Regular Exercise

First Thoughts

Regular exercise provides many health benefits to those who engage in

the activity. In addition to its direct benefits, regular exercise is an essential part
of healthy weight management and any effective program to lose weight. The
broad public health implications of exercise therefore include its pivotal
importance in dealing with the obesity epidemic.
Definitions of term exercise

Physical activity is any body movement produced by skeletal muscles

those results in a substantive increase over the resting energy expenditure.
Leisure-time physical activity is an activity undertaken in the individual's
discretionary time that leads to any substantial increase in the total daily
energy expenditure.

Exercise is a form of leisure-time physical activity that is usually

performed on a repeated basis over an extended period of time (exercise
training) with a specific external objective such as the improvement of fitness,
physical performance, or health.

It is important to note that regularity, exercising on a repeated basis

over an extended period of time, is included in the standard definition for
exercise. Sessions, workouts and going to the gym are terms that are used
interchangeably with regular exercise throughout this lecture.

Counseling

The most recent recommendation on counseling for regular exercise

concluded that there is insufficient evidence to determine whether counseling
patients in primary care settings to promote physical activity leads to sustained
increases in physical activity in adult patients.

recent controlled studies suggested that counseling for regular exercise in

clinical practice may be effective in helping patients to become regular
exercisers. Whether there is high-quality evidence to support exercise
counseling in the primary care setting, patients may request advice on how to
become more physically active.

The goal of this lecture is to guide on how to provide exercise counseling

to their otherwise healthy patients: the sedentary person who wants to
exercise; the sedentary person who needs to exercise for risk factor
modification; and the exerciser who is looking for advice because of injury,
burnout, or a need for consultation and reinforcement.

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 This lecture does not specifically address the role of regular exercise in
either the treatment or management of diseases or pathologic conditions (such
as hypertension), or rehabilitation, although many of the basic principles for
helping any patient to become a regular exerciser would hold true.
Epidemiology of Exercise

Epidemiologic data show that regular exercise promotes general health,

while its lack, known variously as physical inactivity or sedentary lifestyle,
increases the risk of a variety of diseases and negative health conditions. On
Physical Activity and Fitness in Healthy People 2010 it is stated that:

Research has demonstrated that virtually all individuals will benefit from
regular physical activity . Moderate physical activity can reduce substantially
the risk of developing or dying from heart disease, diabetes, colon cancer, and
high blood pressure. Physical activity may also protect against lower back pain
and some [other] forms of cancer (for example, breast cancer). On average,
physically active people outlive those who are inactive. Regular physical activity
also helps to maintain the functional independence of older adults and
enhances
the quality of life for people of all ages.

The position taken in these report was shaped by four important

developments that have taken place over the past half century. First, the
biomedical community identified and clearly described those aspects of
physical fitness that are related to health.

Second, the scientific knowledge base underlying the original hypothesis

that regular physical activity benefits health became firmly established. Third,
the epidemiology of physical activity and inactivity has been studied and
described in increasing detail over the years. Fourth, it has been recognized
that both moderate and intense physical activity benefit health.

A major challenge is how to use all of our knowledge and understanding

to actually help patients become regular exercisers at a level that is both
comfortable and useful to them. Sound clinical advice, provided in an
appropriate way by clinicians, can help patients unleash their own motivational
process to become regular exercisers.

There are no known clinical trials of different approaches to the nuts and
bolts of regular leisure-time exercise. Controlled research comparing the
effectiveness of one particular leisure-time exercise program versus another in
fostering an ongoing pattern of regular exercise would be difficult to design and
very expensive to conduct.

On the other hand, there is research on various exercise programs used

as therapeutic interventions for the treatment of specific diseases and

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disorders. Therapeutic exercise regimens (and there are many very useful ones)
are beyond the scope of this lecture.

Exercise: Aerobic and Nonaerobic

There are two types of regular exercise based on level of intensity:
aerobic and nonaerobic. Exercise is considered aerobic when it is intense
enough to lead to a significant increase in muscle oxygen uptake.

