Small steps can lead to big changes when physicians use the power of a prescription pad to get patients up and exercising, experts say.
“There's nothing more frustrating to a patient than to be told bluntly, 'You need to exercise every day and lose 60 pounds,'” said Dr. Michael Fleming, past president of the American Academy of Family Physicians and someone who has struggled with obesity since childhood. “When someone told me that, I knew I was doomed. There was no way I could do it.”
Physicians share that defeatist attitude, he said in an interview. “It's incredibly frustrating to try to take care of someone who won't make lifestyle changes. And the frustration coming from both sides turns the patient off to whatever the doctor is trying to say.”
But change is possible, he said, and a recently published paper offers a valuable model for physicians who want to help their patients achieve it. “Helping Sedentary Patients Become More Active,” a case study and commentary by Dr. Caroline Richardson and her colleague Dr. Thomas Schwenk focuses on the power of incremental change (J. Clin. Outcomes Manage. 2007;14:161–71).
“The key to success, which this paper stresses, is the concept of taking small steps,” said Dr. Fleming, a former member of the advisory panel for the group Americans in Motion, an AAFP program that helps physicians promote fitness. “I can't start walking 10,000 steps a day tomorrow. But if someone suggests that I increase my walking by 2,500 steps a day, that's doable. I don't have to climb a mountain. Instead, I can go one hill at a time.”
Although patients may express frustration with their weight and exercise habits, most realize that they could benefit from change. At the same time, they doubt their ability to succeed. A pep talk about exercise and some vague dietary advice won't be strong enough to counteract that doubt. Instead, Dr. Richardson asserts, inactivity should be regarded as a potentially harmful condition that needs treatment. That treatment should include a physical exam with an assessment of the patient's current activity level, counseling that addresses barriers to change, and a prescription for addressing the problem.
The activity assessment should include questions about the frequency, duration, and intensity of daily activity. However, it is not always easy to get accurate answers, Dr. Richardson admitted in an interview. “People will say what they think you want to hear.” Patients also often incorrectly describe their activity level because they don't understand the difference between activity and structured exercise. “People might overestimate their activity because they feel as if they run around all day, [and] they're stressed and busy and exhausted at night. But this isn't the kind of activity that gives you any health points,” said Dr. Richardson. Conversely, people who walk constantly during their daily work might say they live a very sedentary life because they never visit the gym. “These perceived discrepancies are part of the reason people aren't successful in starting an exercise program.”
A baseline pedometer assessment can shed some light on how much exercise a person is getting. “It's a simple tool that gives patients an accurate reflection of what they are really doing and a way to set a concrete goal,” she said.
After the activity assessment is complete—and it could take two visits to get the full picture—you can begin setting goals. During the discussion, most patients will identify at least a few barriers to change, such as work, or having a busy schedule, or health issues.
“Physicians have played a big role” in enabling patients to use medical problems as an excuse, Dr. Richardson said. “We have a history of telling people to take it easy, not to exert themselves when they're in pain or don't feel good, especially people with chronic illness or the elderly. But this culture is actually making people sick. The truth is that it's not safe to remain sedentary.”
After the patient agrees that more exercise is necessary, the physician should formalize the recommendation by writing a prescription for a specific regimen, usually a walking program.
“Giving an exercise recommendation the authority of the prescription pad can make a big difference. The patients can look back on it as a reminder and as a trigger for action,” said Dr. Richardson.
The prescription should be specific, with goals that are easily attainable. The first step might be small, such as a 10-minute walk every day during lunch. But success in that small way might help bolster the patient's belief that change is possible.