MDs seen as key players in move to encourage active living in Canada
Nicole Baer
CMAJ 1997;156:1605-8
[ en bref ]
Nicole Baer is a freelance writer living in Nepean, Ont.
© 1997 Nicole Baer
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In brief
Despite ParticipACTION's preaching about the need to stay physically active, only a small percentage of Canadians exercise regularly at the level recommended for fitness. Nicole Baer discusses the issue with physicians and experts in the field, and also looks at American efforts to introduce Physician-based Assessment and Counselling for Exercise.
En bref
Même si ParticipAction prêche l'activité physique, un faible pourcentage seulement de la population canadienne fait régulièrement de l'exercice au niveau recommandé pour être en bonne condition physique. Nicole Baer discute de la question avec des médecins et des experts du domaine et jette aussi un coup d'œil sur les efforts déployés par les Américains pour mettre en œuvre l'évaluation par les médecins et les conseils relatifs à l'exercice.
A little-known corollary to the medical maxim that common conditions occur most commonly states that the most obvious option is not necessarily the most apparent.
That at least appears to be the problem with physical exercise, fitness, or what is now known as "active living." How else to explain that only 10% of Canadians exercise regularly at the level recommended for fitness, and that active living is by no means universally emphasized by doctors? This has happened despite Particip-
ACTION's preaching of the active-living gospel for the past 25 years.
Still, there may be room for optimism. Several initiatives, backed by substantial research on the health benefits of exercise, are finally under way.
Recent trends do show some improvement, though hardly enough to send the nation's hearts racing. Surveys conducted by the Canadian Fitness and Lifestyle Research Institute (CFLRI) show that 65% of Canadian adults were active enough to derive some health benefits in 1995, up from 54% in 1988 and 38% in 1981.
Unfortunately, there has been no significant increase in the percentage of Canadians exercising at a level necessary to improve fitness -- at least every other day, for 30 minutes or more at a stretch, at moderate or greater intensity. That proportion has remained stuck at just over 10% since 1981.
Disquieting gaps
Moreover, the research institute has turned up some disquieting gaps. Only 50% of Canadians aged 18 to 24, and 33% aged 25 to 64, are physically active. For seniors over age 65, fewer than 25% are active.
Dr. Mary-Louise Engels of Montreal, who still practises clinical psychology at age 65, is one of the fitness exceptions. During adolescence she perceived that she wasn't good at sports and therefore was not cut out for physical activity. By the time she reached her 40s, however, the benefits of fitness were becoming clear.
Today she has a personal trainer, who comes once a week to help her work on weights and muscle strength, flexibility and aerobics. Between sessions, she exercises 3 or 4 times a week, and walks, hikes and gardens whenever possible.
She hopes to build her strength and endurance, although she acknowledges that "realistically, it's not going to be onward and upward forever. At a certain point, the maintenance of function, or at least decreasing the diminution of function, will be the best I can hope for."
Dr. Storm Russell, senior researcher at CFLRI, says participation in activities such as jogging has not changed significantly since 1981. However, there has been a marked growth in the popularity of moderate- to low-intensity activities such as walking.
For most adults, lack of time, energy or motivation remain by far the strongest barriers to a regular exercise program; other obstacles include a shortage of affordable facilities and suitable programs.
Overwhelming evidence
The evidence in favour of active living is overwhelming, with research linking regular, moderate physical activity to significant reductions in the risk of coronary heart disease, obesity and many other problems.
Dr. Rodney Tee, a family physician from Nepean, Ont., often looks to exercise as an appropriate alternative to prescription drugs. "I think there's a need for a greater awareness of the benefits, not just generically but in terms of specific disease management," Tee notes, adding: "I will actually offer to write on a prescription pad a prescription for exercise."
He even urges his most sedentary patients with potentially chronic conditions to get a dog so they'll at least take regular walks. "If I were in the shoes of a patient I saw this morning, in his 30s with a cholesterol of 7 and a bad profile, and I [might have] to take some potentially toxic drug for the rest of my life, I think I'd buy a dog. I tell him, 'I can prescribe a medication for you for the rest of your life -- potentially 50 years -- or you can get more serious about your diet and about exercise.' And in that light, they tend to take notice."
So why aren't more people -- indeed most people -- fit, or at least active? Dr. David Lau, head of the Division of Endocrinology and Metabolism at the University of Ottawa, believes people know exercise is positive but aren't sure why and don't know how to go about it. "If you have a weight problem and the doctor says, 'now go and get some exercise,' that's easier said than done. It depends on what kind of exercise you're talking about." Moreover, physicians and health professionals "are relatively ignorant about exercise prescription."
