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Enhancing exercise by prescription

Telling people to take exercise “for their own good” is largely ineffective unless it is part of a prescribed treatment regime – ie cardiac rehabilitation or pulmonary rehab.

When exercise is “prescribed” by the doctor it is only taken up by a minority and adhered to by even fewer. The long-term effect on fitness and health is minimal. Exercise schemes may be more successful if the recommendation is combined with a lot of input to encourage the individual and nurture the changed attitudes and behaviour which are required. Even then it is hard to change the habits of a lifetime.

A New Zealand study enrolled 1,089 women aged 40–74 into a controlled trial of exercise referral and achieved a modest increase in exercising rate in the treated groups at two years. The intervention included initial motivational interviewing, regular follow-up telephone calls (a total of 75 minutes per patient) and a home visit at six months. (Motivational interviewing is an effective counselling method that promotes behavior change by encouraging the individual’s motivation rather than giving authoritative instructions). Even with this level of input the apparent increased exercise was not associated with improved clinical outcomes but unfortunately was associated with an increased risk of falls and injuries.


For those who would promote exercise nagging is not the answer, but gentle persuasion just might work – a bit. People need to be convinced of the joys of exercise. They should choose an activity that they will enjoy and go for it. The feel-good effects will be surprising and the post-exercise glow has been described as ‘on the orgasmic spectrum’.

Nudging people into exercise can be helped by remembering those motivating factors identified by the Allied Dunbar Fitness Survey. For men they were ‘to feel in good shape physically’, ‘to improve or maintain health’, ‘to feel a sense of achievement’ and ‘to get outdoors’. Specifically for men were ‘having fun’ and ‘relaxing’, and for women ‘looking good’ and ‘controlling body weight’. Remember also than many people are put off exercise because they do not regard themselves as ‘sporty’, because they are shy, feel overweight or lack energy. Older people may think that exercise is just undignified and not for them.

The community approach

The promotion of exercise in the community requires a politically led multidisciplinary approach strongly supported by the medical profession. Unfortunately, we do not yet know how this may best be implemented. Sport England, which was set up in 1994 with National Lottery money to do just this, has overseen a reduction rather than an increase in sports participation over the past few years. Now Sport England has joined with the Faculty of Sport and Exercise Medicine and Public Health England to launch a new project, ‘Moving Medicine’. This aims to educate doctors and their patients to turn to exercise as the treatment of choice for many clinical problems and to introduce a culture of physical activity into the lives of us all.

It is encouraging to see how many other organisations are involved in promoting exercise and producing policies to enable exercise to become the norm rather than the exception – the World Health Organisation, the National Institute for Health and Care Excellence, the UK Health Forum, Sustrans, the Sport and Recreation Alliance, the Department of Transport, the Local Government Association, the Royal Society for Public Health, to mention just a few. My hope is that political actions and public education will produce a cultural shift that will make inactivity as unacceptable as cigarette smoking. To be effective, this needs to be supported by the full weight of public opinion and public pressure and the example of the medical profession  – though it will be difficult to tax it!