This original article was written by Brad Biskup,  a Physician Assistant at the University of Connecticut Health system. He is a Diplomat of the American College of Lifestyle Medicine and primarily focuses on lifestyle health in cardiovascular patients. He discusses the importance of giving patients an individualized exercise prescription that is appropriate for their level of fitness, rather than simply using standard guideline recommendations. This approach can help to improve compliance and health benefits and minimize the risk of injury.


Adapted from original article in  The Conversation, December 26, 2017

Gyms across the country are often packed with people vowing to “get moving” to lose weight. Much of their effort will be for naught, however, and may ultimately lead to injury and frustration in many.

Currently, the Centers for Disease Control and Prevention exercise guidelines call for all individuals to do 150 to 300 minutes of moderate-intensity exercise or 75 minutes of high-intensity exercise per week, in addition to two days of strength or muscle strengthening. As defined by the American Heart Association, moderate-intensity exercise includes activities such as brisk walking, riding a bicycle at less than 10 mph, and doubles tennis, while high-intensity activities include jogging or running, swimming laps, singles tennis, riding a bicycle at greater than 10 mph, and jumping rope. For an individual, it is even more important to determine the level of intensity by his or her perceived level of exertion. We can attempt to objectively measure this by using either the  original or the modified Borg scale, both of which are intended to objectively assess a patient’s RPE (Rating of Perceived Exertion). See the table below for the modified Borg scale which is used more commonly due to its simplicity. Read more about exercise intensity on the American Heart Association website.


Modified Borg Scale


Currently, there is a large gap between guidelines and reality, considering less than 10 percent of individuals meet even the the non-strength training portion of the recommendations. We’ve lost the focus on using the guidelines only as guidelines, and have forgotten the importance of individualizing an exercise prescription for our patients. It is imperative that this becomes a priority.


A customized approach

The medical profession has learned a few things in recent years about exercise as it relates to obese and diabetic patients in that not all exercise nor its benefits are equivalent.

The ability to burn fat is greatest during aerobic activity which is achieved during moderate intensity exercise. This type of exercise is ideal for patients who are obese. On the other hand, improving insulin sensitivity in diabetics is more related to the duration of the exercise rather than the intensity. In fact, exercise has been shown to reduce the risk of becoming diabetic by up to 50%, with individuals who are obese benefiting the most.

Despite our exercise recommendations, people who are overweight or obese may not be able to actually perform moderate intensity exercise for any significant duration without sustaining an injury. The risk of injury and noncompliance should be the two of the first things discussed when prescribing an exercise routine.

The risk of lower extremity injuries such as plantar fasciitis and knee pain is up to four times greater when patients perform high-intensity exercise, such as jogging, as compared to moderate-intensity exercise, such as walking, particularly in individuals who are obese. Injuries are a major factor in driving exercise noncompliance.

It is important for most deconditioned patients to start slowly once an exercise program is prescribed. Simply educating diabetic patients that minimizing prolonged periods of sitting throughout the day can improve control of their blood sugars may motivate them to make this realistic change that is associated with long-term health benefits.


Walking the walk

Understanding the importance of exercise, one would assume that physicians spend a lot of time counseling on the topic.

However, in 2010, fewer than 31 percent of physicians recommended physical activity for those who are overweight and less than 47 percent for individuals who are obese during an office visit. This was an increase, however, from fewer than 17 percent for overweight and 35 percent for obese in 2000.

This may be partly due to the way health care providers are educated, with less than 20 percent of medical schools in the U.S. requiring even one class in physical activity or exercise. More than half of the physicians trained in the United States in 2013 received no formal education in physical activity making many underprepared to properly advise about exercise.

Moving forward, it is important to educate our health care professionals during their medical training on exercise physiology and the medical importance of physical activity, both of which will enable them to write an appropriate exercise prescription and help patients to understand the health benefits of being active. The more the physicians focus on exercise, the more likely patients will exercise, and the more providers discuss our patient’s lifestyle and find ways to get them moving more, the more successful they will be.

One way to have providers focus more on the patient rather than simply the guidelines when forming an exercise prescription is to have the physician  walk with the patient during his or her office visit. Walking with a patient can allow a doctor to assess a patient’s level of fitness. Health care providers can assess whether patients have any limitations such as knee or back pain. They also can explain the difference between aerobic and anaerobic exercise, which is best done by explaining the “talk test”. If a patient can talk but not sing while exercising,  he is maintaining fat-burning aerobic metabolism (moderate-intensity).  If a patient is unable to say more than a few words without pausing for a breath, he is exercising anaerobically and burning sugar (high intensity).

In summary, it is important for health care providers to assess a patient’s current fitness level, to prescribe a customized exercise prescription based on these findings, and to educate patients on both the risks and benefits of different exercise regimens. This is an major piece of the healthcare puzzle that can help to further reduce the burden of chronic disease.


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