Promoting Physical Activity in Chronic Disease with Dr Emma Lunan

Join us for the next episode of the Movement Prescription podcast, which focuses on how we can realistically encourage our patients with chronic disease to  move more. 

Suzy interviews GP, Sports Exercise consultant and fellow enthusiast Dr Emma Lunan, who was involved with Movement for Health from its inception. Movement for Health is a coalition of Scotland’s leading health charities who are committed to support the least active people living with long term health conditions to be more physically active, inspired by The Richmond Group and the Movement for All programme. 

During this episode these two frontline GPs discuss the realities and possibilities of incorporating physical activity interventions into routine general practice, with all patients including those with chronic disease, being aware of the barriers and challenges (often starting with ourselves). A cautiously optimistic account, which we hope you will enjoy.

Produced using funding from NHS Tayside Educational Fund and the British Society of Lifestyle Medicine.

Find us at https://themovementprescription.co.uk/

Transcript

0:00:06 - Hussain
Welcome to episode 6 of the Movement Prescription podcast, and my name is Hussain and you're lucky today because I'm not going to be chairing this podcast. Instead, my incredible colleague Suzie is going to be speaking with Dr Emma Lunan about how we can realistically encourage our patients With chronic health conditions to move more. Emma is a GP with a specialist interest in sports and exercise medicine, a recently chair of the Movement for Health Charity in Scotland, set up as an answer to the work of the Richmond Group Charities in England. You may have heard of the we Are Under Feet book campaign. We have them featured on episode 2 of this podcast. In today's episode they touch on the importance of having the confidence to start these conversations as per the bar. They're not always with the patients, but often in us too. They talk about the power of peer support. They introduce some key resources and helpful charities where you can find out more. So, further ado, I introduce episode 6. 

0:01:28 - Suzy
Welcome to this week's Movement Prescription podcast. The aim is to provide CPD for primary care staff around physical activity, to inspire them to take up more physical activity and promote this to their patients, and to educate the listeners to the latest knowledge, current guidelines, national and local opportunities and further resources in education. My name is Dr Suzie Scarlett and I'm a GP and GP trainer in Northwest Edinburgh working in an area of deprivation. I'm NHS Lothian Primary Care Lead and have previously worked with the East Region Diabetes Prevention and Remission Program. I have a BSLM diploma and now integrate my learning techniques and evidence into my everyday practice where possible and hope to inspire you to do the same. 

All views here are my own interpretation of the guidelines and resources mentioned and the show notes. It's an absolute delight this week to be here with Dr Emma Lunan, a GP, sports and Exercise Consultant and clinical lecturer at Glasgow University for Sports and Exercise Medicine. She's recently chaired the Movement for Health, a Scottish coalition of Scotland's leading health charities working together to make it easier for people with long-term and health conditions to be more active for social, physical and mental health benefits outlined in episode 1. Emma, it's wonderful to be here. Did you want to introduce yourself? 

0:02:43 - Emma
Thank you so much for having me, suzie. That was a lovely introduction. Yes, as you said, I have a number of hats. Primarily, though, I am also a general practitioner working in the west of Scotland, so most of my patients are living with long-term conditions, which is why this is particularly relevant to me and my work. 

0:03:07 - Suzy
So today's show we're going to talk about trying to get our patients moving a little bit more. So it's the patients on the ground, and, whilst I'm aware that you are a keen sportswoman and involved in quite a lot of elite sports as well as your involvement with chronic health, that your feet are firmly on the ground when it comes to the reality that most GPs face every day. 

0:03:30 - Emma
Yes, I would definitely say, having spent most of my working life in the west of Scotland, glasgow, and now my practising in Kilmarnock, that the majority of my patients are not elite athletes by any means, and absolutely many have long-term conditions and face many barriers to becoming physically active because of that. So yes, I would like to think I am. My feet are firmly on the ground. 

0:03:55 - Suzy
So a few rapid fire questions for you to get us started, Emma. So in which chronic disease or diseases do you think the evidence is strongest for physical activity interventions? 

