Creating Exercise Strategy with Physician Counseling

Did you know that only 27.6% of adults meet the recommended amount of weekly exercise? According to a recent research finding, heart disease is the leading cause of preventable death with over 600,000 cases in 2017 alone (National Safety Council, 2017). While some aspects of this disease are genetic factors, many include the lack of physical activity or other controllable factors. In fact, regular physical activity can decrease the risk of cardiovascular disease by 20% (Estabrooks, Glasgow, & Dzewaltowski, 2003). Other diseases that can be somewhat controlled with regular physical activity include diabetes mellitus, cerebrovascular accidents (strokes), and hyperlipidemia, to name a few. Physician influence plays a large role in increased physical activity adherence in patients, causing them to pick up healthier habits and maintain them long term (Kreuter, Chheda, & Bull, 2000). The purpose of this paper is to investigate the effects of physician counseling on increasing physical activity in sedentary individuals. We will look further into the significance of routine exercise, factors affecting exercise adherence, barriers preventing individuals from remaining active, different counseling strategies that physicians use to enhance patient adherence to exercise, and future directions of physician practice that will minimize sedentary behavior.

Benefits and Effects of Exercise

In order to explain how exercise produces its positive benefits, we must look into the physiological functions during such activities. When exercising, a cascade of hormones and chemicals are released from both endocrine and exocrine systems, traveling throughout the body to participate in various physiological activities. One of these hormones is glucagon, which is released when the body’s blood sugar level is low. When released, glucagon plays a direct role in the breakdown of stored glycogen to glucose, as well as the release of free fatty acids from adipose tissue. This helps the body maintain the appropriate blood sugar levels as the body uses these sugars as a source of energy. In addition, it can help individuals maintain healthy weight and carbohydrate levels. Epinephrine and norepinephrine are more hormones released during exercise that are tied with the sympathetic nervous system, or the fight-or-flight response. These hormones stimulate increased cardiac output, constricted blood vessels, glycogen breakdown, and more. Increased cardiac output means that the blood is being filtered and processed at a faster pace, thus removing waste products quicker, as well as delivering a greater amount of oxygen to cells around the body. On a greater level, this can decrease the chances of blood clots, which can lead to dangerous effects, such as pulmonary emboli, cerebrovascular accidents, or deep vein thromboses. Another important hormone produced during exercise is testosterone. This hormone plays a role in muscle protein synthesis and repair of proteins damaged by exercise. (McCall, 2015). One more chemical group that is released during exercise that will be discussed are endorphins, which are chemicals in the brain that act as natural painkillers. These chemicals are also released during other activities, including meditation, massage therapy, and acupuncture, to name a few. Endorphins are also known to improve the ability to sleep, reduce stress, and improve self-esteem. As little as 5 minutes of aerobic exercise can stimulate these effects. (Anxiety and Depression Association of America.). These are only few of the many chemicals released by the body in response to physical activity. Now that we have a basic understanding of what goes on at a microscopic level during physical activity, we can discuss the larger-scale effects and benefits.

Regular exercise plays a crucial role in maintaining a healthy lifestyle. While physical activity has many benefits associated with it, the lack of physical activity can be detrimental to one’s health. Physical inactivity leads to at least 250,000 deaths annually in the United States, and more than one half of Americans fail to meet recommended physical activity levels (Meriwether, Lee, LaFleur, & Wiseman, 2008). On the other hand, exercising regularly promotes physical and psychological health during pregnancy, the physical development of children, and sustained health-related quality of life throughout adulthood and in old age. Of course, these are just a few of the very many benefits related to exercise. It can decrease the risk for cardiovascular disease by 20%. In addition, participation in regular physical activity delays the onset of first stroke, type 2 diabetes, and osteoporosis. Physical activity is also an important component for managing diseases such as arthritis, diabetes mellitus, and easing the discomfort of cancer treatment. On the psychological standpoint, it helps decrease mental disorders including anxiety and depression. (Estabrooks et al., 2003). A matched pairs study was conducted to show the effects that exercise intervention has on individuals compared to those who remained sedentary. One year into the study, patients with behavioral risks who had the intervention were more likely than matched controls to report positive changes with regard to exercise adoption, use of seatbelts, weight loss, and reduction of alcohol intake (Andersen, Blair, Cheskin, & Bartlett, 1997). This study shows that physical activity has a direct correlation with physical and mental health. Those who exercised regularly experienced less chronic health problems and improved physical and psychological functions. So how exactly does exercise provide these benefits?

