Objective To assess the effects of interventions to promote walking in individuals and populations. Design Systematic review. Data sources Published and unpublished reports in any language identified by searching 25 electronic databases, by searching websites, reference lists, and existing systematic reviews, and by contacting experts. Review methods Systematic search for and appraisal of controlled before and after studies of the effects of any type of intervention on how much people walk, the distribution of effects on walking between social groups, and any associated effects on overall physical activity, fitness, risk factors for disease, health, and wellbeing. Results We included 19 randomised controlled trials and 29 non-randomised controlled studies. Interventions tailored to people9s needs, targeted at the most sedentary or at those most motivated to change, and delivered either at the level of the individual (brief advice, supported use of pedometers, telecommunications) or household (individualised marketing) or through groups, can encourage people to walk more, although the sustainability, generalisability, and clinical benefits of many of these approaches are uncertain. Evidence for the effectiveness of interventions applied to workplaces, schools, communities, or areas typically depends on isolated studies or subgroup analysis. Conclusions The most successful interventions could increase walking among targeted participants by up to 30-60 minutes a week on average, at least in the short term. From a perspective of improving population health, much of the research currently provides evidence of efficacy rather than effectiveness. Nevertheless, interventions to promote walking could contribute substantially towards increasing the activity levels of the most sedentary.

https://www.bmj.com/content/bmj/334/7605/1204.full.pdf

Interventions to promote walking: systematic review

The dynamics of change: Cancer patients' preferences for information, involvement and support

In recent years there has been increased emphasis on involving people in decision-making about their medical care. However, few studies have addressed the questions of why women with cancer want information, and what they believe to be the important factors influencing their decision-making. In order to examine these questions 20 women with cancer were interviewed via telephone 2 weeks after their first consultation with one of 6 medical oncologists. Recruitment continued until informational redundancy was achieved. While women cited the risk of recurrence, life expectancy, side-effects, and quality of life as influencing their decisions, they placed at least as much emphasis on their personal relationship with the specialist. These 'personal' factors included: feeling that the doctor cared for, understood and respected them; that they could trust and have confidence in the doctor; that the doctor would give them enough time; that they would be listened to; and that the doctor would be open and honest. If these factors were felt to be present, many women were happy to accept the doctor's recommendation, confident that they would receive the optimum treatment. However, many women felt there was no decision to be made: further treatment must be undertaken to reduce risk, and minor variations in the treatment protocol were of little significance. These results underline the importance of establishing patient priorities and concerns before embarking on discussions about treatment.

Lay constructions of decision-making in cancer.

To objectively examine the contribution to adult physical activity levels of walking to work. Employees (n = 103; 36.3 ± 11.7 years) at 17 workplaces in south-west England, who lived within 2 miles (3.2 km) of their workplace, wore Actigraph accelerometers for seven days during waking hours and carried GPS receivers during the commute to and from work. Physical activity volume (accelerometer counts per minute (cpm)) and intensity (minutes of moderate to vigorous physical activity (MVPA)) were computed overall and during the walk to work. Total weekday physical activity was 45% higher in participants who walked to work compared to those travelling by car (524.6. ± 170.4 vs 364.6 ± 138.4 cpm) and MVPA almost 60% higher (78.1 ± 24.9 vs 49.8 ± 25.2 minutes per day). No differences were seen in weekend physical activity, and sedentary time did not differ between the groups. Combined accelerometer and GPS data showed that walking to work contributed 47.3% of total weekday MVPA. Walking to work was associated with overall higher levels of physical activity in young and middle-aged adults. These data provide preliminary evidence to underpin the need for interventions to increase active commuting, specifically walking, in adults.

/pdf/the-contribution-of-walking-to-work-to-adult-physical-4ka9twqc19.pdf

The contribution of walking to work to adult physical activity levels: a cross sectional study

We modelled the financial and environmental costs of two commonly used anaesthetic plastic drug trays. We proposed that, compared with single-use trays, reusable trays are less expensive, consume less water and produce less carbon dioxide, and that routinely adding cotton and paper increases financial and environmental costs. We used life cycle assessment to model the financial and environmental costs of reusable and single-use trays. From our life cycle assessment modelling, the reusable tray cost (Australian dollars) $0.23 (95% confidence interval [CI] $0.21 to $0.25) while the single-use tray alone cost $0.47 (price range of $0.42 to $0.52) and the single-use tray with cotton and gauze added was $0.90 (no price range in Melbourne). Production of CO2 was 110 g CO2 (95% CI 98 to 122 g CO2) for the reusable tray, 126 g (95% CI 104 to 151 g) for single-use trays alone (mean difference of 16 g, 95% CI -8 to 40 g) and 204 g CO2 (95% CI 166 to 268 g CO2) for the single-use trays with cotton and paper Water use was 3.1 l (95% CI 2.5 to 3.7 l) for the reusable tray, 10.4 l (95% CI 8.2 to 12.7 l) for the single-use tray and 26.7 l (95% CI 20.5 to 35.4 l) for the single-use tray with cotton and paper Compared with reusable plastic trays, single-use trays alone cost twice as much, produced 15% more CO2 and consumed three times the amount of water Packaging cotton gauze and paper with single-use trays markedly increased the financial, energy and water costs. On both financial and environmental grounds it appears difficult to justify the use of single-use drug trays.

