Exercise counselling – is it worth the effort?

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In Norway, a qualifying course called “Exercise as medicine” is now offered to general practitioners in Oslo. In Trondheim, a similar course has alreadybeen offered for some years already. The course aims to strengthen GPs’ knowledge and use of physical activity in the prevention and treatment of various diseases. Internationally, the global health initiative “Exercise is Medicine”, initiated by the American College of Sports Medicine and American Medical Association, have contributed to elevating the status of exercise in general practice. What role can GPs have to encourage people to become more physically active?

Several studies show that GPs and other health professionals have great trust and credibility among people and thus potentially a great influence on our health behavior. Basically, people listen to their doctor.  However, in order to get one inactive person physically active as recommended, a GP has to guide at least twelve patients a recent study says. Eleven will therefore be equally inactive after one year. Is it still worth the effort and the time spent?

Read also: Doctor bias: Physician BMI and obesity care

Firstly, these are in fact far better results than shown for consulting on for instance smoking cessation. A 2008 report showed that the corresponding figures on counseling to stop smoking is 50-120 people per successful story. Similarly, preventive drugs are prescribed in increasing amounts although a significant proportion of patients will never even pick them up. Still, few doctors would be reluctant to advise their patients to stop smoking and take their pills as prescribed.

Secondly, given the high prevalence of inactivity worldwide, even a small increase in physical activity participation has a potential huge effect. According to a study in the Lancet, a 1% reduction in inactivity per year, for the next nine years, will save 533 000 deaths a year. In comparison, the prevalence of smoking has been reduced about 0.75% per year, and considered one of the greatest success stories of preventive medicine.

Thirdly, for those actually managing to take up exercise regularly the effects may be striking and with virtually no side-effects. Achieving a moderate level of fitness confers a 30-50% reduction in mortality compared to being sedentary and unfit. Would a doctor ever hesitate to prescribe it, if it came as a drug?

Read also: Test your fitness level – see your risk of dying from cardiovascular disease

However, no single solution is likely to solve the world’s growing inactivity problem. Previously, we wrote about how a coherent and comprehensive approach across several sectors may be necessary to deal with the inactivity pandemic in the “7 investments that work” blog. Nevertheless, we believe that GPs could play a more active and important role in assessing and promoting regular exercise.
Here are some practical tips on how GPs can effectively advise on exercise within the limited time available. These advices were published in an editorial in British Medical Journal.

1. Ask about physical activity at every consultation; consider it a vital sign

2. Guide the counselling by using the “6As” -assess, advise, agree, assist, arrange, and assess again
3. Provide a written “prescription”
4. Display a poster with the physical activity guidelines prominently in the waiting room

5. Consider categorizing patients into frailty levels. There is no need to medicalize physical activity for most people

6. Refer on—consider appropriate physicians, physiotherapists, clinical exercise physiologists, and certified fitness instructors
7. Know your local resources for activity—the people and the places

8. Remember that walking is free!

9.  Follow up the patient to chart progress, set goals, solve problems, and identify and use social support

Bjarne Martens Nes, postdoc at CERG