0:04:07 - Emma
I think that there are, as we know, a multitude of diseases In fact the majority of diseases, non-communicable, are all benefited by increasing our physical activity. I guess the majority of evidence is in cardiovascular disease, because that's where a lot of the research is. However, in saying that the research is increasing exponentially in all diseases, so diabetes, respiratory disease, neurological disease, so that's maybe a failure to answer that question in a winner, but I would say cardiovascular. 

0:04:48 - Suzy
And I guess what lots of GPs will be worried about is the safety of recommending our patients with, for example, cardiovascular disease to move more as a quick reassurance to people. What would your sort of top tip be? 

0:05:02 - Emma
So I think that people tend to overthink it and think we're going to make them go out and run a marathon or do a 10K or but literally just any kind of movement is going to be beneficial One minute, five minutes, 10 minutes, any movement that fits that person, so that could be moving at home, chair based, moving a variety of things. So don't be scared. And there's lots and lots of resources out there that are amazing, that can help clinicians introduce the concept of physical activity to patients with conditions such as cardiovascular disease and diabetes and COPD, and we'll touch on this later. But in general, movement is a good thing. We want to be physically active and it's the majority of physical activity that's going to harm a patient is absolutely minimal, so don't be scared. 

0:05:58 - Suzy
Brilliant. Start low, go slow. Yeah, that's always my line to patients. I had one who promised me he was going to do that and then injured himself at Park Run the next week. So we do have some more details to share as well. But absolutely every movement counts, as the WHO saying. I love this phrase. If physical activity was a drug, we would refer to it as a miracle cure for the great many diseases that can prevent and cure. But do you see physical activity prescriptions becoming a routine part of clinical practice in the next 10 years? 

0:06:31 - Emma
So I guess it depends on the definition of prescription in terms of it might not be that we are going to be didactically prescribing you must do this, this, this, and lots of patients will not respond to that. I would maybe say physical activity conversations will be increasing and incorporated into our daily practice. Some patients will respond to a prescription per, say, or an referral to exercise prescription. Some might just need that initial conversation to spark an interest. So I would. I would like it to be, but it might be more of a spectrum of discussion with patients. 

0:07:13 - Suzy
And I suppose that brings me on to my last rapid question, which is are you in a Royal College of GPs active practice? Are you on that charter? 

0:07:21 - Emma
Yes, we are. We are indeed, and I would say that that was one of the first things that really got me interested in increasing physical activity with my patients and with our staff, and I think initially it was a bit daunting. You can look at it and think you know this looks like quite a lot of work, but actually it's really easy to become an active practice. The RCGP website has got so many top good top tips. There's so many resources out there and lots and lots more practices are coming on board. It really gives the practice a boost. The staff get on board admin, clinical staff, non clinical staff, the GPs and obviously the patients as well. So I would wholly recommend that if anyone is not involved with it being an active practice, they go and have a look at that. 

0:08:19 - Suzy
And Emma, I just would like to give you some positive feedback. I don't know if you remember when we first started chatting many, many months ago, you told me about World Walking app that you did in your practice with your staff. 

0:08:32 - Hussain
Oh yeah they loved it. We are now just starting. 

0:08:34 - Suzy
Yeah, we love it. We're now on our 14th walk as a practice, so thank you for introducing me to that. We're about to walk Vietnam. That's the current route. 

0:08:44 - Emma
Amazing, and it's such a simple thing to do and get involved Such a simple thing. 

0:08:49 - Suzy
Yeah, like you said earlier on, I think we over complicate so many of these things, and keeping it simple and straightforward and engaging people, I think, is really the beauty behind all of these things. So absolutely Great, right. Well, I wanted to talk a little bit about the science, then, behind physical activity and in chronic health. So can you explain to me as you know, frontline GP, I don't have a qualification in sports science, but why is it that physical activity is so good for our health? 

