Exercise Is Good Medicine:Prescribing Exercise In A Busy

Clinical PracticeThomas 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.

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Physical inactivity - 4th leading risk factor for global mortality

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Contributors to Overall Health Status;The Power of Health Behaviors

Source: CDC 2000

10%

20%

20%50%

Contributors to Overall Health Status;The Power of Health Behaviors

Source: CDC 2000

ExerciseSmokingDiet

Patient’s deserve to know the facts…

Irrefutable Evidence for Exercise in the Primary and Secondary Prevention of:

• 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 andhealth effect of physical inactivity, the issue

should be appropriately described as Pandemic, with far-reaching health, economic,

environmental and social consequences.”

http://curetogether.com

Exercise

Adequate sleep

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PaxilAbilifyEffexorTrazadoneLithiumElavil

http://curetogether.com

Pilates Yoga

LyricaSpine FusionNeurontin

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?

• 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.

What Can We Do?

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

None Insufficient SufficientKP EVS 35.7% 33.6% 30.7%NHANES – Self-report

12.5% 27.9% 59.6%

NHANES - Accelerom

53.0% 38.8% 8.2%

Results compare favorably to most recent NHANES physical activity measures, providing more conservative estimates than self-report, but higher than accelerometry measures.

The Exercise Prescription “Think FITT”

F = FrequencyMost days of the week; 5 or more.

I = IntensityModerate; 50-70% of max HR or use “sing-talk” test.

T = TypeUse large muscle groups; something enjoyable.

T = Time30 minutes.

“What fits your busy schedulebetter, exercising ½ hour a day or

being dead 24 hours a day?”

Common Barriers to Exercise

• Competing demands (work/kids/spouse)

• Not enough time• Too tired• Physical limitations• Too boring• Sedentary habits

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

Admit

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38 yo female s/p cholecystectomy

Hospital Ambulation Project

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!

NO!

Do You Really Think We have a Chance

Without Exercise?• Obesity• Coronary artery disease• Diabetes• Hypertension• Cancer• Depression and anxiety• Arthritis• Osteoporosis• Etc, etc, etc…

YouYour Patient

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!