A Dose for Doing: Healthcare Providers and Exercise Specialists Struggle With Prescribing Physical Activity

For pills, injections, and infusions, proper dosing is imperative to safety and efficacy. So why should exercise, which some view on par with pharmaceuticals for maintaining health, be any different?

Unlike doling out drugs, dispensing advice on exercise can require a bit more subjective judgement. There’s a thin line between giving patients too much or too little direction when it comes to their physical activity, and providers can run the risk of demotivating some patients with confusing or technical instructions. There are also the issues of how physicians are trained to incorporate exercise recommendations into their practice, how to effectively track improvement or regression in physical fitness the way they do cholesterol or blood pressure levels, and how they’re reimbursed for their efforts.

In 2010, only about one-third of US adults reported being advised by their physician to begin or continue an exercise program, according to a data brief published by the National Center for Health Statistics in 2012. While this shows an improvement from the 22.6% seen in 2010, it begs the question: how many people, especially those at risk for cardiovascular disease, are meeting the current US physical activity guidelines?

TCTMD set out to learn more about how cardiovascular health professionals approach the challenge of prescribing physical activity through a reader survey and by in-depth interviews with cardiologists and others active in this field. Many, like exercise physiologist Keith Diaz, PhD (Columbia University Medical Center, New York, NY), admitted that physicians are “not that great” at this task. 

Likewise, Steven Blair, PED (University of South Carolina, Columbia), a past-president of the American College of Sports Medicine (ACSM), told TCTMD that it is “not enough” for a doctor to merely say, “You need to get 30 minutes of exercise at least 5 days a week.” That’s a good start, but a more nuanced approach is needed, he said.

The current system, at least in the United States, rewards the prescription of pills over exercise recommendations, something most physicians are sensitive to yet ill-equipped to challenge. Physical activity is a “wonder drug,” according to exercise specialist Felipe Lobelo, MD, PhD (Emory University, Atlanta GA), who pointed to literature showing that, “in many cases, exercise has the same benefit as the pharmaceutical or sometimes even better effects” for treating a range of chronic conditions. The problem, said Lobelo, is: “There is no big pharma for exercise.”

50 mg BID of Jumping Jacks

US physical activity guidelines recommend 150 or 75 minutes per week of moderate- or vigorous-intensity exercise, respectively, as well as muscle strengthening exercises twice a week for adults. But just how to tailor or prescribe exercise for individual patients remains a sticky subject. Asked whether they think exercise should be dosed like medication, healthcare providers had mixed responses.

“I wouldn’t go that far,” Peter Duffy, MD (FirstHealth of the Carolinas Reid Heart Institute, Pinehurst, NC), told TCTMD. “But it should be seen as a part of a comprehensive care program for any patient with a cardiovascular disease process.”

Duffy, the president-elect of the Society for Cardiovascular Angiography and Interventions, said he gives his patients a daily checklist to help with their risk factor management. In it, diet and exercise are placed right alongside hypertension, diabetes, cigarette smoking, and dyslipidemia.

Likewise, interventional cardiologist Joshua Krasnow, MD (The Heart Center, Huntsville, AL), told TCTMD that dosing exercise is “fortunately. . . a little bit like aspirin.” Most people need about the same minimum dose to achieve “basic goals,” he said. “When you look at exercise and the benefits, it’s an asymptotic curve. The incremental benefits fade off. You get the biggest bang for your buck early, and you don’t need to be tailoring things the same way as a strength and conditioning coach would be.”

Clinical nurse specialist Lindsay Thomas (Stanford University, CA) advised against providing “too much specific information in prescribing exercise” because of a knowledge gap in clinical research. “It’s actually one of the difficulties I find with all these new activity monitors,” she told TCTMD. “Patients want to know how many steps they should have or what their heart rate should be for how long, and we don’t really have a lot of data on that.”

Indeed, in the past year, a number of studies have highlighted the complexity of incorporating consumer-grade wearable fitness trackers or heart-rate monitors into healthcare and whether these actually translate into weight loss or improved health outcomes. “We struggle [as providers] being overinundated with all this data,” Thomas said. Acknowledging that while she is happy to answer specific questions about the information provided by wearable devices, Thomas added, “I definitely don’t enjoy when a patient brings to me a huge log of data from their device asking what I think.”

