© 2002 Tufts University, 1096-6781/02/$15.00/0 Nutrition in Clinical Care,Volume 5, Number 3, 2002 93–94

Editorial

Just Do It—Talk to Your Patients About Exercise

One older brother

A deep, abiding trust in him

A fierce sense of competition with him

Those are the ingredients that, when mixed vigor-ously, make a foolproof prescription for turning asedentary person into a physically active one. Ihappened to get hold of that prescription morethan half a lifetime ago, when I was 21.

My brother, always something of a jock, hadtaken up jogging and wanted me to go runningwith him one weekend when I was visiting fromout of state. “No,” I said. This was 1979, before jog-ging was as commonplace as it is now, and Icouldn’t think of anything more ridiculous thanrunning around the streets of Brookline, Massachu-setts, in a pair of gym shorts.

Besides, gym shorts were anathema to me, asymbol of miserable days as a pasty faced juniorhigh and high school student being picked last forteam sports, making a fool of myself on the parallelbars, being shoved into lockers—you get the drift.But my brother prevailed with equal parts encour-agement and cajoling, and before I knew it wewere making our way down wide thoroughfaresand across narrow lanes. My first day out I went amile and a half, which shocked my brother (not tomention me) and in turn goaded me to go two fullmiles the next day.

My thighs ached like they never had, but I washooked, not just on jogging but on physical activityin general. Today I run at least three miles severaldays a week, often take a brisk, hour-long walk atlunchtime, enjoy heavy-duty yard work that in-volves digging, weeding, and the like, and, when

my neighbor Tom can stand it, mangle a game oftennis with him. A basketball hoop will soon go upon the garage for me and my son to enjoy.

Now, in truth, it wasn’t just having an olderbrother that got me active. After all, I had had anolder brother my whole life. It was the

timing.

Sixmonths earlier, I had lost 25 pounds of “baby” fat andthus was feeling more comfortable about challengingmy body. At the same time, I had since gained backnine of the pounds—twice. I was getting tired of go-ing back into the super-mindful, small portions, no-sweets dieting mode to take off the regained weightand found that physical activity allowed me to eatmore freely without putting on pounds.

The challenge for you, of course, is to get thetiming right with your patients so that

they’ll

beginto engage in some physical activity. It might seemlike an impossible task. Doctors and patients don’thave a sibling-type relationship in the first place,and windows of opportunity are often serendipi-tous and hard to pinpoint. No wonder so manyphysicians don’t discuss exercise with their pa-tients, even though so few people get any. The as-sumption is that patients are not going to be opento their doctors’ overtures; the timing is never right.

But as both David Blackburn and Christine Ritchieet al. so effectively point out in this issue, the doc-tor can

create

timing, or at least nudge it along. Justyour bringing up the subject can shock a patientinto thinking seriously about exercise as opposedto viewing it as a vague public health recommenda-tion that can easily be ignored. That is, your talkingabout exercise to your patients can make it per-sonal in a way that it may never have been.

That may not seem like enough to you, sinceyour aim is not to get patients to think about exer-cise but to actually go and get some—to make the

94

�

EDITORIAL Nutr Clin Care, May/June 2002–Vol 5, No. 3

change, so to speak. But if a patient goes from noteven thinking about exercise to considering it, heor she

is

changing, even if you can’t see it. The pa-tient is working through a process that can

lead

todaily or near-daily physical activity.

In other words, as Dr. Blackburn puts it, youneed to “re-define the criteria for a successful en-counter” because “patients often are not at a pointto make the behavior change we wish to encour-age.” In fact, he says, “one of the greatest pitfalls ofany type of lifestyle counseling is a mismatch be-tween the messages delivered by the provider andthe readiness of the patient to make the discussedbehavioral change.” Thus, don’t tell yourself it’s notworth it to talk to a particular patient about exer-cise because you know he or she won’t go out andstart jogging the next day. Instead, tell yourself thatif you help move your patient along a continuumfrom not thinking seriously about exercise to mak-ing some mental notes about it, you’re succeeding.

The way to “get a read” on where your patient ison the continuum is to ask some nonjudgmentalquestions. “Do you happen to do any exercise?”“Have you thought much about it?” “Is exercisesomething you’d like some help with?” The an-swers to such questions will let you know whethera patient is ready for an exercise plan (which, unfor-tunately, is rarely the case) or could first stand someeducation, some consciousness-raising, about thetopic. Perhaps you could raise interest simply by ex-plaining that the greatest health benefits accrue bygoing from a sedentary lifestyle to a moderately ac-tive one rather than from a moderately active one toa very active one. Or maybe you could inform yourpatient that a sedentary lifestyle raises the risk forheart disease as much as smoking does. You couldalso inform your patient that while adding physicalactivity to the day seems like it would be exhaust-ing—and often is at first—people who exercise reg-ularly actually have more energy than those whodon’t move their bodies much. You could pointout, too, that with regard to various diseases, exer-cise could replace, or at least cut down on the needfor, drugs, which come with a host of side effects.(That might work especially well for someone with,say, diabetes.) Finally, you could explain that exer-cise isn’t about being a jock; it’s about using yourbody instead of a machine for just 10 minutes threetimes a day. Then, walking up the stairs instead ofriding the elevator doesn’t seem useless.

You also have to let patients sound off about notwanting to exercise without judging them. It’llkeep them from becoming defensive about physi-cal activity and digging in their heels. That’s not tosay you should shy away from making the case thatexercise is important and that you want your pa-tients to eventually become more physically active,Dr. Blackburn points out. But the patient who is lis-tened to and whose concerns are taken seriouslywill be less likely to feel pushed into something be-fore he or she is ready—and will be more likely tofeel ready earlier on.

There’s a couple more things that you, as physi-cian, have to do. You have to tell your patient thatyou’re going to follow up—see how he or she isfeeling about exercise at the next visit. That way,the patient knows this exercise “business” isn’t justgoing to go away.

You also have to give your patient permission totake two steps forward and one step backward.People tend to see the one step backward as fail-ure. But James Prochaska, a University of Rhode Is-land psychologist who has specialized in studyinghow people alter their behavior and written exten-sively on the stages of change, says that “failure” isa lesson you could use to figure out what you did“right” and where you need to reexamine your ap-proach. That way, it becomes a learning experi-ence rather than a loss, a catalog of what worksand what doesn’t. Maybe a patient ready to takethe plunge tries to become too active too soon, ortries to exercise too intensely, or tries to start anexercise program at a time of great emotionalstress that demands all of his or her energy. It’syour role as the doctor to help patients identify theobstacles and remove or get around them ratherthan beat themselves up over them.

It’ll keep you from beating yourself up, too, be-cause the short-term goal will no longer be to “get”people to exercise but to move them toward it sothey can launch into it successfully when they’reready.

The good news: with your input, they’ll be readysooner rather than later.

Lawrence Lindner

Executive EditorTufts University Health & Nutrition Letter

Tufts UniversityBoston, Massachusetts