0:09:19 - Emma
in a nutshell, In a nutshell, because it has so many positive benefits on so many different systems. So I mentioned cardiovascular disease with the positive benefits to our cardiovascular system endocrine, immunological, our central nervous system, our musculoskeletal system. So all these systems are effective when we exercise and when we exercise regularly. It produces lots of anti-inflammatory mediators and reduces the pro-inflammatory cytokines that are causing all these, you know, inflammatory based diseases such as diabetes and obesity. We increase our skeletal muscle mass, which improves our glucose uptake, and we also reduce our body fat, which obviously, again, is pro-inflammatory, as well as all the lovely hormonal changes that happen with exercise and that can be ranging from a reduction in cortisol to stabilizing our sex hormones. So if you imagine all these different chemicals being released, hormones being stabilized and improvements in our MSK system overall just have lots and lots of positive benefits. 

0:10:39 - Suzy
And that can come from simple movements. Or does it have to be that you, you know, go out for a 20 minute run or you're doing your strength training, however many times a week, it is that you manage, so I mean, obviously the WHO guidance you might have discussed before, is that we try and undertake 30 minutes at least 32 an hour of moderate activity, and that's five times a week. 

0:11:08 - Emma
As well as strength and balance, but even really tiny amounts of exercise are beneficial. So I don't want people to think I must be doing that or I'm going to fail or there's no point in me doing anything because I need to be doing this five times a week. You know, as you said, susie, start low, go slow and anything counts. And even you know things like high blood pressure, hypertension is being shown that as little as three minutes three to 10 minutes can have a longer lasting effect on blood pressure. So I would, you know, happily say to patients just do something for three minutes, and that we know from studies that that's going to have a positive effect on your blood pressure. It's so easy. 

0:11:55 - Suzy
It's brilliant when you can break it down to that sort of simple statistic, isn't it so that that is something achievable, I think, for patients to aim for and something that is relevant in their day as well. You know a lot of my patients. We spoke about the World Health Organization physical activity and century behavior guidelines. I think they're brilliant and I absolutely love the infographic I spoke about it in my last podcast as well with the trajectory that you get with however many minutes you do of physical activity within the week, and so often we're dealing with a guy sitting in the chair and the trajectory there. They just do a little bit more. They are the ones who are going to gain the most, aren't they? Absolutely. So it's having a chat with someone who is maybe a gamer or, you know, maybe in the older generation with their cardiovascular disease or COPD if they love to sit and watch telling it's about having that trigger. You know, see the commercial break. Stand up, walk around the room, do a couple of chair squats, whatever it might be, lift your legs up. 

0:12:51 - Emma
Is that the sort of, yeah, go and make an extra cup of tea, go and just something really simple, but just keep moving. And I get you kind of touched on, obviously, sedentary behavior, which is a huge problem, an equal measure. So it's not just increasing physical activity but reducing the time that we're just sitting, and then that can be obviously the older generation, as you said, but now, as we're all working people and as GPs, we're just sitting all the time. So a simple thing that I do is just get up and walk to get my patients, which two years ago I'd stopped doing because I was so busy. 

0:13:28 - Suzy
And I feel like a broken record because I'm always bang it, harping on about my standing desk, which is the first. One of the first things the patient will see when they come into my room is that my desk is permanently up and I'll sit and I will focus on them and talk to them and then I'll, you know, say, do you mind if I just stand up to use the computer? And they say, well, why are you doing that? And it starts a conversation, doesn't it? 

0:13:47 - Emma
It's actually good you know, opener to conversation, and they either think you're crazy or I think this is great. Why not? It's brilliant. So, yeah, we like our standing desks as well. We have them. 

0:14:01 - Suzy
And I think you know, particularly in other chronic conditions you know you've mentioned ones like cardiovascular disease and we've touched on others that chronic pain which I think is one of the most difficult ones to tackle, because you know you're in pain, you don't want to move. How do you break out of that cycle? 

