Physical Activityy y

Maximising potential inMaximising potential in primary care: Options for

ti t t t dprevention, treatment and management.g

Dr Richard WeilerDr Richard WeilerMBChB, MRCGP (Distinction), MSc Sport & Exercise Medicine (Distinction), MFSEM (UK)

Specialist Registrar in Sport & Exercise Medicine and General PractitionerGPSI in Sports & Musculoskeletal MedicineExternal Lecturer University College LondonExternal Lecturer, University College London

Aims:S i h f• Start in the future

• Work our way swiftly back to the present• Recognise primary care benefits

• Challenge current practice• Present evidence & guidancePresent evidence & guidance• Recognise strengths & weaknesses

• Provoke discussion

The pledges

• HM Treasury proposed the proportion of children who spend a minimum of two hours per week on high quality sport should increase from 25% intwo hours per week on high quality sport should increase from 25% in 2002 to 75% by 2006 and 85% by 2008

• 2002 Government’s Strategy Unit: to increase the proportion of the adult l ti h ti i t i 30 i t f d t h i l ti it fipopulation who participate in 30 minutes of moderate physical activity five

or more times a week to 70% by 2020!

• 2003 Scottish Health Executive set a target that by 2022, 50% of the adult2003 Scottish Health Executive set a target that by 2022, 50% of the adult population should participate in 30 minutes of moderate activity on 5 or more occasions each week. The Scottish target for children is to increase the number of children taking at least one hour a day of moderate activity on 5 or more days a week to 80% by 2022on 5 or more days a week to 80% by 2022.

• There are no physical activity targets set for Wales or Northern Ireland

Lifestyle disease & deaths

• 60% of global deaths from non-communicable diseases (WHO)

• Genetics impact minimal• I.e. Environment & Lifestyleinduced

Economics – Annual costEconomics – Annual cost

• Physical inactivity £8.2bn* (DoH, 2002)• Smoking £1 5 billion (Parrott BMJ 2004)• Smoking £1.5 billion (Parrott, BMJ 2004)• Alcohol £3.0 billion (Balakrishnan, J PH 2009)

Ob it £4 2 billi (HSE 2008)• Obesity £4.2 billion (HSE, 2008)

*But physical inactivity cost was estimated on ~5 diseases

Physical inactivity – 40+ diseases

• osteoporosis• muscle atrophy

• dyslipidemia• metabolic syndrome• muscle atrophy

• arthrosis• rheumatoid arthritis

• metabolic syndrome• asthma• some cancer (e.g. breast)

• low back pain• coronary artery disease• peripheral artery disease

• degenerative problems (e.g. in brain)

• depression• peripheral artery disease• stroke• high blood pressure

depression • pain• sleep problems

bl d l i• diabetes 1 and 2• obesity / overweight

• blood clotting• erectile disfunction

H lth b fit f h i l ti itH lth b fit f h i l ti itHealth benefits of physical activityHealth benefits of physical activity

Regular physical activity at the correct intensity:

• Reduces the risk of heart disease by 40%• Lowers the risk of stroke by 27%• Reduces the incidence of diabetes by almost 50%y• Reduces the incidence of high blood pressure, by almost 50%• Can reduce mortality and the risk of recurrent breast cancer by almost

50%50%• Can lower the risk of colon cancer by over 60%• Can reduce the risk of developing of Alzheimer’s disease by one-third• Can decrease depression as effectively as Prozac or behavioural therapy• Can decrease depression as effectively as Prozac or behavioural therapy

Physical inactivity worse than smoking?

• Increased physical activity reduces mortality by as much as smoking cessation, even in later lifeas much as smoking cessation, even in later life

• Statistically a week spent inactive has similar• Statistically a week spent inactive has similar health costs to smoking a packet of cigarettes

Smoking cessation universally endorsed but is it effective?

• Abstinence rates for smoking cessation ~5-25% (BMJ 2007)(BMJ, 2007)

• In many areas GP’s paid ~£30 per abstinent patientpatient

• So on computer systems & rewarded in QOF

• Smoking cessation universally accepted?!

“What do points make?”What do points make?

