How to Counsel Patients About Exercise
An Office-Friendly Approach
F. Daniel Duffy, MD; with Lisa Schnirring
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2021
In Brief: Despite the demands of a busy office setting, a brief physician counseling session about exercise can be highly effective and well worth the precious time. Components include delivering a clear message about exercise, stepping back to assess the patient's readiness to change, and using the patient's cues to set an activity agenda. Physician counseling about exercise is crucial to improving patients' health status and to the success of the several activity recommendations contained in the federal government's Healthy People 2010 report.
The links between exercise and its effect on health improvement and disease prevention are steering public health policy and are echoed continuously in media reports. However, most patients are not taking action. According to the US surgeon general's report on physical activity and health (1), Only 22% of US adults are active enough to receive health benefits from physical activity, 53% are somewhat active, but not at a level to benefit health, and 25% are sedentary.
One could argue that patients are failing to take responsibility for their own health, but it's also useful to analyze the physician's potentially powerful role in encouraging patients to exercise. Activity recommendations are likely to be more palatable to patients than physicians might think: It's generally easier to add a healthy behavior such as exercise than to take away an addictive behavior such as smoking.
Current Counseling Status
The Healthy People 2021 report recommended that physicians counsel 50% of their patients about exercise (2). (The Healthy People 2010 report does not include a specific goal.) However, reality fell short. The most recent survey of physician exercise counseling practices indicates an overall rate of 34% (3).
The survey provides further details about exercise counseling practices. Rates did not vary significantly by physician specialty or by patient race or gender; however, patients who were older than age 30, were married, or who were of higher socioeconomic status were more likely to be counseled about exercise. Physicians were more likely to counsel patients who were obese, had cardiac disease or diabetes, or reported frequent office visits, but less likely to counsel patients who were sedentary (with no other risk factors) or had body mass indexes lower than 25.
In their comments on the study, the authors call for more aggressive counseling of obese patients and those who have chronic health problems. They also note that the documented failure to counsel healthy younger adults between ages 25 and 35 represents a missed opportunity to lower the risks of weight gain. An article on exercise counseling by Andersen et al (4) notes "Patients often interpret a lack of advice to become more active as an endorsement of the view that physical activity is not important."
Does Exercise Counseling Work?
There are few data on the effectiveness of physician counseling about exercise. A study (5) that evaluated a structured physician exercise assessment and counseling program found that 3- to 5-minute counseling sessions increased physical activity. In the randomized trial, patients questioned 1 month after being counseled by physicians about physical activity reported increases in exercise duration but not frequency.
A multicenter cohort study (6) of exercise adoption and other lifestyle changes found that patients who received counseling intervention were more likely than matched controls to report positive behavior changes regarding exercise.
How to Raise the Exercise Issue
The primary caveat when counseling about exercise is to avoid preaching or lecturing to the patient. The ideal exercise counseling session should be short. Sessions that run longer than 10 minutes probably involve the physician lecturing the patient. The counseling code (99401 through 99404) can be used for reimbursement.
The two most important steps are to deliver a clear message about a specific health problem to be solved or prevented by exercise and to assess how the patient feels about exercise. Examples are:
Emotional shutdown, or a patient's reflective turning inward, after physicians deliver medical news—including suggested lifestyle changes such as becoming more active—is normal. When physicians realize this, they can avoid prematurely launching into exercise recommendations at a time when the patient is unprepared to receive them. Instead, validate the response: "I can see you are surprised (or concerned)," and ask directly what the patient knows or thinks about an exercise program.
Interview Clues Guide the Approach
In the realm of therapeutic interventions, many patients are likely to perceive exercise as less concrete than, for example, a medication. Given that exercise is often a vague term, the physician must ask patients what they think exercise means. Some patients might have worked with a personal trainer in the past and have a sophisticated concept of exercise. For many, their last experience was an unpleasant one in a high school physical education class. Others may be overwhelmed at the prospect of exercising.
Not every patient will be ready to adopt an exercise program. The likelihood the patient will begin often depends on his or her mental stage of change. These stages are precontemplation, contemplation, determination, action, maintenance, relapse, and termination (7), all of which are normal (table 1). Questions that are useful for determining the patient's stage of change include:
These initial questions help patients come up with their own exercise plan. The physician's role, then, is to help them mentally walk through the steps they might take to adopt an exercise routine. Questions are targeted to evaluating the barriers to and benefits of exercise; most patients are willing to engage in self exploration. Then, using the patient's own words, the physician amplifies the benefits of exercising (eg, more energy) and diminishes the barriers (eg, having to take two showers a day).
The patient's answers to the preceding questions also elicit concerns about exercise. For some, foot pain or another treatable musculoskeletal complaint may be an anticipated obstacle. These patients may benefit from footwear recommendations or an anti-inflammatory medication. For others, obstacles are chronic-illness related, such as glycemic control or asthma symptoms.
Steps That Encourage Patient Success
Once patients indicate that they're willing to become more active, the physician's role is to help them become aware of available options and emphasize the importance of social commitment to continue activity.
The exercise patients choose must be appropriate for their physical capabilities. For example, swimming might be the best choice for patients who have foot problems, and weight lifting at a gym might not be appropriate for patients who have cardiovascular disease. Let the patient, though, decide what is best. Skills-based activities such as golf may not lead to permanent change unless patients previously enjoyed the activity. Above all, focus on fun to help keep patients engaged in their activities. (See "New Exercise Options for Sedentary Patients," below.)
