My column on the promotion of exercise in the shadow of the Olympics has provoked an upsurge of moral indignation and a flurry of references from an international group of elite specialists and academics.1,2 Their response suggests a remoteness from the realities of primary health care, indeed from the real world. I do not claim the authority of scientific evidence or that of prestigious medical institutions, but from the perspective of a jobbing GP point out three self-evidently absurd propositions in the arguments of the exercise zealots.
‘Inactivity is a major cause of ill-health’. Over the 30 years in which I have been a GP, the most dramatic change in the health of my patients has been the increase in life-expectancy in old age, most spectacularly confirmed by the growing ranks of centenarians. This increase in longevity has taken place in a population in which only a tiny minority engage in any form of exercise (this is, of course, particularly true of women, who make up the greater proportion of this thriving elderly cohort).
‘At least 30 minutes a day of at least moderate intensity activity on five or more days a week is necessary to achieve and maintain good health’. I know club runners and committed footballers who fall short of the exercise standard now being promoted by the Department of Health and endorsed by the Chief Medical Officer. Indeed, a brief survey of friends, relations, and colleagues reveals nobody who meets it. I do recall a patient with obsessive compulsive disorder and anorexia who met this target, but he was quite ill.
‘A brief intervention by a GP can transform a couch potato into an athlete’. A belief in the magical powers of GPs to change established patterns of behaviour (including alcohol consumption as well as inactivity) in the course of a routine consultation (in 3–5 minutes in a popular Australian model) has become widely established in the world of health promotion. But it could not possibly be true that a chat with a doctor could achieve such transformations — and solve, at a stroke, major social problems such as those associated with alcohol. This faith in the power of brief interventions reveals wishful thinking and professional hubris on a cosmic scale.
I am grateful to my GP colleague Rachel Pryke for drawing my attention to Let’s get moving: a new physical activity care pathway for the NHS.3 It is true that this 86–page document provides numerous assertions like that of our academic trio that ‘the evidence is incontrovertible’, but no actual evidence, for which the reader is referred to its 43 references. ‘Skimming through’ these — time is tight and like Pryke I have my QOF targets to consider, especially as these are now being monitored by the exercise police — I find studies flawed by small scale, short duration, using diverse measures of exercise, and unreliable ‘self-reporting’, all showing modest effects, even after moving the outcome goal posts to guarantee ‘success’. Let’s get moving is permeated with the jargon and dogma of ‘motivational interviewing’, reflecting the baleful influence of behavioural psychology in medical practice.4,5
- © British Journal of General Practice 2012