Indicator Details Points Payment stages% CHD in whom the last blood pressure reading (measured in

CHD 6. % CHD in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 or less 17 40-70%

CHD 8. % CHD whose last measured total cholesterol (measured in the previous 15 months) is 5mmol/l or less 17 40-70%% diagnosed with hypertension diagnosed after 1 April 2009 who are given lifestyle advice in the last 15 months for:

PP 2. increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet. 5 40-70%

STROKE 6. % with TIA or stroke in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 or less. 5 40-70%

STROKE 8% with TIA or stroke whose last measured total cholesterol ( d i th i 15 th ) i 5 l/l l 5 40 60%STROKE 8. (measured in the previous 15 months) is 5mmol/l or less. 5 40-60%

BP 5. % with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less. 57 40-70%

DM 23. % with DM in whom the last HbA1c is 7 or less in the previous 15 months 17 40-50%% with DM in whom the last HbA1c is 8 or less in the previous

DM 24. % with DM in whom the last HbA1c is 8 or less in the previous 15 months 8 40-70%

DM 25. % with DM in whom the last HbA1c is 9 or less in the previous 15 months 10 40-90%

DM 12. % with DM in whom the last blood pressure is 145/85 or less 18 40-60%% with DM whose last measured total cholesterol within the

DM 17. previous 15 months is 5mmol/l or less 6 40-70%The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and

MH 9. preventi 23 40-90%

CKD 3. % on CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less 11 40-70%TOTAL 199 ~£124.03TOTAL CLINICAL 697Percentage 29%Percentage 29%Equivalent income £24,682

E i l iEquivalent income

£24 682£24,682

Ph i l A ti itPhysical Activity

P tiPrevention or Treatment

Physical activity:Physical activity: only for disease?only for disease?

Effect of Fitness (CRF) on Mortality

40 842 Men & 12 943 Women ACLS

( ) yAttributable Fractions (%) for All-Cause Deaths

141618

MenWomen

40,842 Men & 12,943 Women, ACLS

8101214 Women

468

02

L O S H H DLow CRF*

ObeseSmoker

Hypertension

High Chol

Diabetes*cardio respiratory fitness on

Cooper Aerobics Center Longitudinal Study, 1970-2004. In progress

cardio respiratory fitness

Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009; 43:1-2.

P l ti tt ib t bl i k (PAR)Population attributable risk (PAR):‘estimate of proportion of public health burden for one risk factor’ – i.e. Physical inactivity/sedentary behaviour

Powell & Blair (1994, MSSE) Ruwaard & Kramers (1997, Utrecht: Elsevier/De Tijdstroom)( , ) Elsevier/De Tijdstroom)

• CHD = 35%• Colon cancer= 32%

• For CHD alone:▫ Smoking = 43%

• Type 2 DM = 35% ▫ Diet = 13%▫ Obesity = 14%▫ Sedentary= 40%▫ Sedentary= 40%

P l ti tt ib t bl i k (PAR)Population attributable risk (PAR):‘estimate of proportion of public health burden for one risk

Ruwaard & Kramers (1997, Utrecht: Elsevier/De Tijdstroom)

factor’ – i.e. Physical inactivity/sedentary behaviour

Elsevier/De Tijdstroom)• CHD = 35%• Colon cancer= 32%

• For CHD alone:▫ Smoking = 43%

• Type 2 DM = 35% ▫ Diet = 13%▫ Obesity = 14%▫ Sedentary= 40%▫ Sedentary= 40%

A physically active lifestyle helps maintainA physically active lifestyle helps maintain body weight, leads to favourable dietary habits and a decline in smokinghabits and a decline in smoking. (1995, Vuori & Fentem, Strasburg: Council of Europe Press:11-90)

Are there institutional and research failings?

QRISK2 – Risk of CHD/CVD• Patient age (35-74)• Patient gender• Current smoker (yes/no)(y )• Family history of heart disease aged <60 (yes/no)• Existing treatment with blood pressure agent (yes/no)• Postcode (postcode related Townsend score) - an area measure of• Postcode (postcode related Townsend score) - an area measure of

deprivation• Body mass index (height and weight)

Systolic blood pressure (use current not pre treatment value)• Systolic blood pressure (use current not pre-treatment value)• Total and HDL cholesterol• Self assigned ethnicity• Rheumatoid arthritis• Chronic kidney disease• Atrial fibrillation

JBS2 CHD & Stroke RiskJBS2 – CHD & Stroke Risk Assessmentssess e t

Risk FactorsMove through RISK FACTOR boxes to enter & amend data.Use cursor keys to move through boxesUse cursor keys to move through boxes.

