Bruce Arroll

The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners.

OBJECTIVES The purpose of this study was to determine whether written advice from general practitioners increases physical activity among sedentary people more than verbal advice alone. METHODS Sedentary patients (n = 456) received verbal advice on increasing physical activity and were then randomized to an exercise prescription (green prescription) group or a verbal advice group. RESULTS The number of people engaging in any recreational physical activity at 6 weeks increased substantially, but significantly more so in the green prescription group. Also, more participants in the green prescription group increased their activity over the period. CONCLUSIONS A written goal-oriented exercise prescription, in addition to verbal advice, is a useful tool for general practitioners in motivating their parents to increase physical activity.

Prevention and treatment of the common cold: making sense of the evidence

The common cold is an acute, self-limiting viral infection of the upper respiratory tract involving the nose, sinuses, pharynx and larynx. The virus is spread by hand contact with secretions from an infected person (direct or indirect) or aerosol of the secretions and virus.[1][1] The incubation

Rethinking primary care systems for obesity

Paul Aveyard and colleagues, in The Lancet, provide optimistic news for the management of obesity in primary care. In this parallel, two-arm, randomised trial of screening and a brief intervention for obesity in primary care, Aveyard and colleagues identifi ed a net weight loss benefi t at 12 months from a 30 s active intervention by primary care physicians. A striking feature of the study was that patients with obesity (bodymass index of at least 30 kg/m2 or at least 25 kg/m2 if of Asian ethnicity) were invited to participate with no assessment of their readiness to change, yet the majority (2263 [83%] of 2728 potentially eligible participants) were willing to do so, of whom 1882 individuals were eligible to enrol in the trial. 940 patients in the active intervention group were off ered a specifi c appointment (made before leaving the clinic) to a weight management group (12 sessions of 1 h each, once per week) with follow-up support and advice, and 942 patients in the advice only (control) group were simply advised by the primary care doctor that their health would benefi t from weight loss. At 12 months, mean weight change was 2·43 kg in the advice plus support group compared with 1·04 kg in the advice only group, giving an adjusted diff erence of 1·43 kg (95% CI 0·89–1·97). The number needed to treat to achieve a 5% weight loss (about 5 kg) at 12 months was 8·8, which is very good for a preventive intervention. By comparison, the number needed to treat for nicotine replacement therapy with respect to 12 month quit rate is about 152 and exercise prescriptions for 12 month achievement of physical activity guidelines have a number needed to treat of about ten. It is surprising that this is the fi rst study in primary care to investigate a brief intervention for obesity, perhaps refl ecting the nihilism about weight loss that pervades medical care. A survey of family physicians in the USA found that, of ten chronic disorders, obesity treatment was regarded as less eff ective than all but treatment for drug addiction. This fi nding supports our experience with physicians who report how diffi cult it is for patients to lose weight and keep it off . Physicians might see the task as being too complex, lack confi dence in giving nutrition advice, or have become disillusioned with the poor outcomes. Clinicians might also fear insulting patients by raising the issue of obesity, yet in this study only four (<1%) of patients said the interventions were inappropriate and unhelpful. Clinicians’ own weight problems might also inhibit discussion, but Perri Klass suggests that health professionals must acknowledge their own weight struggles and “do the job eff ectively”. Eff ective resources are available in the form of commercial weight loss courses, but cost could be a barrier. Long-term behaviour change is hard and failed attempts at weight loss are ubiquitous. For some patients, such as those with a history of weight cycling, it could be time to move away from the sisyphean task of pursuing weight loss goals and onto achieving other valued health goals. The eff orts needed to yet again break out of the metabolic, physical, psychological, and environmental vicious cycles that trap them in the state of obesity might be better directed at healthy eating and physical activity with no further weight gain. However, far from giving up on weight loss entirely, Aveyard and colleagues’ results should trigger a rethink of the primary care approaches to obesity on two counts. First, the positive results of the 30 s active intervention signal a need for further such studies so that the evidence base for brief interventions for weight management matches that for quitting smoking, exercise prescriptions, and alcohol problems. This brief intervention as part of a usual consultation capitalises on opportunities within the current systems of primary care practice. Published Online October 24, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31913-4

A brief treatment for fear of heights: A randomized controlled trial of a novel imaginal intervention

Objective To assess the effectiveness of a novel imaginal intervention for people with acrophobia. Methods The design was a randomized controlled trial with concealed randomization and blinded to other participants’ intervention. The intervention was a single novel imaginal intervention session or a 15-min meditation. The setting was in Auckland, New Zealand. The participants were a convenience sample of the public with a score >29 on the Heights Interpretation Questionnaire (HIQ), a questionnaire validated against actual height exposure. The primary outcomes were the proportion of participants with a score <26 on the HIQ at eight weeks and difference between the HIQ scores between the two arms of the study. Results Ninety-eight participants (92%) returned their questionnaire and were included in the intention to treat analysis. The HIQ score <26 was 34.6% (18/52) in the intervention group and 15.2% (7/46) in the control group RR = 2.26, 95% CI (1.05, 4.95) and p = 0.028. The numbers needed to treat is six 95% CI (3 to 36). Participants with scores <26 report their fear of heights is very much improved. There was a 4.5-point difference in the HIQ score at eight weeks (p = 0.055) on the multiple regression analysis. Conclusions This is the first randomized trial of this novel imaginal intervention which is probably effective, brief, easily learnt, and safe. It may be worth considering doing this prior to some of the longer or more expensive exposure therapies. This study will be of interest to family doctors, psychiatrists, and psychologists.

An exploration of the basis for patient complaints about the oldness of magazines in practice waiting rooms: cohort study

Objective To explore the basis for patient complaints about the oldness of most magazines in practice waiting rooms. Design Cohort study. Setting Waiting room of a general practice in Auckland, New Zealand. Participants 87 magazines stacked into three mixed piles and placed in the waiting room: this included non-gossipy magazines (Time magazine, the Economist, Australian Women’s Weekly, National Geographic, BBC History) and gossipy ones (not identified for fear of litigation). Gossipy was defined as having five or more photographs of celebrities on the front cover and most gossipy as having up to 10 such images. Interventions The magazines were marked with a unique number on the back cover, placed in three piles in the waiting room, and monitored twice weekly. Main outcome measures Disappearance of magazines less than 2 months old versus magazines 3-12 months old, the overall rate of loss of magazines, and the rate of loss of gossipy versus non-gossipy magazines. Results 47 of the 82 magazines with a visible date on the front cover were aged less than 2 months. 28 of these 47 (60%) magazines and 10 of the 35 (29%) older magazines disappeared (P=0.002). After 31 days, 41 of the 87 (47%, 95% confidence interval 37% to 58%) magazines had disappeared. None of the 19 non-gossipy magazines (the Economist and Time magazine) had disappeared compared with 26 of the 27 (96%) gossipy magazines (P<0.001). All 15 of the most gossipy magazines and all 19 of the non-gossipy magazines had disappeared by 31 days. The study was terminated at this point. Conclusions General practice waiting rooms contain mainly old magazines. This phenomenon relates to the disappearance of the magazines rather than to the supply of old ones. Gossipy magazines were more likely to disappear than non-gossipy ones. On the grounds of cost we advise practices to supply old copies of non-gossipy magazines. A waiting room science curriculum is urgently needed.