Exercise Is Good Medicine:
Prescribing Exercise In A Busy
Clinical Practice
Thomas M. Best, MD, PhD, FACSM
Exercise and Health
• The benefits of exercise in the prevention and
treatment of disease has been clearly established.
– There is a linear relationship between physical activity
and health status.
– Inactivity is a powerful and modifiable risk factor for
chronic disease and premature death.
• Physicians and other healthcare providers have an
ethical (legal?) obligation to assess & prescribe
exercise
– Inform patients of the risks of inactivity.
– Recommend proper amounts of PA essential to health.
Source: WHO's report on "Global health risks"
Physical inactivity - 4th leading risk factor for global mortality
60% of global deaths due to NCDs
Contributors to Overall Health Status;
The Power of Health Behaviors
20%
50%
20%
10%
Source: CDC 2000
Contributors to Overall Health Status;
The Power of Health Behaviors
20%
50%
Exercise
Smoking
Diet
20%
10%
Source: CDC 2000
Patient’s deserve to know the facts…
Irrefutable Evidence for Exercise in the
Primary and Secondary Prevention of:
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Diabetes mellitus
Cancer (breast and colon)
Hypertension
Depression
Osteoporosis
Dementia
Coronary Artery Disease
All-cause and cardiovascular-related death
“In view of the prevalence, global reach and
health effect of physical inactivity, the issue
should be appropriately described as
Pandemic, with far-reaching health, economic,
environmental and social consequences.”
http://curetogether.com
Music with Spend time
exercise
with pet
Abilify
Effexor
Trazadone
Lithium
Elavil
Paxil
Alcohol
Exercise
Adequate sleep
http://curetogether.com
Pilates
Lyrica
Spine Fusion
Neurontin
Yoga
Exercise Is Medicine: Physicians should
prescribe it, Patients should take it!
• Exercise is the long sought vaccine to prevent
chronic disease and extend life.
• If we had a pill that conferred the proven
health benefits of exercise, physicians would
prescribe it to every patient and healthcare
systems would find a way to make sure every
patient had access to this wonder drug.
Why Has the Medical Community
Neglected Physical Activity as a Treatment?
• Easier for physician to issue a prescription to reduce BP,
cholesterol, glucose or BMI.
– Medication adherence is very low (1 in 6 take meds as
prescribed).
– Reliance on pills transfers responsibility for health to doctor
resulting in lower patient physical activity.
• Widespread belief we cannot change physical activity
habits. However:
– Evidence brief counseling and pedometer programs can
increase physical activity.
– We are able to convince patients to take insulin shots,
Coumadin, chemotherapy, etc – why not exercise?
What Can We Do?
• Include exercise in all treatment plans:
– Every patient; Every visit;
Every treatment plan.
• Use our Physical Activity Vital sign to
remind all patients to get 30 min of mod
exercise, 5 days per wk.
• Message should be the same from
every medical provider.
• We must begin to merge the fitness
industry with the healthcare industry.
Health Burden of Inactivity Vs Smoking
• One day of being inactive has
roughly an equivalent health
burden to smoking 3 cigarettes.
• So, being inactive for a whole
week has equivalent health
burden to smoking a pack of
cigarettes.
– Do you advise your patients not to
smoke?
Khan MK, BJSM May 2010; 6:395
‘The Real Focus of the Affordable Care Act is Wellness’
Kathleen Sebelius
Exercise – The Missing Vital Sign
• Simple way to get the topic of exercise into the exam
room with every patient visit.
– Consider assessing the exercise habits of every patient you
see with an exercise vital sign.
– Based on the evidence, this should be standard of care.
• Can be effectively incorporated into an Electronic
Medical Record.
– Medical assistant can ask and record.
– Record with BP, HR, temp, BMI and smoking history.
Smith, John W
KP Exercise Vital Sign
• Began use KP So Cal in Oct 09’; KP No Cal began Jan
11’. KP Northwest and CO in 2012.
– For 1 year ending 1/31/2013 in So Cal (2,408,537 adults):
• 92 % (age 18-64) had EVS on chart.
• 96% (age > 65) had EVS on chart.