Female?(yes=1,no=0) 0Age(years) 0g (y )SBP (mmHg) 0DBP (mmHg) 0Smokes?(yes=1,no=0) 0

C ( / )Total - C (mmol/ l) 0HDL - C (mmol/ l) 0Diabetes(yes=1,no=0) 0

Known to haveECG-LVH? (yes=1,no=0) 0

Period of predicted risk 10(years)

CVD risk predictionCVD risk prediction

• Existing scores determine whether an asymptomatic patient needs preventive intervention & relies on surrogate outcomes– E.g. cholesterol, diabetes, BMI, blood pressure,

smoking

• No physical activity, no cardiorespiratory fitness:– Are they not causal factors? – Why are they ignored?

Consider incentives - QOF

• Annual average extra payments for the clinical care domain is ~ £65 000clinical care domain is £65,000

• Cost of new QOF point ~£1million

“PP2 Primary Prevention of CVD: The percentage of people diagnosed with hypertension who are givenpeople diagnosed with hypertension who are given lifestyle advice for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet”healthy diet

QOF – Primary care incentivesQOF – Primary care incentives• Often a tick box on computerOften a tick box on computer

system• Is GP trained for complex p

behaviour change?• Why one lifestyle factor and

h ?not another?• Why not train GP’s in

behaviour changebehaviour change techniques? (Motivational interviewing)interviewing)

Who’s responsibility?Who s responsibility?

A selection of National Guidelines recommending physical activity promotionpromotion…

Duty of careDuty of care• Medico-legal duty of care to follow guidelines• Medico legal duty of care to follow guidelines

where appropriate

• Need to document in medical records/notes

Why deliver PA in primary care?• Powerful voice

• Perceived as most reliable/credible source of health information[L b l F D l J F k E B J S t M d 2009 43 89 92][Lobelo F, Duperly J, Frank E. Br J Sport Med 2009;43:89-92].

• 185million GP consultations/year• 185million GP consultations/year

• Regular contacts with patients (~3/yr): reinforces• Regular contacts with patients (~3/yr): reinforces messages & allows regular follow up

REALITY

• 54% of patients said their GP had not• 54% of patients said their GP had not even provided advice on diet and

iexercise[Lord Darzi's NHS Next Stage Review Final Report]

• ~1 in 4 people in England say they would b ti if th d i d t dbe more active if they were advised to do so by a GP or nurse[HSE 2007]

NICE public health guidance PH2Primary care practitioners should whenever possible:

( ) f• Using a validated tool (GPPAQ) to identify inactive adults and advise them to aim for at least 30 minutes of moderate activity on 5 days of the weeky y

• Take account of individual needs, preferences and i t l d id ittcircumstances; agree goals; and provide written information about the benefits of activity and the local opportunities to be active

• Follow up at appropriate intervals over a 3 to 6 month periodperiod

NICE Guidance on PA Promotion

•Evidence basedEvidence based

• ‘Exceptional value for money’• Exceptional value for money  

[NICE & Department of Health]

Let’s Get Moving• Behaviour change programme with a Physical Activity

Care Pathway based on NICE recommendations

• LGM designed to assist practitioners in guiding inactive adults aged 16-74 towards gradually become more active

Let’s Get Moving – Uptake?

• GPRD Gold database: of 9 556 849• GPRD Gold database: of 9,556,849 patients, 660 patients (0.007%) have GPPAQ codes across 524 practices in theGPPAQ codes across 524 practices in the UK. (March 2010)[Weiler R Stamatakis E Br J Sports Med 2010 Oct;44(13):912 4 ][Weiler R, Stamatakis E. Br J Sports Med. 2010 Oct;44(13):912-4.]