While physical and mental health is positively affected by exercise, it has also been shown that ambulation can improve with minimal amounts of weekly exercise. Research conducted by Harvard Medical School consisted of around 1,700 elderly adults between 70-89 years of age. The goal of this experiment was to determine the amount of exercise needed to actually show a benefit in ambulation among adults at high risk of mobility issues, such as falling. This trial separated the participants into two groups—the exercise group and the non-exercise group. The exercise group was tasked to perform a 20-minute exercise twice a week. This exercise involved 10 minutes of walking, followed by 10 minutes of lower-body resistance training, exercises, and stretches. The non-exercise group participated in workshops that explained nutritional benefits, travel safety, and healthcare topics. The conclusion of this study showed that after six months, the exercise group displayed significant improvement in walking speed in over 400 meters, mobility and balance tests, and frequency in ambulation throughout the day. This study also showed that after one- and two-year follow-ups, the exercise group still displayed these benefits and improvements. The largest display of improvements, however, came from those who participated in at least 48 minutes of exercise per week. (Harvard Health Publishing, 2017) Though exercise plays a large role in maintaining good health, individuals often find themselves struggling to overcome barriers associated with beginning or adhering to exercise programs.

Factors Affecting Physical Activity Adherence

Physical activity adherence is something that millions of Americans struggle with. This can be the result of many different factors. Identifying reasons why patients do not adhere to physical activity could highlight ways to approach new strategies for physicians to use. According to the World Health Organization, it is proposed that exercise adherence is affected by various factors. One of these factors includes the health care system or provider-patient relationships. These relationships are vital to patients’ adherence to physician advise. A poor relationship results in distrust in the physician, causing the patient to withhold information that may be vital for the physician to know for the treatment process. Additionally, it has been found that the time spent with patients is not so much important as the physician’s willingness to hear the patients’ concerns and description of their health problems. Patients tend to feel more valued and heard when the physician actively listens to them. Other important aspects of a good relationship include giving information to the patient regarding their health and developing a treatment plan that the patient can help create (Goold & Lipkin, 1999).

Another factor that affects exercise adherence is patients’ histories of chronic diseases. Some diseases may include diabetes mellitus, hypertension, and dyslipidemia, to name a few. Ironically, exercise helps manage many of these diseases and can prevent them in patients who are at risk of developing these diseases. Symptoms of these diseases, such as fatigue, polydipsia, and respiratory distress, can dissuade and even discourage these patients from participating in exercise. Treatment is another factor that can affect patients’ adherence to exercise. This can easily be described by how the patient feels about a treatment plan prescribed by a physician. For example, a sedentary patient who wants to improve their aerobic capacity should not be given an exercise plan that requires the patient to run long distances at intense speeds. Instead, the patient should be given a treatment plan that begins with distances and intensities that the patient can handle. From there, the patient can slowly increase his or her distances and intensities as time goes on. Not only will this help with exercise adherence, but it will also reduce the chances of injuries as the patient improves his or her health at a manageable rate. Finally, socioeconomic factors can affect exercise adherence. Income and education specifically influence exercise adherence. Someone with limited education about the benefits of exercise or their health may not find it as important to exercise on a regular basis as someone who understands the benefits it has on health. Income can limit an individual’s ability to afford a gym membership or exercise equipment. It may also play a role in their living environment and access to parks, gyms, sidewalks, safe neighborhoods, etc. (Zolnierek & DeMatteo, 2010).