0:14:17 - Emma
So I think it's very difficult, and particularly after we've come out of the COVID pandemic and we've got thousands, if not you know, millions, of thousands of patients waiting on joint replacements. We know that burden has gone up and particularly when they're in pain, as you said, they don't want to move. So I guess it's a bit about education that they're not going to do themselves any more harm by being active, that these tiny movements count. So it might just be looking at joint flexibility, but hopefully we know that exercise, as we touched on, reduces the pro-inflammatory cytokines and inflammatory mediators. Obviously I wouldn't say that to a patient, but the exercise will help in our pain control. And then, you know, looking at different types of exercise. So hydrotherapy is great for patients with joint issues and arthritis, if that's available in your area, or even just going to the swimming pool and taking the weight off your joints. So yeah, pain is a very difficult thing, but there's, again, amazing resources out there for talking to patients. So moving medicine, for example versus arthritis, has got some wonderful resources. 

0:15:40 - Suzy
Looking at pain, I really like the resources on the Flippin Pain website as well as my Live Well With Pain. I use them with a chronic pain group, actually and just understanding the pain cycle and, as you say, understanding the theory behind pain and the pain doesn't always equal damage here, and I remember dropping that phrase in a pain group and the room went silent and they all started looking at each other and there's this beginning of this shared understanding that, oh, hang on, that's been a belief for years and it stopped me doing so much. Maybe there is a different possibility, maybe there is a different way of doing things. 

0:16:18 - Emma
So in one of my hats I'm dealing with a lot of more able patients that maybe have injuries or long-term issues, but certainly they are in pain all the time. But I would always say well, you can keep moving within the realms of your pain. You don't want to push it beyond a certain level, or, if it's getting worse, but you're not doing any more damage. In fact, we need to stop that perception of things. 

0:16:47 - Suzy
So yeah, so that's fantastic. So we've touched on anti-inflammatory pathways, musculoskeletal health, and you were referring there to, I think, the glucose sink in what I would think of very simply as the glucose sink in diabetes. How can we help patients understand that the more active you are, the better your body utilises the glucose? 

0:17:09 - Emma
I guess, as I said, we could talk about how, as we get more active, we are reducing our fat in our bodies and increasing our muscle mass, and our muscle mass provides this amazing reservoir for glucose, and obviously the problem with diabetes is that we've got far too much sugar I talked to patients about that and then they just it's mopped up by the muscles and the exercise increases this. So I guess, to keep it in really simple terms and try and get them to understand that it's just a way of regulating their diabetes by exercising more and they're not going to do any harm. 

0:17:53 - Suzy
And I suppose if this is a patient with type 1 diabetes, then the fear from a clinician, if they don't necessarily understand the science behind it, is well gosh. What if I cause hypos? What would you say to that clinician? 

0:18:07 - Emma
I mean. The thing is that hopefully, well, there's different options. Firstly, so I would always advise, if it was a type 1 diabetic patient, probably to have make sure that they are, they've got enough nutrition on board, that they've maybe got a supply of carbohydrates short acting there, that they're aware that they're hydrated, that they know how much exercise that they're going to do and so they're not going to be caught short A lot of time. Now the patients have freestyle leopards as well, which is great. I've just done that myself as part of the Zoe study, which was very interesting, so they can look at their blood sugar immediately, which is fantastic, and I would advocate that on anyone. 

0:18:59 - Suzy
The technology that I think is going, you know, is really helping and removing some of these barriers that we see, and hopefully we talk a bit more about barriers shortly. But I think we can't ignore either the not only the disease specific benefits that you've already mentioned, but the social benefits and the societal benefits and it's you know, we're hoping and we need the government to prioritise this and I suppose, with your hat on from chairing the movement for health group, maybe you've got some insight into whether this is coming from the top down, because obviously we're grassroots bottom up approach. But what about the top down approach? 

0:19:38 - Emma
Yeah, I guess, from my time in movement for health, I've realised that we can all, we can all do a bit and we all should do a bit. 

But it's absolutely of utmost importance that the government, I guess, pays more heed to the ongoing issues with physical inactivity and that policies are introduced that change things. 

And it's got to come from the top down and I must say it is quite hard to influence. 

