Prescription Exercise

Few would argue the benefits of regular exercise on overall health. Physical activity may be the single most effective nonpharmacologic intervention to ward off diabetes, heart disease and a host of other chronic diseases. It is also a key ingredient to losing or maintaining weight. This is not a new concept. In 300 BC, Aristotle suggested that “a man falls into ill health as a result of not caring for exercise.”1

The American Heart Association recommends 150 minutes of moderate intensity aerobic exercise per week for most adults, yet according to the Centers for Disease Control and Prevention, only 1 in 5 adults meets these overall physical activity guidelines.The estimated economic burden of physical inactivity in the United States in 2005 was $24 billion, which accounted for 2.4% of total health expenditures.Strategies to promote recruitment and retention in an exercise program have been met with limited success. What is it that keeps most Americans from being active? Or, perhaps more importantly, what can we do to help them not only get moving, but keep moving?

Contributors to Sedentary Behavior
The physical and social environments in which we live are changing in ways that reduce the demand for physical activity. Common behaviors that contribute to inactivity include TV viewing, computer use and electronic gaming. People of all ages are spending more time interacting with technology: the Internet, video games, cell phones and MP3 players.In fact, Gen Y’ers (Americans born after 1979) are known as “screenagers.”4 Drive-through windows, elevators, escalators and automation have made our lives more efficient, but less active.

Barriers to Physical Activity
Eighty percent of Americans are not active at the recommended levels.5 The successful management of obesity must include the identification of obstacles to regular physical activity. Barriers include perceived lack of time, lack of resources, family obligations and embarrassment. For many, pain, injury and disability encourage sedentary behavior. A lack of energy, motivation and confidence are among the top reasons adults cite for not adopting a more physically active lifestyle.5

Consequences of Sedentary Behavior
Sedentary behavior is one of the leading preventable causes of death.Participation in regular physical activity decreases the risk for cardiovascular disease, type 2 diabetes, osteoporosis, depression, obesity, and breast and colon cancer.In older adults, it also decreases the risk of falls.6

SEE ALSO: The ACA and Public Health

Most importantly, the health risks stated above may decrease with as little as 30 minutes of moderate-intensity physical activity per day in people who are physically inactive.And it is important to note that inactivity has been identified as the fourth leading risk factor for global mortality, responsible for a staggering 3.2 million deaths annually.7

Benefits of Exercise
Almost all patients benefit from physical activity, but some require risk stratification.Increasing physical activity is effective in the treatment and prevention of chronic disease and improving overall health and well -being. The specific benefits of exercise are summarized here:8

  • Reduces the risk of premature death by up to 40%
  • Lowers the risk of stroke by up to 40%
  • Reduces the incidence of diabetes mellitus by at least 30%
  • Reduces the incidence of high blood pressure by up to 50%
  • Can reduce mortality and risk of recurrent breast cancer by almost 50%
  • Can lower colon cancer risk by 27%
  • Can reduce the risk of developing Alzheimer disease by one-third
  • Can decrease depression as effectively as medication.

Prescribed Exercise
The thinking in today’s society is that exercise is a tool to cure. If physical activity is considered normal and necessary for good health, the notion that physical inactivity is a cause of chronic diseases will be easy to support.1 Healthcare professionals play an important role in promoting physical activity and weight management. Primary care starts with primary prevention. General practitioners have access to a large proportion of patients with co-morbidities, obesity and sedentary lifestyles and are a respected source of advice.Prescribing exercise as prevention should be a responsibility of primary care providers.

Although most primary care providers deliver the advice to exercise, they must go a step further. They must recommend effective interventions such as behavioral strategies, goal setting, problem solving, self-monitoring and feedback.Because prescriptions represent a well-understood interaction between patient and provider, prescription exercise may be taken more seriously than advice alone.9 What better time is there to administer this advice than during the office visit, when the patient is most receptive to receiving information about his or her health?

