Whole Health Library

* Examples of moderate-intensity exercise include brisk walking and gardening.

** Examples of vigorous-intensity exercise include swimming or jogging.

*** A MET, or metabolic equivalent, is a unit used to gauge the intensity of exercise.1 MET is being sedentary. A MET-minute incorporates how long is spent at various intensity levels. For more information, refer to the http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_Intensity_table_2_1.pdf.

The U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans[7] are nearly identical to the above guidelines for healthy adults. They also provide additional guidelines for special groups such as children, pregnant women, and persons with disabilities. Visit the CDC website for more information.

Of course, being active for longer than is stated in these guidelines still has added health benefits. Additionally, if individuals are unable to meet the minimum recommended amounts of activity, health benefits are still noted with lesser activity. Given that only about 20% of American adults meet physical activity guidelines with respect to both aerobic and muscle-strengthening,[8] it is reasonable to support patients in moving however and whenever it is possible. This accommodation is especially important since many jobs rely on virtual and/or computer work, and this contributes to prolonged sitting and limited time for intentional exercise.

Additionally, the importance of non-aerobic exercise and fitness is generally under-recognized in practice,[2,9,10] and also may be under-emphasized by current activity guidelines.[10] In light of our increasingly diverse society, we should consider unique forms of exercise (like yoga and tai chi) as well as unscheduled sources of physical activity (like walking for transportation and gardening for neuromuscular benefits) to optimize our health.

A final consideration based on recent research is to prescribe a variety of physical activity, and alter this prescription over time, to maximize total energy expenditure through exercise. Medical anthropologists at Duke University recently published a study of a modern hunter-gatherer tribe in Tanzania known as the Hadza. While the Hadza exercise the same amount in one day as Americans exercise in one week, they burn the same number of calories as the average American each day [21]. One hypothesized explanation for this discrepancy is that the body gets accustomed to certain movements and undergoes energy conservation. If this is true, it is reasonable to consider changing the type of movements we perform to prevent the body from getting accustomed to these movements. Certainly, more research is needed to substantiate this theory.

While every provider should develop his or her own unique style of prescribing movement, having a general framework for recommendations can be more helpful than a haphazard approach. The key points listed below may help provide that general framework while also working within a Whole Health model for care:

• Learn and utilize structured techniques such as motivational interviewing and health coaching. As with facilitating other lifestyle or behavioral changes, these approaches might help support a collaborative, respectful, and open-minded process. (For more information, refer to the Motivational Interviewing Network of Trainers and the Global Advances in Health and Medicine May 2013 special themed issue.[11])Many VA clinicians have already been trained in this interviewing method.
• Use a structured, brief intervention when recommending exercise.The UK's National Institute for Health and Care Excellence (NICE) has published evidenced-based guidelines on "providing brief [activity] advice for adults in primary care."[12] The NICE recommendations for offering advice on physical activity are summarized as follows:
  • Advise those who are inactive to be more active, targeting minimum physical activity recommendations (such as the ACSMs) and emphasizing the benefits of physical activity.
  • Tailor the brief advice to the persons motivations, goals, current activity and ability, circumstances, preference, barriers, and health status.
  • Provide information about opportunities to be physically active.
  • Consider giving a written summary of the advice given.
  • Record the outcomes of the discussion.
  • Follow up on progress when there is the opportunity.
• Write your specific exercise prescriptions on a prescription pad. Some authors have argued that given the potency and risks of exercise interventions, they should be dosed with the care warranted for the prescribing of drugs.[13]
• Offer low-cost alternatives for patients who do not have the time or money to join a gym. Consider the “make your body work” resource at the end of this handout, which offers links to 50 popular and effective at-home exercises. Or consider utilizing one of many free exercise applications for smartphones (such as “the 7-minute workout” or the “30-day squat challenge”). Check with the local YCMA. Some VA facilities have their own gyms.
• When articulating an exercise plan, specify the FITT: [14,15] 
  • Frequency
  • Intensity
  • Type
  • Time (duration)

In addition to following these recommendations, a Whole Health approach might emphasize some easily-overlooked features when creating recommendations for exercise. The following are some points to consider:

• Prioritize approaches to exercise that enhance mindful self-awareness. On one hand, exercise may deepen and enrich one’s feeling and awareness of the body. On the other hand, exercise may solidify old habits of ignoring and suppressing important biological cues such as pain. True to the Whole Health approach, exercise forms such as yoga and tai chi can help patients develop insight into the body, breath, and mind.
• Practice and teach exercise as a way of understanding the body. Mindfulness can be applied to virtually any physical activity, and any exercise is an opportunity to develop self-awareness of the body. As trained clinicians we have the opportunity not only to develop a personal understanding of our bodies through exercise, but also to share this process of discovery with our patients.
• Encourage balance as a guiding principle. Hans Selye was the first to apply the term “stress” to physiological systems, and he also described how repeated exposure to an appropriately intense stressor leads to adaptation or conditioning.[14] The emphasis here is on appropriate intensity. In lay terms, we might teach our patients about the “Goldilocks Principle” by focusing on exercise that is neither too intense nor too relaxed, but just right.
• Consider multipurpose activity if time is an issue. Whereas multitasking with exercise (e.g. reading a magazine while running on a treadmill) may be the opposite of a mindful approach, multipurpose physical activity (e.g. walking for exercise and transportation) might be the most practical approach for a busy schedule. This is also known as unstructured physical activity. Consciously recognizing and remembering the multiple intentions served by a given physical activity (e.g. gardening for neuromotor fitness, prevention, recreation, and food production!) might also help to sustain motivation for healthy behaviors.
• Encourage the integration of physical activity and exercise in daily life. There is fair support for using short bursts of activity frequently throughout the day instead of the traditional continuous daily session.[1,16] One may not have time to peddle an exercise bike for an hour 5 days a week, but one may be able to spend an hour biking to and from work 5 days a week. These activities would be roughly equivalent in terms of benefits. • Reminder: carefully consider all important contraindications and precautions for your patient and the potential exercise. In addition to comorbid illnesses, exercise history, and current level of physical fitness, also consider the patient’s belief system and goals, not to mention access and environmental hazards, when making recommendations. Consider a separate preparticipation assessment for patients with numerous comorbidities.
• Model and disclose healthy behaviors to your patients. Physicians who disclose their own healthy behaviors such as exercise are more likely to motivate patients toward healthy behaviors.[17,18] In addition, positive exercise habits may increase providers’ credibility to patients[17] and make them more confident in recommending exercise.[19]
• Encourage fun. Most people like to have fun, and enjoying physical activity will increase a patient’s likelihood of maintaining an active lifestyle. Emphasize activities that patients find more pleasurable and help patients link healthy activities to rewards.

• VAs MOVE!
  • Program Excellent resources related to weight loss, and physical activity is no exception
• American College of Sports Medicine website
  • Numerous guidelines and resources for clinicians
• Centers for Disease Control information
• American Council on Exercise
  • Informational materials
• Department of Health and Human Services, Office of Disease Prevention and Health Promotion
  • Physical activity guidelines
  • Summary available at health.gov/paguidelines/guidelines/summary.aspx
• How to Fit Exercise into a Busy Daily Routine
  • Free instructions to workouts that involve minimal supplies and can be completed at home or while traveling

Prescribing Movement was written by Surya Pierce, MD, ABIHM, RYT and updated by Sagar Shah, MD, (2014, updated 2018).