https://journals.sagepub.com/doi/pdf/10.1177/0310057X1003800320

The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays.

Advocates for action on climate change face two main challenges. The first is to make everyone aware of the enormity of the problem. The second is to persuade anyone that anything can be done about it. Ignorance is bad enough, but inertia—induced by despair, denial, or the hope of a miraculous technical fix—is even more dangerous.

Climate change, as Robin Stott argues in this week's BMJ,1 poses grave risks to health.2 It threatens the essentials of life. It brings drought, floods, storms, and extremes of heat and cold that can lead to famine, homelessness, dislocation, destruction of communities, the spread of disease, and even mass migrations and armed conflict as people vie with each other for land, water, food, and energy. And let's not forget the effects on mental health of anxiety, insecurity, and a sense of powerlessness as we watch the grass wither and the ice-caps melt.

If medicine is about saving lives, not just by last ditch interventions but by trying to avert illness, then working to alter patterns of behaviour that contribute to climate change could arguably become a priority for clinicians—as an urgent preventive measure. Debating the health implications of climate change may also be the best way to get the general public to take the problem seriously. Concepts such as “sustainable development” and “global warming” can strike the average person as either too daunting to consider or too distant to concern them. But we can all relate to the idea of risks to health that may affect ourselves, our children, and grandchildren. So there are good reasons to put climate change at the heart of the health agenda.

Likewise, the climate change debate belongs at the heart of health service management. The institutions of health care have enormous power to do good or harm to the natural environment and to increase or diminish carbon emissions. This applies particularly to the NHS, with its sheer bulk—still growing year on year. In 2006-7 the annual NHS budget in England is expected to be £83bn (€121bn, $156bn), with a total UK health expenditure of £97bn.w1 NHS purchasing power is estimated at £17bn a year.w2 It is one of the largest employers in the world, beaten only by the likes of Wal-Mart and the Chinese army. It employs more than 1.3 million peoplew3 and runs 259 NHS trusts.w4

Consider the huge amounts of food; furniture; medical, cleaning, and office equipment; road vehicles; and building materials the NHS has to buy—directly or indirectly—to keep itself going. Consider the great expanses of land it occupies, the vast amounts of energy and water it consumes, and the mountains of waste it produces every year. Ideally, an organisation committed to safeguarding health would deploy its powers and resources in ways that help reduce carbon emissions. In truth, most decisions are made with scarcely a nod to the needs of the natural environment. The Royal Society for Nature Conservation has assembled the evidence on the NHS's consumption of energy, materials, and water; generation of waste; and travel (see details on bmj.com).w5 w6

There are some exceptions. For example, hospitals in Cornwall have set up a project to purchase food from local suppliers; Addenbrooke's Hospital in Cambridge has a “green travel plan” that encourages walking, cycling, and using public transport; a trust in North Glamorgan has cut carbon emissions and saved money by creative energy management. Such examples are chronicled in a web based guide on good corporate citizenship recently launched by the Department of Health to help doctors and managers in the NHS use their resources more wisely.3,4

But good practice still depends on highly committed individuals innovating against the odds. Mean-while, the largest capital development programme in the history of the NHS has brought on a rash of largely unsustainable building. By 2010, more than £11bn is expected to have been spent on 100 new hospitals and more than £1bn on new primary care buildings.w7 w8 Most of the new hospitals will have large car parks and energy intensive air conditioning, heating, and lighting. They will often involve costly demolitions of buildings that might have been adapted at less cost in financial and environmental terms. Many will encroach on green field sites beyond urban centres, where access depends heavily on private cars. They will routinely use construction materials from unrenewable sources. They will produce almost unimaginable amounts of waste. And they may not ultimately be necessary, as demographic, technological, and policy changes alter the patterns of health care.w9

The truth is that, despite an impressive array of official guidance,w10-w12 incentives in the NHS run in the opposite direction. “Efficiency” is what matters most, and it is still defined as what works best for the financial bottom line. “Value for money” is a limited concept that does not yet recognise virtue in farsightedness. NHS targets are geared towards improving clinical performance and cutting waiting times. No one gets fired for failing to reduce the carbon footprint of a hospital or clinic.