But what I have realised is there are lots and lots and lots of people practitioners, academics, government official, politicians and we all want we do want the same thing is just to try and keep influencing the top, top level to spend their money in the right way and create the right policies. So I do think things are changing. There's certainly enough people that want to make a change, that want to make a difference, but, as I said, it's got to come from the top down. There's been a recent policy document by the DCMS, just released on the 30th of August, and that's the get active document and is looking at the strategy for the future of sport and physical activity and it says they're building a healthier nation by tackling high levels inactivity, making sure that sport and the physical activity sector is thriving for future generations, so I would urge people to go and have a look at this document. The government governments across the nations are definitely thinking about things and getting involved and putting policies in place, but we definitely need to do more. 

0:21:31 - Suzy
I'm fully aware that there's all sorts of public health priorities in Scotland that comes under my diabetes work and things, and you know it is there, the willingness is there from the top down. But I guess us as GPs, we're often the last ones to see that until we go out looking and seeing what's available in our communities. And I see a large part of our role not necessarily in offering these physical activity programs, which I know. There's lots and lots of initiatives like talk with a doc, run, talk, run. What else have we got? You know Hussain, who does a lot of these podcasts. He is running a fantastic lifestyle group. Oh yeah, he's prolific, amazing. 

For people like you who are juggling many plates and trying not to drop any, then often it's about reaching out and seeing what's in our communities. What's available already, you know, is our local leisure group. So here in Edinburgh we've got Edinburgh leisure. They have got an active community is a whole menu of options for people, from weight loss to getting back to movement if you haven't done it for a while to chronic disease groups, to chronic pain groups. We've got local football groups. They're doing walking football, mental health football. There's all sorts of things out there. 

0:22:45 - Emma
It is amazing, and I think actually, if you delve into any community, any health board, any area, there's just a plethora of activities, as Callum Callum Lease knows from all his work. So, yes, it is amazing. It's just trying to signpost to the right places, isn't it? 

0:23:07 - Suzy
And yes, and that's where the knowledge comes into it. So that brings me nicely on to asking you for a little bit more information about this movement for health charity that you worked with before. Tell us about your time with them. 

0:23:21 - Emma
So I was really lucky to get involved with movement for health. 

Just as in section A, movement for health is a coalition of 19 charities within Scotland and also several partners including the University of Edinburgh and Public Health Scotland. 

That really came about as a group to help improve and inspire people with long term conditions to be more physically active and over the past three years I would say we've really started from nothing and built up some brilliant resources. We have a really good website with lots of resources and local activities that you can look at that we've linked in with all these charities and we've been able to join several important groups in Scotland that really help influence the increasing physical activity in people with long term conditions. So it has been really exciting what I've realised it can take quite a wee while just to get things moving and as a GP, we're used to firing things getting done quickly, but when it comes to influencing government and policy, it can take a wee while. So at the moment we're just having our movement for health just undergoing a review to see what direction best to focus on, but it's really exciting and hopefully we'll be able to have some positive outcomes in the future. 

0:25:06 - Suzy
And they've been looking at things like active health and social care, active travel, active places and spaces. So it's really sort of thinking about that whole system, not just getting individuals to move more. It's more looking at the bigger picture, isn't it Definitely? And there's such a broad spectrum of charities that are involved, isn't it Everything from Dementia UK and my right in thinking, macmillan and Asthma UK and all of these ones. 

0:25:32 - Emma
Yep, there's so many charities that we've got on board and they're all amazing and it was absolutely. It was great in the latter stages of COVID we would have we have three monthly meetings and everyone all the charities would come and tell us what they'd been doing and for the people they work for, and with the long term conditions, and there were so many positive things going on that I just didn't know about. 

0:26:02 - Suzy
So the whole expedience has been amazing and you know one of the things I saw on the movement for health website was that the evidence demonstrates that those with long term health conditions are twice as likely to face the greatest barriers to participation. So what can we, as GPs, do about these barriers to participation? 