Barriers that Prevent Exercise Adherence

Now that we understand some of the factors that play a role in physician influence and exercise adherence, we can look at some of the main barriers that prevent individuals from maintaining an active lifestyle. One of the largest barriers is the perception of the lack of time, whether it be due to work, family, or some other responsibility. This concern is often overexaggerated by the individual where they do not think they can find enough time in the day to squeeze a quick workout in. Sometimes it is due to the feelings that one will have to get ready beforehand, come up with a workout program, take a shower after, and other time-consuming activities that add up. This may lead to anxiety and ultimately cause the person to come up with excuses to remain sedentary.

Another barrier is the lack of desire or interest in exercise. Some people simply do not find exercise “exciting” or “fun” and may want to focus on their areas of interest. Often, this is due to the person’s lack of knowledge or availability for various activities that one can participate in. Bad weather can be another barrier to exercise, especially when the activity is performed outdoors. The lack of social support may contribute to sedentary behavior. If someone finds that their friends or family are not supporting their active lifestyle, then they have little to no reason or motivation for continuing. As per the Self-Determination Theory of Motivation, these individuals likely exhibit introjected regulation. This type of extrinsic motivation states that individuals participate in activities to maintain pride or avoid guilt of letting others down. (In-text citation) Another barrier includes the lack of available facilities or resources for the individual. For example, those who live in areas with no close-by gyms, parks, walking paths, etc. tend to find it difficult to use whatever they may have available to exercise. This barrier may also intertwine with low-income individuals if the person cannot access these facilities due to monetary issues.

Finally, individuals may be afraid of acquiring injuries from exercises. This may be a legitimate concern, as exercise-related injuries are not uncommon. Certain diseases, such as osteoporosis, can make it difficult for those affected to bear weight or push limits without causing life-altering bone injuries. In many cases, however, people often do not stretch before or after they exercise, which can drastically increase the chances of injury. Though this is not the only reason people injure themselves in these situations, it is likely one of the most preventable causes of injury (Tappe, Duda, & Ehrnwald, 2009). In all, learning and understanding patients’ thought processes behind barriers to exercise can lead to physicians developing better intervention strategies.

Physician Counseling Interventions on Exercise

Physicians develop numerous strategies for maximizing the effectiveness of their counseling techniques through training, practice, and acquired knowledge. These strategies prove to be most effective when the patient trusts their physician and holds them to high respect. When this is true, the patient will more likely listen to what the physician has to say and follow their advice, as they believe the physician is most likely telling them what is in their best interest. Another important factor is how the patient interprets and utilizes the advice that the physician offers them. Since individuals tend to have different personalities and behaviors, different strategies will impact them in various ways. In fact, multiple strategies and techniques exist that accommodate for the physician and the patient. One strategy may prove more effective than another to a particular physician when informing the patient.

Physicians often report having limitations in time, reimbursement, knowledge, confidence, practical tools that prevent proper exercise counseling, or a combination of the forementioned when counseling patients on exercise. As a result, various strategies have developed to help maximize the effectiveness of physician-patient encounters that give patients the resources they need to successfully adhere to the physician’s advice. One of many models developed was the 5 A’s Model: Assess, Advise, Agree, Assist, and Arrange. Assessing the patient involves evaluating his or her psychosocial needs, typically by using a standardized assessment tool. One example of this could be asking the patient how confident they feel about adhering to a certain type of exercise, on a scale from 1 to 10. Advising consists of the guidance that the physician gives the patient to move forward and begin a program. For example, the physician may state that the patient is overweight, and can recommend an exercise strategy to follow that would help reduce their weight. Agreeing involves taking into consideration the patient’s needs and interests when developing a strategy. The importance of this stage is ensuring the patient is comfortable with the exercise routine that is being developed, and incorporating their interests and capabilities into the program. Assisting includes a debriefing on the counseling, such as addressing obstacles, solutions, referrals, and take-away information. This could mean discussing how the patient’s social support will influence their behavior or how they will overcome obstacles that have stopped them in the past. Finally, arranging means setting up a follow-up appointment, as well as the participation in a support group or education session that will help with adherence. It is important to schedule an appointment to assess the patient’s progress, as well as give them information about nearby facilities that promote healthy activities, such as a gym or a YMCA. This method has been proven to help physicians deliver brief, individually tailored physical activity messages to patients (Meriwether et al., 2008).

