Chapter 4 and Chapter 5 for more information about what is available under Medicare, including links to MBS templates.
Factsheets are a good way for general practice teams to provide their patients with information related to physical activity and various conditions.
Patients should be reviewed at 3–6 month intervals, determined by the general practice team in line with the MBS. The practice information system should generate reminders or lists of patients overdue for follow-up (refer to Section 4.5.1).
Many patients find it difficult to sustain changes in physical activity, especially if it is not a regular part of their daily activity. Evidence from randomised controlled trials on techniques for improving adherence to physical activity promotion advice in primary care is limited. However, a systematic review of interventions to improve adherence to exercise for chronic musculoskeletal pain in adults suggests:129
- the type of exercise prescribed (eg. aerobic versus resistance exercise) does not influence levels of exercise; therefore, patient preference should be considered in an attempt to motivate and initiate a new exercise program
- interventions such as supervised or individualised exercise therapy may enhance adherence
- incorporating specific adherence-enhancing strategies within an exercise program, such as positive reinforcement, goal-setting, feedback, development of problem-solving skills to overcome barriers to adherence and self-monitoring through use of an exercise plan, contract, and/or logbook, may have a positive impact on adherence.