Interventions
Interventions should focus on improvements in the level of physical activity, and strategies need to be informed by determinants of modifiable sedentary behavior. The main considerations in the promotion of physical activity and the prescription of regular exercise are as follows:

  • Intensity: Duration, frequency, dose
  • Mode: Type of exercise
  • Method of assessing exercise intensity: Heart rate, rate of perceived exertion
  • Monitoring progress: Regular assessment and feedback
  • Ongoing evaluation of goals and outcomes: Consistent with behavioral approaches

How well the exercise prescription is individualized may have the most influence on adherence and interest and should be a strong consideration.1,9 A systematic literature review found that significant increases in physical activity occur most often when interventions included individualized social support.10 Participants report a sense of commitment, accountability and a strong sense of group identity as important factors in their participation in physical activity interventions. These findings are important considerations when designing future interventions. Community-based programs are removing barriers to exercise by providing affordable supervised options in local fitness facilities. Worksite interventions and strategies to overcome common barriers are summarized in the table accompanying this article. These strategies can help make physical activity part of daily life.

Implications for Practice
Regular physical activity improves overall health and fitness and has the potential to reduce the risk for chronic diseases. In addition, exercise can decrease depression as effectively as medication.10 Reducing inactivity among sedentary adults could have considerable impact on health expenditures. Promoting physical activity as normal and necessary for health should be the basis for any intervention designed to increase exercise behaviors. It is the responsibility of the healthcare provider to encourage sedentary people to become active. Interventions that include social support as a motivator of physical activity have the highest rate of exercise retention.

Therefore, as health care providers, we are challenged to design systems that include strategies that are sustainable and contain measures of support and accountability. Healthcare providers should review and assess each patient’s physical activity level at every visit. Determining the most effective approaches to promoting exercise is a challenge. It is unlikely that there is a one-size-fits-all intervention. Improving modifiable risk factors of physical inactivity will likely require multiple measures, including legislation to improve access and availability of physical activity opportunities.

References
1. Hills AP, Byrne NM. State of the science: a focus on physical activity. Asia Pac J Nutrition. 2006;15:40-48.

2. Blackford K, et al. Office-based physical activity and nutrition intervention: barriers, enablers, and preferred strategies for workplace obesity prevention, Perth, Western Australia, 2012. Prev Chronic Dis. 2013;10:130029.

3. Katzmarzyk PT. Cost-effectiveness of exercise is medicine. Curr Sports Med Rep. 2011;10(4):217-223.

4. Griffiths MD. Trends in technological advance: implications for sedentary behavior and obesity in screenagers. Educ and Health. 2010;28(2):35-38.

5. Sallis JF, Hovell MF. Determinants of exercise behavior. Exerc Sport Sci Rev.1990;18:307-330.

6. Marcus BH, et al. Physical activity intervention studies: what we know and what we need to know: a scientific statement from the American Heart Association council on nutrition, physical activity, and metabolism (subcommittee on physical activity); Council on Cardiovascular Disease in the young: and the Interdisciplinary Working Group on quality of care and outcomes research. Circulation.2006;114(24):2739-2752.

7. World Health Organization (WHO). Physical inactivity: a global public health problem. http://www.who.int/dietphysicalactivity/factsheet_inactivity/en/

8. Law KH, et al. Prescribing health: exercise. Singapore Med J.2013;54(6):303-308.

9. Swinburn BA, et al. The green prescription study: a randomized controlled trial of written advice provided by general practitioners. Am J Public Health.1998;88(2):288-91.

10. Ickes MJ, Sharma M. A systematic review of physical activity interventions in Hispanic adults. J Environ Public Health. 2012;2012:156435.

11. Centers for Disease Control and Prevention. Overcoming barriers to physical activity. http://www.cdc.gov/physicalactivity/everyone/getactive/barriers.html

Glenna W. Lattimore is a nurse practitioner at Hillcrest Family Practice in Simpsonville, S.C.

About The Author

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