For example, weight loss requires low-intensity, long-duration exercise, while cardiovascular maintenance and rehabilitation requires high-intensity aerobic forms of exercise. "Most doctors think that exercise is exercise -- if it burns up calories, then it's all the same. But that's not true."
Neither the College of Family Physicians of Canada nor the CMA have developed explicit policies on exercise, although the CMA did pass a resolution in 1991 urging that "all physicians be asked to encourage their patients of all ages to participate in an active physical lifestyle."
FPs and exercise
What exactly should the FP's role be? Lau says counselling by physicians is the most effective approach, far superior to mass-market messages of the sort disseminated by ParticipACTION. "You just can't target everybody with the same message," says Lau.
Others perceive the need for a less "medicalized" approach. Although Americans are often advised to see a doctor before beginning an exercise program, Canadian organizations and, increasingly, governments are issuing generalized calls for activity.
In that context, some fitness advocates see doctors as just another pro-exercise voice -- albeit one with an unusual degree of credibility. "Physicians can speak passionately and with an unequivocal level of authority," notes Dr. Art Salmon, national technical director for ParticipACTION. "If your family physician says you should exercise, that will have a greater impact on your starting and maintaining a program than if your spouse says it or your colleagues around the water cooler."
Roger Passmore, executive director of Active Living Canada (ALC), a group linking more than 20 national organizations, says Canadians must be encouraged to get off the couch. In short, argues ALC, physical activity should be natural and pleasurable. Passmore doesn't believe doctors do enough to encourage patients to become active. "About as far as they go is, 'you really should get some exercise.' "
However, ALC, in partnership with other national organizations, has developed a plan to promote active living. A draft, Toward an Active and Healthy Canada, has been sent to the federal health minister. It would establish mechanisms, such as methods of billing, to help doctors and others convey the active-living message.
Active-living guide
ALC is also contributing to another initiative, a guide to active living, that will be a close cousin to Canada's Food Guide. The project, headed jointly by Health Canada and the Canadian Society for Exercise Physiology (CSEP), will likely comprise a single page and a 16-page guide. Physicians will help evaluate prototypes of the guide, expected to be ready for distribution later this year.
It will recognize that there are distinct stages in modifying behaviour. For instance, people may be "precontemplators" (sedentary, with no plans to become active), or "contemplators" (thinking about exercise, but unsure how to start).
Bill Hearst, executive director of CSEP, says the guide will be most useful for those just starting to exercise and "will also point the way to where you might be able to go to get more information."
CSEP already trains people to do fitness appraisals and set up personalized exercise programs. The National Fitness Appraisal, Certification and Accreditation Program teaches some 5000 people a year to evaluate and counsel people on a fit and healthy lifestyle. Hearst says few physicians take the training, which at the basic level takes up to 32 hours.
Somewhere between the mass market and the individualized theory of physical activity is the CFLRI, which identifies groups with different needs that require different policy approaches. Men, for example, tend to be more active, though irregularly; women tend to stick to regular patterns of exercise, but of less intensity.
Some work is now under way to understand such distinctions. This spring, the Ottawa Heart Institute will launch a 6-month pilot project to determine what motivates adult women to become and stay physically active. After thorough screening, 100 women will be randomly assigned to 1 of 2 groups. Half will pursue a regular walking program on their own; the rest will receive special equipment (a pedometer and a stop watch), monthly pep talks and regular monitoring of their progress.
Brief interventions
While the scientific evidence is assembled, some doctors just take it for granted that patients need coaching on fitness. Dr. Susan Hauch, a Winnipeg FP who helps train family practice residents at the University of Manitoba, raises the issue during all periodic health exams, even with children. She asks what patients do to exercise and explains why it is important.
Hauch, who works out 3 times a week, recommends specific activities and ways to overcome obstacles. "I think a lot of people realize that as they get older they have to exercise and many of them . . . will certainly [do it] -- if you give them a specific prescription." The entire dialogue may only last a few minutes, but Hauch believes that brief interventions, repeated frequently, can be highly effective.
Back in Nepean, Ont., Dr. Rodney Tee sees exercise as a form of preventive maintenance. "I often [say] that exercise should be as important in your life as brushing your teeth. It should be just as frequent." But he concedes the message can be a hard sell. "Often patients want me to do something to absolve them with the sign of the cross and say, 'There you are, you don't have to exercise. Just take your pills and you'll be happy.'
"Well, I never say that."
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