0:26:24 - Emma
Yeah, I guess we need to identify what the barriers are. So what about patients with disability? Yeah, so disability Scotland are some of the members, or one of the members, in the coalition, and they actually have a new policy in place to increase physical activity in those with disabilities. So it's starting with, you know, top level, improving access to facilities, changing the leisure facilities that are available, making sure that people have the resources, because, you know, things cost money. I went to the Scottson leisure centre, for example, to look at their disability tennis and to participate and to hire the hall. It costs an absolute fortune. So it's giving resources to trusts and sectors to be able to allow, you know, to give these opportunities to people for less, because money is a huge thing. So, resources, yeah, there's so many barriers, unfortunately, but there are things we can do, which is the positive thing. 

0:27:40 - Suzy
And, again, as GPs, you know we're very aware of the stigma I think that a lot of people experience when it comes to thinking about getting involved in movement, physical activity, possibly exercise but I don't like to use that word with my patients because I think a lot of them will just switch off as soon as I mentioned the E word and I try very hard to sort of soften my language. But you know, what can we as GPs? How can we overcome the various stigma? I think it's a massive thing, isn't it? Particularly with weight, with culture and ethnicity. If this isn't something that people in your culture do, how can we help that? 

0:28:21 - Emma
Yeah, I think we need to be comfortable talking about it for a start. So the way that I've gone about things is just to try and bring up activity in every consultation if possible. It's not always possible, it's not always appropriate, but in the majority of consultations I can, I just treat it as I would previously in terms of smoking or alcohol and try and incorporate that way and having a conversation, a dialogue and, if any, if the patient seemed open to it, then I would then talk a wee bit more about opportunities. I think that there are many, many barriers to physical activity and, yes, it's about eliciting what that individual patients barrier might be and then trying to guide them or empower them. We need to empower patients. We don't want to be tailing them what to do. They need to want to do it. 

0:29:23 - Suzy
If people want to know more about motivational interviewing. Dr Callum Lease is talking in another podcast episode with Hamish Reid about motivational interviewing and engaging patients, so hopefully you can listen to that one at a later stage too, but I think it is. It's about engaging patients. It's about helping them see what's possible for them. It's everything that, to me, lifestyle medicine is about is about understanding your patient in their context, meeting them where they are and nudging them forward just a little bit, helping them to see that there's. You know it doesn't have to be a transaction in every GP consultation. It doesn't have to be a prescription. We know they don't take off their prescriptions anyway. So you know, little statistical treats like what you gave us about three minutes of physical activity can improve your blood pressure. And you know, if we can, if we can have a script or a few nuggets of information like that, I think that can really be very helpful. 

Just a little, just drop it and absolutely, and you know what you were describing there as well was a readiness assessment, wasn't it? You know, is this patient? Where are they on the cycle of change? Is this a conversation that I've got time to talk about, or should I just plant the seed today and leave it there, come back to a later stage? Absolutely so. I have a question for you Do you use exercise questionnaires in your daily practice? I don't. 

0:30:46 - Emma
I don't because I miss this, so this is a barrier for me, but I probably feel I don't have enough time and I, I, I don't need to. But but in a different practice, not in GP, we sometimes use exercise questionnaires, so good research tool. 

0:31:08 - Suzy
and and then the different practices, that more sort of athletic, or individuals or yeah, so that would be in a musculoskeletal set. 

0:31:17 - Emma
I do have a musculoskeletal clinic that I do, so we have 40 minutes per patient and I can easily do an exercise assessment like that, but in general practice I don't have a lot of time. 

0:31:30 - Suzy
And does that go for prescriptions as well? I mean, have you ever written a physical activity prescription for a patient? 

0:31:36 - Emma
Yeah, yeah. So what I'm what I'm talking about in terms of, like Parkour assessments, readiness assessments I probably, on a personal level, go through things quickly in my head and can work it out, but I do use the fit approach and I would write prescriptions for patients if that's what they want me to do, and I think some patients do appreciate that and some would not, and I've often been. So. You can exercise for frequency twice a week. Intensity would be moderate, timing might only be 10 minutes, type would be a walk, so something really simple, but they actually like that and that's not for everyone, but yes, I do. I do occasionally write prescriptions. 

0:32:32 - Suzy
Brilliant, using the fit approach. Now, that's not one that I've used before, but I think maybe that that's something. I'll see if I can work that in into a consultation over the next week or two. There's a goal for me there, emma. I'm always inspired by you. Good to commit these things to paper, though, isn't it, because otherwise it's just an aspiration. 