In the future, Thomas would like to see a system where patients can track themselves and be on the lookout for prespecified issues much like side effects with a drug. “These types of devices will be better utilized when we can clearly identify specific targets with them that the patient can achieve and also specific things to tell them when to be concerned,” she said.

In TCTMD’s survey, one in five respondents said they use specific heart-rate targets when prescribing exercise to some patients, while half report using the “whatever gets the patient moving” mentality. Walking was the most common method of recommending physical activity, with 70% of respondents claiming that approach.

Duffy uses each of these tactics, but noted “there is very little overlap” between the patients whom he advises to reach specific heart-rate targets versus those he encourages any form of movement. He defines heart-rate goals for the patients who either have misconceptions of what exercise is— such as someone who thinks gardening is sufficient—or those who use wearable activity trackers, citing a “marked increase” in the latter group of late.

For wheelchair-bound patients or “couch potatoes,” it’s a different story. Duffy said for them he believes any level of movement is better than nothing, whether it be hand and foot exercises and stretches for the former or walking beside the golf cart instead of riding in it for the latter.

Specificity vs Motivation

The difficulty with using heart-rate targets is not just that “everyone’s are variable,” but also that many cardiac patients are older and often less tech savvy, according to Krasnow. He said he never gives his patients specific heart-rate goals. “I really do it more on perceived effort, and I really keep it simple so people aren’t confused,” Krasnow reported. “As a goal for most people, I have them walking to a level where they feel like they are exerting themselves but they could still carry on a conversation.”

Goals like what Krasnow describe are what Cara Hendry, MBCHB, MD (Manchester Royal Infirmary, England), uses in an effort to not overload her patients with information. “A feeling of success is really important to people,” she told TCTMD. “If you are asking them to do something for health benefits or preventive benefits, they need to feel that they’ve achieved the target you set for them. Otherwise, they just kind of fall away from it and feel like they’ve failed in some way.”

Seeing himself as more of a motivator than someone who needs to provide “a lot of domain-specific knowledge,” Krasnow added that “there’s a big trend in a lot of ways to make everything quantifiable and metric-oriented. But I really feel like part of a healthy lifestyle is having a ‘healthy lifestyle,’ and exercise is part of that. And if you focus too much on metrics, sometimes that becomes too intimidating and it’s just a blocker for people.”

That said, Diaz’s concern with a provider not specifying heart-rate targets is that patients may not be “getting the right dose. It would be like underprescribing a medication at a specific dose and it’s not doing anything for you because it’s not a high enough dose,” he said, adding, “We know that activity at any level is good, but the evidence is stronger for moderate-to-vigorous intensity exercise being more beneficial than light.”

Injecting a bit of realism into exercise counseling can also be effective, according to Sheila Sahni, MD (University of California, Los Angeles), who is completing her fellowship in interventional cardiology. “Our cardiac patients have to stay moving, because that’s the litmus test for their angina to come back,” she told TCTMD. “The first thing someone does when they start to have angina is they start to take the elevator. So I encourage all my patients, ‘Always walk. Always take those stairs. Because the day you can’t do it is the day I need you to call me or go to the emergency room.’”

The ABCs of Physical Activity

Much of the confusion over exercise counseling stems from the fact that very few physicians feel they have been taught the necessary skills. Fewer than one in five respondents to TCTMD’s survey said they’d ever received any formal education training on prescribing exercise.

For any positive change to occur, the medical training curriculum needs to be addressed, said Blair. He cited a 2015 study of 74 US medical schools that found that medical students on average receive just 8 hours of mandatory training in physical activity over 4 years. Moreover, only half of the programs felt like they were giving their students sufficient training to be able to successfully counsel their patients on exercise in the future.

This illustrates that “there is so much ignored by the vast majority of physicians,” Blair said.

Yet it’s clear that there is no standard to which they can adhere when developing their own best practices for prescribing exercise. A review paper published this June in Circulation attempted to outline this for clinical cardiologists, but the authors admit that much remains to be learned and that “refinements in our understanding of how exercise dose across the spectrum affects cardiovascular health are needed.”

