Beyond the Exercise Prescription: Making Exercise a Way of Life
Mona M. Shangold, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 11 - NOVEMBER 98
When we hand a patient a prescription for medication, we may assume that it will be filled and taken as we've instructed. We too often discover later that fears or unanswered questions kept the patient from ever filling the prescription or that side effects led him or her to discontinue its use. And we may never learn what the patient did if he or she wants our approval or fears our response to the truth.
Giving a patient an exercise prescription can be fraught with even more complexities, particularly because regular exercise involves our patients' behavior, routines, goals, and even their view of themselves. Just telling them to exercise is not enough. The benefits of exercise require long-term compliance, so motivating patients to begin and continue physical activity is as important as the prescription itself. To motivate our patients, we have to go beyond the easy role of dispenser of prescriptions to become role models, educators, coaches, and advisers who are familiar with patients' schedules, goals, preferences, and values.
Begin With Basic Guidelines
We know that exercise can be a potent medicine for our patients, so, of course, we have to begin by providing basic information. The guidelines recommended by the American College of Sports Medicine(1) are a good start: 20 to 60 continuous or accumulated minutes of aerobic exercise 3 to 5 days per week and resistance and flexibility training 2 to 3 days per week each. Providing a patient-friendly brochure that explains such guidelines may help patients understand and implement the exercise prescription.
Tackle All the Barriers
Being a role model. To motivate patients, however, we must do more than dispense information. We must also teach by example, and demonstrate that we believe in our exercise-as-medicine message enough to practice it ourselves. We are, after all, members of a community, and what we do in public sends a message. If we ride a bicycle without wearing a helmet, we convey the wrong message. If we ask our patients to exercise without doing so ourselves, we suggest that physical activity is not worth our time, and thus we undermine our credibility. We also may empathize less with the problems patients face in beginning or sustaining an exercise program, and we certainly cannot use our own experience to suggest ways of solving those problems.
Knowing patients' schedules. One of the main obstacles to regular exercise is a lack of time, so helping patients adhere to an exercise prescription may require familiarity with their schedules and routines. Knowing when a patient normally wakes up and goes to bed may enable us to suggest getting up a half- hour earlier to exercise. Familiarity with the work and child care schedule may help us see where a patient can fit in several 10-minute exercise sessions each day. Learning that a woman is expected to prepare the family dinner while others exercise gives us an opportunity to suggest a change of family routines or even meet with the family to ensure that she, too, can exercise. (For more tips on helping patients work exercise into a busy schedule, see the Exercise Adviser "Fitting in Fitness: Exercise Options for Busy People," August, page 83.)
Knowing their goals. Patients deserve unique exercise prescriptions that help them stay motivated and achieve their goals. For example, the woman seeking only weight loss and a slimmer body will not be motivated to exercise to prevent osteoporosis, and her prescription will differ from that of the woman whose main concern is preventing a hip fracture.
Discovering their preferences. Making exercise more enjoyable can help patients surmount obstacles, so we need to inquire about their likes and dislikes. One patient may be more committed to exercising in the company of a friend, while another may be spurred on by joining an exercise group at the local fitness center. Attending a ballroom dance class may be more fun for a patient than a run in the park, and another may prefer the convenience of jumping rope in his basement.
Countering the female stereotype. Persuading girls and women to begin and continue an exercise program can involve a much larger task than learning their individual schedules, routines, goals, and preferences, because often we are dealing with powerful social values. Though girls' and women's participation in sports has burgeoned in recent decades as gender roles have expanded, the small, frail-bodied female stereotype still haunts many women and presents yet another barrier to exercise.
Girls and women are too frequently valued for how they look rather than for who they are and what they do. Most advertisers, for example, present girls and women as objects of beauty rather than as physically active and strong individuals. Many young women grow up believing in this image because it is reinforced by the adults around them.
The young girl who watches her mother apply make-up but never sees her exercise assumes that beauty rather than fitness should be the goal. The teenage girl whose father jokes about her pubertal plumpness or the adolescent runner whose coach tells her she needs to be thinner may develop feelings of inadequacy that can last a lifetime. Such girls may also curry the favor of the men around them by losing weight, often by dangerous means because of unrealistic goals. Frequently they develop low self-esteem, eating disorders, and depression.
Whether the patient is a man or a woman, the challenge of helping patients make exercise a way of life can seem overwhelming, especially if we strive to go beyond the basics. Where do we find the time for such counsel? And what about the reimbursement issue?
It's important to remember that many of us already exercise, and if we don't, we should be exercising for our own health and well-being. Giving a basic exercise prescription takes only a minute or two, and using your own exercise experience as an example can be accomplished while examining a patient or walking down the hall. Offering an exercise prescription requires no special staffing or equipment, and informational handouts are readily available and inexpensive.
Learning about our patients' lives and how their particular situations and emotions affect their attitude and ability to exercise takes commitment and time. Exercise may be medicine, but it is not simply a pill patients take. To gain the full benefits requires lifelong effort. We don't have to accomplish everything in one or two office visits, but we do have to persist in asking about and cheering our patients' progress, encouraging them during their setbacks, and finding solutions to the problems they encounter. Only then can we hope to make exercise a way of life for everyone.
Dr Shangold is director of The Center for Women's Health and Sports Gynecology in Philadelphia. She is a fellow of the American College of Sports Medicine and the American College of Obstetricians and Gynecologists. Address correspondence to Mona M. Shangold, MD, 1601 Walnut St, Ste 1200, Philadelphia, PA 19102.
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