0:32:52 - Emma
Sorry, you're asking about questionnaires. For me it's just easy to. I just have my way of doing things, and then I like to keep things very simple. 

0:33:01 - Suzy
But I think we have to in general practice, because you know we only have 10, perhaps 15 minutes to see these patients. You know, perhaps if you're organised in advance and you know it's someone coming back to see, you can get them to do something before they come. But I think within the consultation, we've got to think about how we use our time. You know, otherwise we're just snowed under, aren't we? 

0:33:21 - Emma
Yeah, we've never gained anyone and we wouldn't mention it. No, no. 

0:33:26 - Suzy
So just a couple of vignettes before we summarise. Can you think of any great examples that you can share with us of patients that you've spoken to, perhaps given some guidance on, and they've come back and their disease, whether it's diabetes or COPD, has been affected positively? 

0:33:49 - Emma
Yeah, I had a lovely patient last year who was and she won't mind me saying this so she was late 30s, had was postpartum and a year after her second baby, type 2 diabetic and really struggling with her weight, was struggling with aching joints and I think initially she'd come in because her diabetic control was quite poor, so she was getting that repeated. And amongst everything, we started talking about her being physically active and active and she was quite isolated just being at home with the two little children. So we got her linked up with the community connector. She got involved in some local physical activity groups and we've got brilliant other resources locally with many groups that patients can go to. 

And I think I saw her maybe two or three times with about her diabetes and her joints and just gradually you could see the difference in her, not only in terms of her markers or HBA. We want to see improved her BMI was improving her mental well being. She just transformed, she wasn't sore and I think now she's still friends with lots of the people that she met in the group and she's now advocating and being more physically active and is happy to talk to other patients about it. So it's really lovely and that's just one patient out of many, and that just started with her coming in to talk about her diabetes and something else. So, yeah, that was, that's a nice, a nice outcome. 

0:35:46 - Suzy
Hopefully she'll her diabetes will keep improving and she'll keep getting fitter and happier and healthier, and it's great, isn't it what you're describing now, what I would describe as the ripple effect, which is where a patient has a positive outcome and then they share that and they want to actively share it, whether it be within their family circle, their friendship circle, whatever other communities that they are believe in to strangers. I had a patient the other week who's been to our local diabetes prevention group, which was a series of structured educational programs, and he really, really enjoyed them, and he specifically wrote me a note and left it in my basket to say you know, dear Dr Scarlett, I would be very happy to recommend this to any other patients who want to get involved. Just having this information is so exciting. I never knew any of this before. There's so much I can do for myself. It's about giving patients that level of control. 

Yeah and that's just so lovely, though that just makes your yeah, they're not all like that, are they all these conversations that we have? 

0:36:46 - Emma
But I think no, but just no, but just just even you know if you feel you've made a difference. I know we're talking about influencing policy and it needs to come from the top down, but you know us as GPs, it's good to have that individual impact as well. 

0:37:05 - Suzy
And I think sharing these stories with people that's what I think inspires and motivates me. And I think you know, when you find yourself and you find your tribe amongst a group of similarly minded enthusiasts, you always come away, don't you sort of fired up to try things a bit differently, Because it can sometimes be a bit lonely when you're trying to do things differently. In general practice, Absolutely. 

0:37:26 - Emma
Yeah, it can, and it's hard because we're you know, we are all busy and stressed and some people are just closed off pre-consemplative. But yeah, when you find your tribe, it's great. 

0:37:41 - Suzy
Fabulous. So just as a reminder for people then, some of that. We've mentioned quite a few resources. You mentioned moving medicine a couple of times. They've got fantastic evidence based guidelines. I think that's really good for trainees. Actually, I mentioned that a lot to trainees. How about yourself, Emma? 

0:37:59 - Emma
Yeah, absolutely, and the evidence behind it, if you delve in, is amazing. They've had a lot of clinicians work on that, so the resource is great just for that one minute, five minute or further conversations with patients, and there's a course that they offer as well. So if anyone hasn't seen it, I would definitely go and have a look at that. 