Hendry, who has been in practice for more than 10 years, agreed that exercise is “not something that is terribly well covered in a curriculum,” since training is more focused on “the drive [to do] procedures, echos, about knowing facts, about techniques, and so on.” Most of what she knows about it comes from her personal affinity for working out, Hendry admits.

Duffy also said that most of how he provides exercise counseling is “self-taught” and “just seems logical,” adding that “I have no idea whether what I’m doing is right or not.”

Even at medical conferences, where healthcare providers are supposed to be able to keep up-to-date with all of the important information necessary for them to do their jobs, Thomas said she finds that exercise is thoroughly discussed “only maybe in 1% or 2% of talks, and yet it probably has some of the most significant benefits for patients.”

Lobelo said he always advises physicians new and experienced to use the FITT acronym for prescribing exercise. Standing for frequency, intensity, time, and type, this technique should help remind practitioners to at least provide a consistent written prescription, he said. An example Lobelo gave of an appropriate recommendation is “30 minutes of walking at moderate pace five or more times per week,” as opposed to just saying 150 minutes of exercise per week, or worse, giving no advice at all.

More than simply knowing what to do, Sahni said, providers need to have faith in physical activity themselves, especially when “prevention is sometimes last on peoples’ lists.” In a patient with complex coronary disease and heart failure, for example, “you have to counsel about medication compliance, smoking cessation, and then metabolic syndrome, diabetes, low salt, and all those dietary restrictions get thrown in. By the time you’re done with the office visit, it’s very hard then to say, ‘Oh and then can you also work out three times a week?’” But, she stressed, that’s exactly what needs to be done.

“We all know how to say, ‘Take your Plavix or your stent will close down,” Sahni added. “It’s the same thing. I make it that serious.”

A More Structured System

In 2007, the ACSM along with the American Medical Association launched an initiative called Exercise is Medicine (EIM), which has grown into an international population health collaboration of 50 national and regional centers dedicated to providing patients with physical activity assessments at every clinic visit as well as counseling or referrals if needed. As of August 2016, more than 15,000 physicians and 12,500 exercise professionals have been trained through their program and more than 16.5 million patients have been affected among 101 registered EIM campuses.

Lobelo, who serves as director of EIM’s Global Research and Collaboration Center, said there are two main inhibitors that may keep physicians from prescribing exercise to their patients—personal and system-based. “A big emphasis of Exercise is Medicine is not only educating physicians, but also pointing out that they are role models and that their own experience with physical activity is going to make them better able to provide counseling,” he said.

Additionally, as advanced as health systems have become, mountains of problems have arisen with electronic health records such that physicians still don’t have a standard way to track metrics like physical activity over time for their patients. “Everyone agrees that it’s important, but it’s not embedded into the fabric of modern healthcare delivery,” Lobelo said. “So if you don’t have those system supports, it goes down to the individual physicians’ willingness to do this above and beyond the call of duty because they’re not billing for it [and] they are not getting better quality measures for it.”

Ideally, Diaz said, he would like to see a system in place where physicians can refer more patients to exercise specialists, especially for primary prevention. “This has been a battle that the field of exercise physiology and sports medicine has been trying to fight for some time,” he observed. However, “we need physicians to advocate for us and want that, and I don’t know if enough physicians really think they need it.”

It’s not that Diaz thinks that physicians are overall dismissive of his field but that perhaps they don’t know there is more to it than “just telling a person they should exercise more.” Clinicians also might not know enough about the job description of an exercise physiologist, as Diaz said he is often confused with a personal trainer, though he partially blames his field for being “terrible at establishing ourselves as medical experts.”

But for a system like this to come to life, Lobelo said, “it boils down to money and resources and the willingness of the health system to pay for or support activities that don’t fit into the traditional models of healthcare.”

Duffy predicted that as the US healthcare system transitions from “a volume-based pay system into an accountable care model, . . . population health is going to become much more important.”

Until then, affordability and access to preventative healthcare are “constant” barriers, said Thomas. “A lot of patients, unless they are savvy enough to seek them out themselves or have the ability to pay for some of these services, are not going to be able to do [so] until they have already had a major cardiovascular event, and that’s really unfortunate.”