Clinicians Lack Confidence in Prescribing Exercise

Experts believe that primary care clinicians who counsel their patientsabout physical activity can getresults.

“We know that when a doctor recommends something, patients startdoing it,” says Tim Church, MD, PhD, MPH, medical director of the CooperInstitute in Dallas. “There's almost nothing as powerful as a doctor'sadvice.”

But in a recent national survey of 9,299 patients, only 34% reportedreceiving counseling on physical activity at their last medical visit.Patients least likely to be counseled were <30 years of age, disease-free,from lower socioeconomic groups, and at risk for obesity. These findingsrepresent “missed opportunities for primary prevention,” theauthorsconclude.¹

Not all clinicians feel equipped to act as physical activity counselors. A1993 survey of approximately 100 primary care physicians from Reading (Pa.)Hospital asked whether they counsel patients on physical activity. Over 90%said they thought doing so was important, says David L. George, MD, directorof medical education at Reading Hospital and Medical Center. But when asked ifthey felt confident in that role, respondents routinely said“no.”

“Results have not changed when compared with more recentreports,” George says.

GET BEHIND THE GUIDELINES

The latest iteration of the Dietary Guidelines for Americans, distributedin January by the Department of Health and Human Services and the Departmentof Agriculture, presents the most specific and stringent recommendations forphysical activity todate.²

The 2005 guidelines advise a minimum of 30 minutes of moderate- tovigorous-intensity activity on most days of the week to reduce the risk ofchronic disease. To combat weight gain associated with increasing age or tolose weight, the guidelines urge 60 minutes of moderate- to vigorous-intensityactivity on most days of the week. And to sustain weight loss of ≥30 lbover many years, they suggest 60–90 minutes of moderate activitydaily.

“The wealth of experimental research evidence clearly shows thatquality exercise is needed to reverse blood-lipid abnormalities, lower bloodpressure, increase insulin sensitivity, lose excess body fat, and improveheart function and volumes,” says Robert Robergs, PhD, EPC, professor ofexercise physiology and biochemistry at the University of New Mexico inAlbuquerque.

It would be beneficial to get all patients committed to a moderatelyintense exercise routine, but for many patients, getting started is thebiggest hurdle. “The majority of exercise comes from just getting offthe couch,” Church says. “Something is better thannothing.”

Engaging the clinician as an activity counselor can be as challenging asmotivating sedentary patients.

BEHAVIOR CHANGE, STARTING IN MED SCHOOL

Increasingly, behavior-change methods are being taught as part of themedical education curriculum, George notes. And yet, medical studentsgenerally do not have the opportunity to practice what they're taught.

“We should be promoting healthy lifestyles in medical students andresidents. We should lead our patients by example,” Church concurs.“For 7 or 8 years of their lives, [medical students] are going to besedentary and eat horribly,” he says.

A recent study designed to encourage resident physicians to improve theirown physical fitness and attitudes toward stages of change, as well as theircounseling behavior, had little positive effect on subjects' fitnesslevels.³ However,they did report improved attitudes toward patient counseling.

Subjects learned the transtheoretical model of behavior change developed byresearchers at the University of Rhode Island Cancer Prevention ResearchCenter in Kingston. The model theorizes that behavior change unfolds through aseries of stages: recognizing the need to change, contemplating a change,making a change, and finally sustaining the new behavior.

“I hope that in learning about these behavioral change concepts,[subjects] felt more comfortable applying them in the patient setting,”says lead investigator Laura Rogers, MD, MPH, associate professor of medicineat Southern Illinois University in Carbondale. “Sometimes, just gettingsomeone ready to exercise is good.” ▪

Quick, Effective Tips for Counseling on Physical Activity

1. Be supportive. “You've got to become a bit of acheerleader,” says David L. George, MD, director of medical education atReading (Pa.) Hospital and Medical Center and clinical professor of medicineat Penn State University.

2. ID incentives. “Certain people are goal-oriented. Others are`group people' and like the idea of walks at the mall,” George says.“Others want to watch TV, so I tell them to put a stationary bike intheir TV room.”

3. Prescribe it. “Write down on a prescription pad the exerciseyou've negotiated with your patient, just as you would any otherprescription,” suggests Laura Rogers, MD, MPH, associate professor ofmedicine at Southern Illinois University in Carbondale.

4. Personalize it. “If your patients can get a sense of howimportant physical activity is, they're more likely to engage in it,”George says.

5. Log it. Ask patients to keep a diary of physical activity for twodays. “The stunning thing most people will find is how much time theyspend sitting down,” says Tim Church, MD, PhD, MPH, medical director ofthe Cooper Institute in Dallas.

6. Track it. “Tracking is critical,” Church says.Pedometers that count the steps the wearer takes can be purchasedinexpensively at sporting-goods stores. When used as part of an intensivelifestyle-intervention program involving regular walking, pedometers have beenshown to reduce the likelihood of developing diabetes in at-riskgroups.¹