0:38:29 - Suzy
The other place. That's really good for information. The Royal College of GPs has got their physical activity toolkit and buried within that are these wonderful motivate to move guidelines which, again, are very, very evident space. There was a lot of work that went into that. Was it by the Welsh University of Wales? I think yes, and I've had just four wheels. We've mentioned the World Health Organization's guidelines on sedentary behaviours. I just love the infographics in there. I think they're really engaging, very colourful, and I love the message that every move counts. 

0:39:03 - Emma
Yeah, I love that. I also like that one. I would say, if we're talking about resources, if you have a specific if a patient with a specific long term condition, if you do go to the individual charity website. So, for example, versus arthritis or McMillan all these charities have Parkinson's UK. They themselves have amazing. I mean, patients are often tuned into that anyway but they'll have examples of local groups and online activities and just masses of things that you can look at. So the individual charity websites are really good as well. 

0:39:49 - Suzy
I've just discovered is it Move Charity, which is encouraging more movement within with patients who are living with cancer and on chemotherapy, and they've got a fantastic initiative. It's 5K your way and it's something that's in partnership with Parkrun. Are you aware of that as well, emma? Yeah yeah, so many points. 

0:40:11 - Emma
I mean some of the yeah, there's so, there's so many amazing things out there. I think we see this every time we speak to each other. 

0:40:19 - Suzy
It's just, it's just knowing about them, isn't it? That's the key thing, isn't it? So listen, emma, it's been absolutely delightful talking to you today about about how we really start these conversations with patients with with chronic diseases and try to help them see what's possible. I'm going to ask you if you've got one or two take home messages for people who've tuned in and, in summary, my take home messages always are you know, little and often don't overcomplicate things. Also, be careful of the boom and the bust. I think of the cautionary tales I've shared, and I have more, but I won't share those now, you know, just caution, but. But slow and steady wins the race, yeah. 

0:41:07 - Emma
I would. I would entirely agree. As, as with the WHO, I would say every move counts. Don't worry that you need to be doing the, the vigorous exercise and be running the marathons and doing all these things. Absolutely Everything counts. So if you've got a patient that chair based exercises, you know, going up and down the stairs, anything so every move counts. And look at all the options that are available and get well into all the resources out there, because it's amazing, yes, there are there are many, and you know. 

0:41:49 - Suzy
don't forget the joy of movement and green prescribing, all these things that I'm always harping on about. Emma, it's been a delight to talk to you on today's movement prescription podcast brought to you by GPs on the front line. Lovely to talk to you, Emma. Take care. 

0:42:07 - Emma
Thank you so much for having me. I'll speak to you soon, Suzy Thank you. 

0:42:13 - Hussain
I hope you found that useful there. You know I really love the conversation between the two of them and it really did help to crystallise a number of areas which, yes, I've heard before but it's important to reframe in order to engage patients with chronic conditions to get the most out of them. And some take home messages for me, including how we go about starting the conversation and how we go about framing that as well as trying to support the patient to avoid the boom bust cycle that we see so many, including maybe even ourselves. 

When it comes to implementing behaviour changes, and you know that whole philosophy of every move counts. You don't have to complete an iron man in order to squeeze out the benefits of physical activity. Simple things, little things, consistency over volume, and I introduced the MIT approach. And when helping patients create the move on goals, I really think that it's quite a well-structured approach about doing it and something that you know I want to try to implement more in the future. And, of course, they spread the word about the active practice charter and to find out more information about that, have a look at the Royal College of GPs Physical Activity Hub, where you can apply to be on the practice charter if you already feel like you are achieving it, or learn on some tips and resources to make that dream a reality. And remember, it's not just there for individual practices, not at all. It's there for networks or clusters, whether you be in England or in one of the other nations of the United Kingdom. 

I hope you found that helpful and thank you to Suzy and Emma there for sharing their insights and their time. Well, I hope you keep active and well until next time on the Movement Prescription Podcast.