Prescribing Exercise: Only One Step in Supporting Physical Activity

In May, I received an email announcing a new initiative by the New Brunswick Medical Society – prescription pads that can be used to prescribe exercise rather than medication. The press release included many voices supporting the initiative as a way “to help patients focus on increasing physical activity in their lives”. While I agree that having a physician prescribe a walking program or other forms of physical activity (depending on the physical capacities of the patient) can be an opportunity to help patients become more aware of the connection between being active and their health and/or addressing particular health problems they have, as a leisure educator I believe more support is needed. Inactivity is a complicated problem that cannot be resolved with a one, simple act (e.g., prescribing exercise).

Example of the prescription pad which the New Brunswick Medical Society is offering free to physicians so they can prescribe walking or other activity when appropriate.

Increasing Activity is Complicated

While there is research to support that being prescribed an exercise program improves physical activity levels, results are mixed (Morgan, 2001; Sørensen, Skovgaard, & Puggaardand, 2006) and it is unclear about the long term affects (e.g., adherence to an exercise routine). So while prescribing exercise it is a first step, I do not believe it is “the answer”. It doesn’t start and stop with a prescription.

Some individuals need more support than simply being told to walk or engage in another form of physical activity. In my experience working with families who were raising a child who was overweight, telling them to engage in more physical activity was not effective and quite honestly, would be quite insensitive to the various challenges that they faced in making a shift to a more active lifestyle. What I observed (Shannon, 2012) was that these families needed much more information, guidance, and support in getting started on and maintaining a more active lifestyle. Parents needed help to figure out what active pursuits they and their children were interested in. They needed help in identifying the available resources in the community that could support more active lifestyles (e.g., low cost or no cost programs). They needed to know when the free swims and skates were in their communities or where to look for this information (some families I worked with did not even realize that there were free opportunities for their family). Some families needed to be made aware of subsidized recreation and sport opportunities. Families needed to know what equipment they needed and where they could get it (and in some cases, where they could get it cheaply). Some needed help with time management in order to find ways to make time for physical activity for their family.

Specifically related to the children, a number of them in the families I worked with were bullied in recreation and sport programs or when playing/biking in their neighbourhoods (Shannon, 2014). Some of them did not have the skill set to keep up with their friends and this affected their enjoyment when playing recreational sports or play on the playground. Some lacked self confidence to join in with friends even when they were interested in active play. There were many reasons why the “be more active” message on its own, regardless of who it was from (e.g., doctor, friends, teacher), was not going to contribute to developing a long term habit of physical activity.

One Size Fits All… Rarely

I struggle with the “one size fits all” approach that appears to come with this prescription idea. Perhaps physicians have the skills set and time to ascertain patients’ attitudes about physical activity, the barriers they experience (e.g., lack of money, perceived or real lack of time, lack of motivations, lack of self-confidence, lack of skill, body image issues, self-esteem issues), the knowledge they have (e.g., about proper shoes for walking, safe places to walk or exercise), and their interests (so they can prescribe activity that fits with the interests of their patients). If physicians do not have the time or inclination to assess various aspects of their patients’ leisure behaviour, will it be as effective?

Personally, I’ve experienced what seemed like random recommendations by physicians when I’ve struggled with anxiety. “Join a gym.” “Relax more.” “Meditate.” “Do yoga.” Some of these recommendations have come when I was a student – when I didn’t have money for yoga; when “relax more” seemed like the most ridiculous thing I’d ever heard as deadlines loomed and pressure mounted; when I had no idea how to meditate or where I would learn to do so. I have walked away with recommendations that I easily dismissed because I couldn’t see how they could work for me (and in one case, a physician did write “yoga” on a prescription pad and give it to me as a “reminder” to do it). The recommendations were not bad ones, but there was no effort to support execution. This is the risk of the one size fits all approach. If there is no consideration for the circumstances of the individual – interests, challenges, skills, knowledge – how effective can the directive be?