Evaluation of PA Care Pathway – London yFeasibility Pilot

• Only 4/300 patients were signposted to exercise on referralreferral

• GPPAQ awareness elsewhere lowGPPAQ awareness elsewhere low• Felt to be time-consuming• Other priorities in average 9-minute consultationp g

Are we equipped in primary care?PA b t f i l l 13% f US• PA absent from curriculum: only 13% of US medical schools have any PA element at all

• Survey in 32 UK medical schools in progress. Anecdotal evidence suggests that the UK reality is gg ysame as US: i.e. Physical Activity education is non-existent

• What about behaviour modification skills?

• Active doctors prescribe PA, inactive do not [Lobelo F, Duperly J, Frank E. Br J Sport Med 2009;43:89-92]

NHS Health CheckNHS Health CheckExample Care Pathway - 2010

• NHS Health Check invitation first letter• NHS Health Check invitation second letter• NHS Health Check telephone invitation• NHS Health Check verbal invitation• Failed to respond to NHS Health Check invitation

• FH: Ischaemic heart dis. >60• FH: Diabetes mellitus in first degree relative• Ethnic status• O/E height• O/E weight• Failed to respond to NHS Health Check invitation

• NHS Health Check completed• Did not attend NHS Health Check• Dietary history• Patient advised re diet• Tobacco consumption

• O/E weight• BMI• Waist circumference• Advice about weight• Refer to weight management programme• Referral to weight management service declinedp

• Smoking Cessation Advice• Smoking cessation advice declined• Referral to smoking cessation advisor• DNA - Did not attend smoking cessation clinic• Seen by smoking cessation advisor

g g• Lifestyle counselling• Referral to health trainer• Referral to health trainer Declined• Seen by health trainer• O/E - pulse rate

• Exercise grading• Patient advised re exercise• Referred for exercise programme• Declined referral to physical exercise programme• Alcohol use disorder identification test consumption questionnaire

Alcohol screen AUDIT C completed

• O/E - pulse rhythm• Cholesterol• Serum cholesterol:HDL ratio• Blood sugar result • Plasma random glucose level

Plasma fasting gl cose le el• Alcohol screen – AUDIT C completed• Alcohol consumption screening test declined• Patient advised about alcohol• Referral to specialist alcohol treatment service• Declined referral to specialist alcohol treatment service• H/O: rheumatoid arthritis

• Plasma fasting glucose level• HbA1c level (DCCT aligned) • HbA1c level – IFCC standardised• Glomerular filtration rate calculated by abbreviated Modification of

Diet in Renal Disease Study Group calculation• Advised to contact general practitionerH/O: rheumatoid arthritis

• FH: CVD• No FH: CVD• FH: Ischaemic heart dis. <60

• QRISK cardiovascular disease 10 year risk score• NHS Health Check completed

NHS Health CheckNHS Health CheckExample of real Care Pathway - 2010

• NHS Health Check invitation first letter• NHS Health Check invitation second letter• NHS Health Check telephone invitation• NHS Health Check verbal invitation• Failed to respond to NHS Health Check invitation

• FH: Ischaemic heart dis. >60• FH: Diabetes mellitus in first degree relative• Ethnic status• O/E height• O/E weight• Failed to respond to NHS Health Check invitation

• NHS Health Check completed• Did not attend NHS Health Check• Dietary history• Patient advised re diet• Tobacco consumption

• O/E weight• BMI• Waist circumference• Advice about weight• Refer to weight management programme• Referral to weight management service declinedp

• Smoking Cessation Advice• Smoking cessation advice declined• Referral to smoking cessation advisor• DNA - Did not attend smoking cessation clinic• Seen by smoking cessation advisor

g g• Lifestyle counselling• Referral to health trainer• Referral to health trainer Declined• Seen by health trainer• O/E - pulse rate

• Exercise grading• Patient advised re exercise• Referred for exercise programme• Declined referral to physical exercise programme• Alcohol use disorder identification test consumption questionnaire

Alcohol screen AUDIT C completed

• O/E - pulse rhythm• Cholesterol• Serum cholesterol:HDL ratio• Blood sugar result • Plasma random glucose level

Plasma fasting gl cose le el• Alcohol screen – AUDIT C completed• Alcohol consumption screening test declined• Patient advised about alcohol• Referral to specialist alcohol treatment service• Declined referral to specialist alcohol treatment service• H/O: rheumatoid arthritis

