AAMC Reporter: February 2006

Curing 'Couch Potatoes': Doctors Play Key Role in Promoting Exercise

By Anne Blank, Special to the Reporter

Most patients, even those who are physicians themselves, have at some point been asked the routine question, "Do you exercise regularly?" by their primary-care doctor. In the past, making this inquiry meant a physician had largely fulfilled his or her duty in promoting exercise. Today, however, with the mounting evidence that lifestyle factors such as inactivity are directly related to a wide range of diseases, including heart disease, diabetes, hypertension, arthritis, osteoporosis, and many cancers, just asking the question is no longer enough.

Identified as one of the leading health indicators by the U.S. Department of Health and Human Services' Office of Disease Prevention and Health Promotion's Healthy People 2010 report, physical activity is no longer viewed by the medical profession as being peripheral to its focus on treating disease; it has become an integral part of quality care.

Meanwhile, Americans are getting heavier. Indeed, a new phrase has been coined to describe the phenomenon that in many parts of the country has become yet another hallmark of Americans' fast-food lifestyle: "supersize adults." Within the past 30 years or so, according to the National Center for Health Statistics,  the percentage of obese adults with a body-mass index greater than 30 has doubled from 15 to 30 percent. The percentage of overweight adults, with a body-mass index greater than 25, was 65 percent from 1999 to 2002, the most recent period examined. From 1988 to 1994, 56 percent of adults were overweight.

Among children, the percentage of overweight 6 to 11 year olds more than doubled from 1976 to 2002, from 7 to 16 percent. With the ubiquity of video games and fast-food restaurants, many children today are leading the kind of high-fat, low-activity lifestyle that is setting the stage for a lifetime of weight problems that may result in chronic diseases and shortened lives.

Last year, the National Committee for Quality Assurance added a new measure to its set of quality-care measurements known as the HEDIS Health Plan Employer Data and Information Set, which requires physicians to ask Medicare patients age 65 and older about physical activity and to give them advice about starting and maintaining an exercise program.

"Right now, whether or not your doctor talks to you about physical activity is one of those things that's going to be checked off," said Marcia Ory, Ph.D., M.P.H., a professor in the department of social and behavioral health at the School of Rural Public Health in the Texas A&M University System.

Christine A. Bruchac, Active for Life team leader, with program participant Vermetta Gilmore

Ory is also the director of the Active for Life National Program Office. Supported by The Robert Wood Johnson Foundation, Active for Life is a nationwide program designed to increase the level of physical activity in people age 50 and older by establishing and maintaining exercise programs in traditional community institutions such as senior centers, public health departments, and religious organizations.

In terms of encouraging and advising patients about physical activity, Ory said the physician's role is analogous to the key that starts your car, and they should tell their patients, "It's safe to do this if you start slowly and go gradually, and here are some programs that can help you learn a new skill."

Ory emphasized that it is critical for physicians, especially primary-care providers, to be familiar with the programs, such as Active for Life, that are available in their community so they are able to refer patients to the most appropriate one.

If physicians are to play a critical role in motivating patients to be active, some experts believe that medical school curricula must include programs that teach students how to effectively talk to patients about the importance of exercise.

A proponent of expanding the curriculum is Wojtek Chodzko-Zajko, Ph.D., professor and the head of the department of kinesiology and community health at the University of Illinois at Urbana-Champaign.

"I think it's imperative that mainstream medical schools prepare clinicians to engage their patients in conversations not only about diseases but also about the prevention of diseases," Chodzko-Zajko said.

Three years ago, Chodzko-Zajko started a collaborative workshop to teach medical students about physical activity and behavioral counseling. The daylong workshop offers lectures on physical activity guidelines and the role of health care providers in helping patients to become and remain active. In addition, workshop participants are encouraged to briefly experience their patients' lives by taking part in an exercise program designed for previously inactive middle-aged and older adults. This part of the workshop is conducted in a room with a simple mat, instead of a big gym with expensive equipment, to give students an idea of what kinds of exercise patients of different economic means can do in their own homes, Chodzko-Zajko explained.

The medical school curriculum is not the only forum in which to emphasize the importance of physical activity and health promotion, said Ory, adding that the concept should be included in continuing medical education programs.

At the University of Rochester Medical Center (URMC), a program called Pediatric Links with the Community is doing just that. For eight years now, pediatric and medicine-pediatric residents during their first or second years of residency at URMC have had the opportunity to work with children in community programs in a number of areas, including exercise. Residents at URMC may also choose to conduct longitudinal community collaborations. Recently, several residents forged partnerships with local elementary and high schools to help expand and/or improve the schools' physical activity programs, said Stephen Cook, M.D., senior instructor of pediatrics and pediatric emergency medicine at The Golisano Children's Hospital at Strong, an affiliate of the URMC.

A year ago, Cook, who is an expert in childhood obesity, helped develop the local chapter of a national program known as the Child and Adolescent Trial for Cardiovascular Health (CATCH), which is part of the National Heart, Lung, and Blood Institute's Obesity Education Initiative. Held at the local YMCA in Rochester, CATCH is an after-school program with activities that encourage children to "get moving," Cook said. Approximately 2,000 children participate in the CATCH program.

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