And so, in the name of health care, gargantuan sums of public money continue to be spent in ways that are careless of the physical and mental wellbeing of future generations. A longer term perspective suggests that this makes poor sense, not only for population health, but also for the business of running a national health service.

/pdf/what-health-services-could-do-about-climate-change-57a478e4w6.pdf

What health services could do about climate change.

Whose Standards? Consumer and Professional Standards in Health Care

“The scientific evidence is now overwhelming: climate change is a serious global threat, and it demands an urgent global response.” This was the unequivocal message of the Stern report, published by HM Treasury last year.1 The time for debate is over—at least about whether climate change is potentially catastrophic and caused by human activity. But who should act and how? This week, the BMA Board of Science publish their report Health Professionals—Taking Action on Climate Change.2 It outlines the basic facts and figures and points to copious sources of further information.

The report endorses Stern’s conclusion that, “urgent action is needed now at an individual, organizational, political and global level.” It summarises evidence about cause and effect, then considers the health implications. A diagram (from the Lancet) points to floods, storms, and other forms of environmental damage leading to “impaired nutrition, health, survival.” 

Turning to how the effects of climate change can be reduced, the report says that the government’s sustainable development strategy, Securing the Future, must be implemented.3 Another diagram, from the International Panel on Climate Change (IPCC), lists “key mitigation technologies and practices that are currently commercially available” and those expected to be on tap by 2030. 

Next, carbon emissions and footprints are explained. In the United Kingdom, the average emission is equivalent to 10 tonnes of CO2 each person each year. Most personal emissions come from household energy consumption and travel, with a sizeable chunk associated with purchases of consumable goods. A sustainable individual footprint is 2 tonnes of CO2 each year. That means a staggering reduction of 8 tonnes per person.

So what solutions does the report propose? Several measures, it tells us, can reduce the amount of CO2 that we emit. These include carbon offsetting, carbon trading, and “contraction and convergence.” Each solution is briefly explained, with references so that people can find out more. No effort is made to assess the relative merits of these very different strategies. 

The report sets out what is being done globally, by the European Union and by the UK government to tackle climate change. It provides recommendations for health professionals. Measure your own carbon footprint; turn appliances off; improve ventilation and insulation; save water; reduce waste; buy fresh local produce; and cut down on meat, dairy products, and saturated fats. Avoid overly processed or packaged foods and bottled water. Use public transport, walk and cycle more, cut unnecessary flying and driving.

Of the NHS, the report says that—as the largest organisation in the UK, with an annual purchasing budget of more than £17bn (€21.5bn; $34bn)—it must take urgent action to reduce its carbon footprint. It sets out examples of where such action might be taken—in building works and in managing energy, water, waste, and transport. It does not mention procurement, which accounts for the largest part of the NHS’s carbon footprint.

For health professionals who want to find out more, the report provides usefully referenced summaries of evidence. Hopefully, however, it will soon be followed by a more concerted effort to confront the heavily barbed challenges of climate change. It mentions, all too briefly, that climate change can affect mental health, and that measures to reduce greenhouse gases can help reduce the risk of cancer, heart disease, obesity, other chronic illnesses, and injuries caused by road traffic crashes. These are vital themes that must be paid closer attention by health professionals and policy makers. 

It sits on the fence about methods of carbon reduction, as though they were equivalent options. Yet carbon offsetting is a highly controversial way of compensating for carbon emissions, rather than reducing them. And contraction and convergence is a profoundly radical strategy for each person on the planet to arrive at equitable and sustainable per capita greenhouse gas emissions.4

The report offers no view on what should happen if NHS trusts fail to cut their massive direct and indirect emissions. It makes no suggestions about how trusts can make sure that their contractors give priority to mitigating climate change. It points out that health professionals “have a responsibility to highlight the public health risks of climate change as well as the numerous health benefits associated with more environmentally friendly economic activities and lifestyles.” Yet it does not discuss where carbon reduction should stand in the hierarchy of clinical responsibilities. Nor does it suggest what health professionals should do if they find their government is dragging its feet—for example, in giving sufficient priority to its own sustainable development strategy. 

Here, surely, is the crux of the matter for the BMA. We have the science. We have something approaching consensus about the causes and scale of the problem. Now what is required, from one of the UK’s most powerful trade associations that is well able to influence cabinet ministers and governments, is a sustained evidence based campaign to match the enormity of the risks to human health.

/pdf/how-should-health-professionals-take-action-against-climate-3t7ooyqvsx.pdf

How should health professionals take action against climate change

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What health services could do about climate change.

Whose Standards? Consumer and Professional Standards in Health Care

How should health professionals take action against climate change