• Plasma fasting glucose level• HbA1c level (DCCT aligned) • HbA1c level – IFCC standardised• Glomerular filtration rate calculated by abbreviated Modification of

Diet in Renal Disease Study Group calculation• Advised to contact general practitionerH/O: rheumatoid arthritis

• FH: CVD• No FH: CVD• FH: Ischaemic heart dis. <60

• QRISK cardiovascular disease 10 year risk score• NHS Health Check completed

Traditional interventions Vs Physical ActivityPhysical Activity

A (simplified) physical activity centred model of CVD causalityA (simplified) physical activity-centred model of CVD causality

Ph i l

Knowledge/Information

Cultural values

Personal l / ttit d

Physical Environment

values/attitudes/health consciousness

Physical CARDIOVASCULAR CardioRespiratory Fitness

SURROGATE: MARKERS:

Activity DISEASE

Psychological(Positive & negative affect)

Fitness

BiomarkersAdiposity

Socioeconomi

Genetic makeup

affect) Smoking

Diet

c circumstances

A (simplified) physical activity centred model of CVD causality

Ph i l

Knowledge/Information

Cultural values

A (simplified) physical activity-centred model of CVD causality

Personal l / ttit d

Physical Environment

values/attitudes/health consciousness

Physical CARDIOVASCULAR CardioRespiratory Fitness

SURROGATE: MARKERS:

Activity DISEASE

Psychological(Positive & negative affect)

Fitness

BiomarkersAdiposity

Socioeconomi

Genetic makeup

affect) Smoking

Diet

c circumstances Current focus of CVD prevention:

pharmacological intervention, obesity, & smoking cessationg

Task : prevent CVD in primary care

GP’s OPTIONS 1: Prescribe medication 2. Lifestyle modification

INCENTIVES OFFERED •QOF payments boosting •None (altruism and idealism?)annual income substantially

SUPPORT SYSTEM IN •Not needed •Let’s Get Moving PLACE

gdocumentation

SKILLS /KNOWLEDGE •Basic pharmacology •Understanding of PA benefitsNEEDED

p gy•Read (drug leaflet)•Write (prescription)

g•Behaviour modification •Counselling skills •Negotiation skills R t ith ti t•Rapport with patient

GP OWNS SKILLS? •Yes •Extremely unlikelyGP OWNS SKILLS? Yes Extremely unlikely

EXTERNAL INFLUENCES/PRESSURES

•Intense “marketing” from drug companies

•None, PA RCTs with “hard outcomes” not feasible/ethical

•Detailed NICE guidance•Large (pharma-funded) trials published in the best medical journals

•PA research sparingly funded

C id T 2 di b tConsider Type 2 diabetesCG66 Type 2 diabetesyp• 3 months treatment with lifestyle measures – focus on

diet with dietician• What about PA support?

• Some experts still recommend going straight to drugs!• “…because lifestyle measures never work”

• Where is the evidence that diabetic medication d t lit & bidit ?reduces mortality & morbidity?

• Risk of macro vascular disease starts 6 8 years• Risk of macro-vascular disease starts 6-8 years before onset of clinical diabetes

Drugs: Adverse effect on survival?ADVANCE StudyADVANCE Study

Medication Physical Activity

Hypoglycaemic events • Risk • No riskyp g y

Hypoglycaemic events associated with hazard ratios 3 3 3 8 for:• Hypoglycaemic events associated with hazard ratios 3.3-3.8 for:

Major macrovascular events

CVD liCVD mortality

All-cause mortality

Changes in weight, fitness, and cardiovascular risk factors for participants in the Intensive lifestyle intervention (ILI) and diabetes

support and education (DSE) groups of the Look AHEAD (Action forsupport and education (DSE) groups of the Look AHEAD (Action for Health in Diabetes) trial

The Look AHEAD Research Group,The Look AHEAD Research Group,Arch Intern Med 2010;170:1566-1575.

Copyright restrictions may apply.

Proportion of Participants in DSE and ILI Who Achieved the ADA Treatment Goals p pat Baseline and Years 1 Through 4

Copyright restrictions may apply.

The Look AHEAD Research Group, Arch Intern Med 2010;170:1566-1575.