• Of those adults with EVS recorded:
– 36% were completely inactive (reported 0 min/wk)
– 33% were insufficiently active (reported 10-149 min/wk)
– 31% were meeting guidelines (>150 min/wk)
Comparing KP EVS to National Data
 Results compare favorably to most recent NHANES
physical activity measures, providing more
conservative estimates than self-report, but higher
than accelerometry measures.
KP EVS
NHANES –
Self-report
NHANES Accelerom
None
35.7%
12.5%
Insufficient
33.6%
27.9%
Sufficient
30.7%
59.6%
53.0%
38.8%
8.2%
The Exercise Prescription
“Think FITT”
F = Frequency
Most days of the week; 5 or more.
I = Intensity
Moderate; 50-70% of max HR or use “sing-talk” test.
T = Type
Use large muscle groups; something enjoyable.
T = Time
30 minutes.
Common Barriers to Exercise
• Competing
demands
(work/kids/spouse)
• Not enough time
• Too tired
• Physical limitations
• Too boring
• Sedentary habits
“What fits your busy schedule
better, exercising ½ hour a day or
being dead 24 hours a day?”
Breaking Down the Barriers
• Make exercise a habit, not an option.
• 150 min per week is goal – not starting point;
so start small:
– 1-2 days per week
– Three 10-min bouts
• Simple recipe for getting your exercise:
– AM; park car 10 min from office, walk in
– Lunch; walk 5 min out, eat, walk back
– PM; Walk 10 min back to car
Breaking Down the Barriers
• Make weekends count!
– Change mindset; weekends are for fitness
– Walk 60 min on Sat or Sun, only need 90 more minutes
during week
• Bump up the intensity!
– 25 min of vigorous exercise (jog) done 3x per wk
– 30 min of moderate (brisk walk) done 5x per wk
• More ideas:
– Find an exercise partner
– Get good shoes and nice workout clothes
– Set goals (fun run or walk, sprint triathlon)
So what kind of physician do
YOU want to be?
• Did you know?
– Physicians with healthy personal habits more
likely to counsel patients to adopt such habits.
– Patients find doctors with healthier exercise
and diet habits to be more believable and
motivating toward healthy patient lifestyles.
– In fact, doctors who exercise and eat right are
better doctors!
• Healthy Doc = Healthy Patient
– Dr Erica Frank
– Professor and Canada Research Chair
Hospital Ambulation Project
• Studies show hospital patients
who walk during hospital stay
have fewer complications and
get discharged sooner.
• Activity monitor can measure
number of steps and minutes
walking in hospital patients.
Hospital Ambulation Project
Activity Sensor
Activity USB Stick
Activity Server
Activity Online Web Application
Hospital Ambulation Project
D/C
Admit
38 yo female s/p cholecystectomy
Why do we have to re-learn that bed rest
or immobilization is a bad thing?
• Shoulder dislocation – prolonged
immobilization replaced with early
ROM and strengthening exercises.
• ACL reconstruction – casting and
bracing after surgery replaced with
Continuous Passive Motion and
early ROM & rehab exercises.
• Being sedentary is bad for you. It
makes every disease or injury state
worse!
Do You Really Think We have a Chance
Without Exercise?
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Obesity
Coronary artery disease
Diabetes
Hypertension
Cancer
Depression and anxiety
Arthritis
Osteoporosis
Etc, etc, etc…
NO!
Your Patient
You
www.everybodywalk.org
Interventions – There Are Multiple!
• Multi-component interventions
• Adapted to the local context
• Culturally and environmentally appropriate interventions
• Using existing social structures of a community (e.g. schools,
weekly meetings of older adults)
• Multistakeholder involvement throughout the process
• Listening, learning and targeting populations needs
• Interventions targeting the built environment
http://www.who.int/dietphysicalactivity/whatworks/
Summary
• Physical inactivity is the major public health
problem of our time.
• Physicians have a responsibility to assess PA
habits, inform patients of risk and prescribe
proper exercise.
– An Exercise Vital Sign is an easy way to bring a
discussion on PA into the exam room.
– Even brief advice can have a significant affect.
– Where time allows, consider formal exercise Rx or
referral.
• Exercise is Medicine that we need to take and get
patients to take!