Next, we have the PACE (Physician-based Assessment and Counseling for Exercise) program, which was developed to provide specific counseling protocols that closely identified with the patient's level of activity and willingness to change. It was found that 3- to 5-minute sessions increased physical activity among patients when counseled in the primary care setting. Eighty percent of physicians in the PACE trial reported that their patients were receptive to some degree to activity counseling. Over half of the providers believed that their patients became more physically active after the intervention (Andersen et al., 1997).

The Physical Activity Assessment Tool (PAAT) is a similar technique that primary care physicians use to quickly assess patients. Similar to PACE, PAAT assesses current patient physical activity and willingness to change exercise habits. However, this method also includes contradictions involved with exercise behavior, social support, and self-effectiveness, or the patient’s belief of whether he or she can change physical exercise habits. After counseling and agreeing with physician advice, patients are given printed materials and self-monitoring tools to guide them through their newly-enlisted exercise routine. Finally, follow-ups are scheduled and referrals are made based on the patient’s interests and goals. (Meriwether et al., 2008). Overall, physicians often encounter limitations to exercise counseling. Multiple strategies and procedures were created to guide physicians in quickly assessing patients and providing them with tailored exercise information. While some of these strategies remain effective, it is important to look beyond our current knowledge and expand on what we may find useful to maximize physical adherence for all patients.

Future Directions for Practice and Research

Exercise is important to both physical and psychological health. With a rise in preventable diseases and inactivity, various reasons exist as to why exercise programs can be difficult to adhere to. Studies have shown the benefits of physician counseling on increasing physical activity for those at risk of health problems. Strategies and assessments help physicians quickly evaluate patients and provide proper feedback on exercise routines that may work for them. These tools are especially significant for primary care physicians who demonstrate the most influence on patients’ exercise adherence. This research gives a base for exercise adherence strategies that addresses a growing concern across the nation. One of the major limitations to this research is the minimal amount of data found linking physician counseling to patient exercise adherence. Most of the data compared exercise habits of individuals within a year of counseling. Sometimes patients do not follow-up with their physicians at all. This can make it difficult to determine whether the strategy they used was beneficial or if they should use a different one in the future. Moving forward, researchers need to look at a more long-term effectiveness of physician counseling. While it is not always possible to do this, it is the most crucial step in determining whether certain methods and techniques actually work in the long term.

In conclusion, we discussed the effects of physician counseling on increasing physical activity in sedentary individuals. We looked at the significance of routine exercise habits, factors that influence exercise behaviors, barriers of active lifestyles, strategies physicians use to enhance adherence, and future directions that need to be followed to maximize overall effectiveness of these strategies. Exercise is important for both physical and mental health, and helps reduce the onset of certain diseases, as well as manage present diseases. Most Americans, however, do not participate in enough exercise due to various reasons. Physicians can implement strategies that counsel patients on how to overcome these barriers and why exercise is important. Data collected shows that primary care physicians have the largest impact on the adherence to exercise for patients at risk of disease. It is highly important to research long-term adherence of physical activity and habits to determine the most effective methods and adjust them as needed. All in all, we have come a long way in maximizing patient adherence to physical activity, though we still have plenty of work to do to implicate the most effective strategies for all patients struggling to overcome physical activity barriers.