Khan, Weiler, and Blair (2011) recommend that if physicians are “not skilled and trained in exercise prescription, probably a majority in most countries,” they should refer patients to someone with these skills such as a sports medicine physical or specialist or a personal trainer. This, of course, requires more local resources and services to support individuals needing to increase their physical activity levels. Even if such resources are available to individuals, not everyone can afford these forms of individual support.

Pushing Physical Activity Outside the Domain of Leisure

I worry that as we see a trend to medicalize physical activity, we move it out of the realm of “leisure.” Leisure is an activity or experience that is intrinsically motivated and in which there is, ideally, freedom of choice. There is also positive affect (e.g., pleasurable feelings; enjoyment). Prescribing exercise without guiding someone through a process where they make some choices about activities they are interested in doing and from which they may experience enjoyment means that it is very unlikely that physical activity will be experienced as “leisure.” Instead, the activity becomes one that serves a specific, instrumental purpose related to health and may, in fact, feel more like work. Certainly engaging in leisure can produce various health benefits and if chosen leisure activities include physically active pursuits, individuals can access the unique physiological benefits associated with physical activity. However, when physical activity is prescribed and individuals undertake it because they “have to” and do something they do not enjoy, individuals may lose out on the benefits that come from freely choosing an activity (e.g., having a sense of control) and the positive affect (e.g., enjoyment) commonly associated with leisure. If an activity is not satisfying or enjoyable, how long might one choose to adhere to it?

The Importance of Leisure Education

I see the prescription pad as one step, but this type of initiative should not be viewed as a stand alone solution to the trend of increasing inactivity levels. More needs to be done to support those who are sedentary in acquiring a more active lifestyle. Leisure education (a process in which individuals develop the values, attitudes, and skills for positive leisure functioning) is an effective strategy for changing leisure behaviours and could be used in conjunction with a physician’s initial prescription.

What might be helpful is a website address (url) on the prescription pad which directs patients to more information about leisure and physical activity. For example, information could be provided that would help patients to: assess their interests and choose an activity that is fun and enjoyable; ascertain whether various needs an individual has could be satisfied along with the physician’s directive to be active (e.g., need to socialize; need to release stress); develop their awareness of the resources in the community that would support physical (e.g., trails, walking tracks, links to schedules for swimming and skating; list of neighbourhoods that are flat where people could walk if their neighbourhood is hilly); develop knowledge of how to choose proper shoes for walking (since this is a specific activity on the prescription pad); understand common barriers to physical activity and strategies for overcoming them; and offer tips on fitting physical activity into busy schedules.

Conclusion

My point here is two-fold. First, we should not oversimplify complicated problems. Far too often, I see blog posts or magazine articles titled, “100 Easy Ways To Get Active” or “Ten Simple Ways to Increase Your Physical Activity” . For many, getting more active is neither easy nor simple and these statements marginalize those for whom it is a struggle. It doesn’t support them. Second, more attention needs to be given to educating people for leisure so they have the knowledge and skills they need to make choices during their leisure time that not only support meaningful leisure experiences, but also their physical and mental health. If more effort went into educating individuals about leisure – how it contributes to quality of life; how different pursuits can meet various needs and achieve various outcomes – perhaps we would not need to prescribe physical activity to individuals as a strategy for motivating changes in leisure behaviours.

References

Khan, K. M., Weiler, R., & Blair, S. N. (2011). Prescribing exercise in primary care. British Medical Journal, 343.

Morgan, W. P. (2001). Prescription of physical activity: a paradigm shift. Quest, 53(3), 366-382.

Shannon, C.S. (2012). Leisure education within the context of a childhood obesity intervention
programme: Parents’ experiences. World Leisure Journal, 54(1), 16-25.

Shannon, C.S. (2014). Facilitating physically active leisure for children who are overweight: Mothers experiences. Journal of Leisure Research, 46(4), 395-418.

Sørensen, J. B., Skovgaard, T., & Puggaard, L. (2006). Exercise on prescription in general practice: a systematic review. Scandinavian Journal of Primary Health Care, 24(2), 69-74.

 

Tagged: exercise, exercise prescription, leisure, leisure education, physical activity, prescription pad