Proportion of DSE and ILI Participants Who Initiated or Maintained Use of Medication p pfor Diabetes, Hypertension, or Lowering Lipid Levels

The Look AHEAD Research Group, Arch Intern Med 2010;170:1566-1575.

Copyright restrictions may apply.

SolutionsSolutions• £25,000 up for grabs with QOF!, p g• Awareness & education• Better care - Think guidelines & legal responsibility

E b d PA ti t t k i t l t• Embed PA promotion computer note-keeping templates▫ GPPAQ & development of 1 question PAQ

• Where is PA promotion in QOF? 1 QOF point=£1m• Where is PA promotion in QOF? 1 QOF point £1m• Role models – Exercise yourself• PA Vs Drugs • Education & training: But who?▫ Can Nurses/HCAs/Physiotherapy/Pharmacists

Practice staff deliver physical activity promotion?▫ Practice staff deliver physical activity promotion?• Strategy – prevention for all or targeted treatment?• GP Consortia: Consider physical activity promotion whenGP Consortia: Consider physical activity promotion when

commissioning local services

Plato427 BC - 347 BC

Greek Philosopherp

“Lack of activity destroys the good condition of every human being whilecondition of every human being, while movement and methodical physical exercise save it and preserve it ”exercise save it and preserve it.

A Case StudyA Case Study• A Hertfordshire General Practice• A Hertfordshire General Practice• List size 12386• 7 partners 2 salaried 3 registrars• 7 partners, 2 salaried, 3 registrars• Audit of Physical Activity Advice

• Use of the Vision clinical system as an aide i d t l t f i t timemoire and template for intervention

• Tie in with local “exercise on prescription” initiative

Hertfordshire Audit Physical Activity AdviceHertfordshire Audit – Physical Activity Advice In Standard Consultations

12th May 2010

4

1

2

171

Out of 202 clinician in house consults

Hertfordshire Audit – Obesity Register

54

Partners/Salaried/Locum

12

Registrars

413

1

2

1

2

413 79

Oth li i iOther clinician

14

Nursing

6

5 1

2

14

1

2

106

689 Patients on Practice Obesity Disease Register

ShortcutsVision

Shortcuts

Vision Vision Guideline

ss

Practical Reminders within Practice

Are you physically active?Are you physically active?Would you like to be more active?

Fill out a physical activity questionaire and ask your GP how we can helphow we can help.

Collaboration with ExerciseCollaboration with Exercise Provider

Hertfordshire Interventions• Embed by design into electronic notes system• Media within patient waiting areasp g▫ GPPAQ in waiting rooms and offered by

receptionistsp▫ Posters on LGM▫ Use of Electronic notice board/TV

• Engage locality exercise providers• EducationEducation▫ All clinicians: “5-a-week”; moderate exercise

Analysis of the Data - SEF

LGM Pilot IslingtonLGM Pilot Islington

Global Initiatives

Exercise Is Medicine™Medicine•“To make physical activity and exercise aactivity and exercise a standard part of a disease prevention anddisease prevention and treatment paradigm in the United States”

•Guiding principles•Program Elements•Program ResourcesS t d b th•Supported by the

surgeon general

Discussion Group AnalysisDiscussion Group Analysis

• Strengths• Weaknesses

• Barriers• RequirementsWeaknesses

• Opportunities• Threat

Requirements• Aims

• Discuss…• Discuss…

Practical TipsPractical Tips• Collaborate with stakeholders and primary care• Collaborate with stakeholders and primary care• Internet resources and global initiatives

• Feel free to contact us:t h h @d t k• stephenchew@doctors.org.uk

• rweiler@doctors.org.uk

ResourcesResources• http://www noo org uk/evaluation portal/SEF• http://www.noo.org.uk/evaluation_portal/SEF• http://www.dh.gov.uk/en/Publicationsandstatistic

s/Publications/PublicationsPolicyAndGuidance/Ds/Publications/PublicationsPolicyAndGuidance/DH_105945

• http://exerciseismedicine org/index htm• http://exerciseismedicine.org/index.htm

Thank you

Questions?Questions?

Thank you to:Dr Emmanuel Stamatakis for his help preparing the presentation