Doctor’s Orders: Prescribe Exercise To Patients, Make Physical Activity A Vital Sign

A team of researchers and physicians has issued a “call to action” to colleagues, urging that exercise become a central component of every medical visit. (frodrig/Flickr)

A team of researchers and physicians has issued a “call to action” to colleagues, urging that exercise counseling become a central component of every medical visit. (frodrig/Flickr)

Imagine stepping into the exam room for your regular medical check-up: Your doctor (or an assistant) uses a cuff to check your blood pressure. A thermometer to check your temperature. A stethoscope to listen to your breathing. And then, to check one more vital sign, a simple question: So what are you doing for exercise?

That’s an ideal reality envisioned by a team of researchers and physicians who just issued a “call to action” to colleagues. They urge that exercise counseling become a central component of every medical visit, including by making physical activity a vital sign and prescribing a specific amount of daily exercise to all patients.

We all know that exercise is good for us. But we don’t often consider just how good.

“Physical activity has been shown to reduce the risk of heart disease, stroke, diabetes, certain cancers, osteoporosis, cognitive decline, [hypertension and obesity], and even depression, at minimal cost and with virtually no side effects,” says Dr. JoAnn Manson, chief of the Division of Preventive Medicine at Brigham and Women’s Hospital in Boston. “Can you imagine if there were a pill that could simultaneously have all those benefits? Everyone would be clamoring for it and physicians would be taking it themselves.”

In a “Viewpoint” piece published this week in the Journal of the American Medical Association, Manson and co-authors from the Stanford University School of Medicine and the University of Central Florida offer a new sense of urgency about prescribing exercise to patients.

“A prescription to walk 30 minutes per day could be one of the most important prescriptions a patient could receive.”

– Dr. JoAnn Manson

“No other single intervention or treatment is associated with such a diverse array of benefits,” they write. Adds Manson: “A prescription to walk 30 minutes per day could be one of the most important prescriptions a patient could receive.”

The overwhelming lack of exercise counseling during medical visits is a missed opportunity to dramatically improve patients’ health, Manson said in an interview. With 506 million primary care visits in the U.S. in 2012 (most for prevention and treatment of preventable chronic health conditions), as few as 34 percent of adults report being counseled about physical activity, the authors write.

They also cite research that shows when doctors and other clinicians emphasize the myriad benefits of exercise to their patients, those patients listen.

“Health care professionals are trusted sources for health related information and they can help patients set priorities to improve their health,” Manson said. “It’s one thing to hear on the news that a study showed physical activity is linked to a reduced risk of heart disease. But it’s another thing to have your own physician or health care provider tell you that it’s an important priority for you to walk 30 minutes a day or increase your activity.”

But, she says, many doctors aren’t having these important conversations with their patients about the value of daily exercise.

“It’s not being done,” she said. “There isn’t really any change in behavior on the part of the health care system, [even while] the burden of chronic disease and health care costs have been escalating. …Only about one-third of patients report that physical activity was discussed during a [medical] visit. Even just having these discussions will demonstrate it’s a priority.”

So how would this actually work?

Manson says a member of the patient’s health care team would ask about exercise just like any other vital sign, and deliver the information to the doctor. Then the physician or provider would have a conversation with the patient about what level of exercise might be manageable. The patient would have to agree to a specific amount of activity, and then the doctor would write out a prescription, for say 30 minutes of brisk walking a day. The patient would track their progress using a pedometer, Fitbit or another method, and then report back at the next visit.

Eventually, this ongoing conversation about exercise routines would become ingrained, with clinicians encouraging positive behaviors and gently nudging patients who fall short of their goals.

For those who say they’ve got no time to walk or workout, Manson says: “They’re not going to have time for the chronic diseases that a sedentary lifestyle and poor physical behaviors will lead to — these conditions will shorten their lives. …Everyone has time: You can work with a patient, for instance, to walk instead of drive, or cycle. Sometimes you can’t build physical activity into every day of the week, but it can be built in to many days and on the weekends.”

For medical students, too, this exercise counseling should be part of their curriculum and training, she said. “So many things are done during a medical exam that have questionable value — even the annual exam itself is being called into question. Exercise and physical activity have demonstrated health benefits.”

What’s more, she says, this activity counseling does not add much to the workload of already overworked physicians if the duties are spread among the clinical team.

Dr. Edward Phillips, an assistant professor at Harvard Medical School and Director of the Institute of Lifestyle Medicine at Spaulding Rehabilitation Hospital in Boston, has been atop the exercise-as-medicine bandwagon for a very long time.

Phillips points out that the harms of inactivity have been widely publicized. In 2012, for instance, The Lancet devoted a whole issue to the very bad health implications of physical inactivity, and determined that 5.3 million people died due to causes related to inactivity compared to about 5 million who died from smoking. That’s the genesis of the now-ubiquitous phrase: “Sitting is the new smoking.”

Phillips says specialists in the exercise-is-medicine movement have already laid the groundwork promoting the centrality of physical activity for health “But, he said, “it’s significant and welcomed that a high-impact journal like JAMA is joining the movement.”

Here are more of Phillips’ comments on the JAMA piece:

It is highly significant that a scientist of Dr. Manson’s stature is specifically calling for physicians to prescribe exercise. The good news is that the infrastructure to train and support the clinician’s in this critical effort is already in place.

I have been promoting this concept since publishing ACSM’s Exercise is Medicine: A Clinician’s Guide to Exercise Prescription (Wolters-Kluwer 2009). The Exercise is Medicine global initiative was launched in 2007 to promote the inclusion of physical activity in every visit with every provider for every patient.

It specifically calls for use of a “Physical Activity Vital Sign” (to assess physical activity levels) and then provision of an exercise prescription.

I am particularly interested in the reform of medical education to include exercise prescription as a competency for medical students.  This has been formalized as a key part of the Lifestyle Medicine Education Collaborative.

Clinician’s exercise prescription is an easily learned, readily applied and highly potent intervention. The exercise prescription is a critical and necessary measure to address the global pandemic of physical inactivity which kills more people than smoking.

Just last week, the prominent American College of Obstetricians and Gynecologists called for more exercise among pregnant women and those considering pregnancy; and here at CommonHealth, we’re all about dragging your body out to move, even a little bit, every day for physical, sexual, mental and spiritual health.

Readers, would you exercise more consistently if you got a prescription from your doctor to do so? Please share your thoughts.

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