Social support introduces the element of accountability into exercise patterns. Going public with the commitment to exercise is important. Patients should be urged to tell people who care about them about the exercise plan so that they can routinely ask their loved ones about their progress. In most studies, social pressure to add a new behavior enhances the experience—working with someone, meeting someone, or having an exercise buddy (8,9). The key to effective social pressure is that the patient should be missed—but not shamed—when he or she doesn't exercise.
Linking exercise to measurable health parameters can help patients maintain their exercise resolve. Physicians can help patients link physical improvements to exercise. For example, a severely deconditioned 90-year-old woman whom you ask to lift two soup cans several times a day can be questioned about functional gains such as being able to reach into her cupboard for a glass. Keeping an exercise log is useful if it helps patients to monitor how they feel and allows them to track and observe improvements in their pulse and blood pressure.
Other tools that are useful in the office setting are lists of area health clubs, mall-walking clubs, air-conditioned places to walk, and patients who successfully adopted exercise and are willing share their experiences with other patients.
Working Through Relapse
It's helpful for physicians to adjust how they view patient relapse into sedentary patterns. Relapse to old habits is so common that it can be expected and presents an ideal opportunity to learn what worked, what didn't, and what life events broke the pattern. Usually, something in the patient's life, such as work or family, becomes a greater priority. Illness is a notorious reason for relapse.
It is often helpful to tell patients to call or make an appointment when they've relapsed. A brief counseling session can help patients learn why they stopped exercise. A useful question to ask is, "What happened a few days before you stopped exercising?" Many patients unwittingly planned to stop because they became bored with their routine.
Physicians can help relapsers avoid shame and demoralization by encouraging patients to stay in the cycle of change, moving quickly back to determination. Relapse is a reminder that the path to change is never a straight one.
Dr Duffy is the executive vice president of the American Board of Internal Medicine in Philadelphia, and Lisa Schnirring is senior editor of The Physician and Sportsmedicine. Address correspondence to F. Daniel Duffy, MD, American Board of Internal Medicine, 510 Walnut St, Philadelphia, PA 19106.
New Exercise Options for Sedentary Patients
Shawn C. Franckowiak
Counseling sedentary patients to become more physically active can help them reduce the risk of premature mortality (1). However, many sedentary patients still believe that exercise must be vigorous to improve health. Physicians can help them grasp the concept that moderate activity can offer similar health and weight-loss benefits, and they can steer patients to specific exercise goals based on new guidelines.
What Counts as Exercise?
Perceptions of what constitutes exercise vary. Under older exercise recommendations (2), a short 3- to 4-mph walk that lasted only 5 minutes would have not have counted as beneficial physical activity. People who had only 5 or 10 minutes of free time resisted exercise because they could not meet the requirement that workouts be continuous and last for 15 minutes or more. Furthermore, physical activity that was less than vigorous was perceived as not worth doing.
However, scientific data pooling on the dose-response effects of physical activity suggests that moderate-intensity exercise promotes health benefits (3), and physical activity research suggests great health improvements for sedentary people who become moderately active (4). The surgeon general, along with organizations such as the National Institutes of Health, the Centers for Disease Control and Prevention, and the American College of Sports Medicine, adopted physical activity recommendations with the goal of producing—as opposed to maximizing—health benefits. The premise is that exercise need not be vigorous or continuous to be beneficial, and that even moderate activities (purposeful intensity) will improve health.
Although it is still recognized that more vigorous exercise is needed to optimize cardiorespiratory fitness, general recommendations state that people should accumulate 30 minutes or more of moderate-intensity physical activity throughout the day on most and preferably all days of the week (5). Short walks and household physical activity do count under these recommendations. Table A (not shown) provides a variety of exercise prescription options based on the patient's activity level.
New Activity Strategies
Two tactics for accumulating exercise time are lifestyle activity and short-bout exercise; both are geared toward promoting adherence. Studies have shown that patients who increase lifestyle activity can lose as much weight as those in traditional exercise programs. Lifestyle activity may even increase an individual's ability to resist weight gain after reaching a weight-loss goal (6). The latest findings suggest that short-bout exercise produces cardiovascular and weight-loss benefits similar to those achieved with traditional continuous long-bout exercise (7).
Lifestyle activity. As a first step to prescribing activity for a sedentary patient, evaluate the patient's activity level and suggest that he or she increase daily energy expenditure by engaging in lifestyle activities that accumulate exercise throughout the day. Examples include walking from the far end of the parking lot when parking the car, taking more walks with the dog, engaging in more housework, gardening more, and walking whenever possible. Two very different examples include mowing the lawn with a push mower for 30 minutes or taking six brisk walks, each lasting 5 minutes, throughout the day. Many patients see the wider exercise and activity options as being less overwhelming than a traditional exercise program, which may improve adherence.
Counseling also involves helping patients identify ways to decrease sedentary activities such as computer and television use.
Short-bout activity. Typically, unfit patients mention difficulty sustaining activity for long durations or feel that long bouts of exercise are boring. The energy expenditure of multiple short bouts of exercise through the day is similar to that of a traditional long bout, providing many health-related benefits and assisting with long-term weight loss. This plan empowers the patient to identify barriers (such as time) that inhibit activity and choose convenient times throughout the day to perform mini-bouts of vigorous physical activity. A program of 10 minutes of brisk walking three times a day is a good example.
Mr Franckowiak is a research coordinator in the Division of Geriatric Medicine and Gerontology at Johns Hopkins School of Medicine in Baltimore. Address correspondence to Shawn C. Franckowiak, Johns Hopkins School of Medicine, Division of Geriatric Medicine and Gerontology, 4940 Eastern Ave, Suite 025, Baltimore, MD 21224; e-mail to [email protected].