Nonaerobic exercise is any physical activity above the normal resting

state involving one or more major muscle groups that is sustained but not so
intense as to cause a significant increase in muscle oxygen uptake.

(Anaerobic exercise is intense physical activity, necessarily of very short

duration [usually measured in seconds], fueled by energy sources within the
contracting muscles, without the use of inhaled oxygen, most often incurred in
competitive sports. It is not a factor in regular exercise.)

The heart rate is a simple measure to distinguish aerobic exercise from

nonaerobic exercise. The exercise is considered to be aerobic when the pulse
reaches or exceeds a level of 60% of the theoretical maximum normal, age-
adjusted heart rate (220 the person's age); 0.6 (220 age).

It is important to note that this commonly used formula roughly

approximates the true degree of increased oxygen uptake by the muscles and
is more accurate for measuring the intensity of exercise in beginners than in
conditioned athletes. Most regular exercisers do not routinely measure their
heart rate during their workouts, relying instead on subjective measures, such
as deep breathing and sweating, to know when they are in the zone.

Patients who are subject to extreme tachycardia should take their pulse
while exercising. To assure that exercise intensity remains at a safe level, the
pulse rate should remain below 85% of the person's theoretical maximum age-
adjusted heart rate (220 age).

Although the evidence to date shows that exercise must be aerobic for it
to be beneficial in reducing long-term risk for coronary artery disease, exercise
at any level above the sedentary state is helpful for weight loss and for
producing the mental benefits associated with regular physical activity.

An even modest level of regular exercise frequency (1 or 2 hours per

week at nonaerobic intensity) probably reduces mortality. Moderate-intensity
physical activity other than regular leisure-time exercise, the so-called lifestyle
approach, may also be beneficial for improving health and reducing mortality.

Objectives for Regular Exercise

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 Regardless of the accumulated data about the long-term health benefits
of regular exercise, most regular exercisers engage in the activity because of
the immediate benefits of feeling good and feeling better about themselves.

When counseling patients about regular exercise, it is very important to

bear this in mind. Most regular exercisers do not engage in the activity in order
to reduce their risk for future disease. Risk reduction does not motivate most
nonexercisers to start exercising either, unless a negative health event such as
a heart attack shocks them into appropriate action, or they are exercising to
promote weight loss.

When patients ask about the benefits of regular exercise, the clinician
should stress the short-term gains: feeling good, improved personal
appearance, and increased self-esteem.

The clinician should point out though that most but not all sedentary
people who become regular exercisers experience these gains. Long-term
benefits will also motivate some patients and should be noted.

Risks of Regular Exercise in the Otherwise Healthy Patient

Regular exercise has its risks as well as its benefits. Virtually all of the
risks are preventable or modifiable. The most common risk of exercise is injury.
There are three types of injuries: intrinsic, extrinsic, and overuse. Intrinsic injury
is that caused by the nature of the activity or sport, for
example, shin splints in running.

Extrinsic injury is that caused by an external factor, for example, a cyclist

hit by an automobile. Overuse injury results from exercising too far, too fast, too
frequently.

The latter is the most common cause of injury in most of the activities
and sports used for regular exercise, such as running, fast walking, cycling, and
swimming.
Intrinsic injury can be prevented by the use of proper equipment and
correct technique.

The risk of extrinsic injury can be significantly diminished by taking

certain, mainly common sense, safety precautions, such as always wearing a
helmet and never wearing a radio headset while riding a bicycle.

Overuse injury can be prevented by choosing a sport along with a workout

schedule that are suitable to the exerciser, and by maintaining moderation in
distance, intensity, and speed. The risk of a variety of pathologic problems is
increased when a previously sedentary person engages suddenly in intense
exercise or when a regular exerciser suddenly increases exercise intensity.

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Therefore moderation and gradual change, if changes are to be made, are as
always, good counsel.

Recommendation versus Prescription

Many clinicians use the term exercise prescription when discussing
regular exercise with their patients. Prescription, however, usually means
telling a patient to do something for a limited period of time. Regular exercise is
by its very nature voluntary. No one can be forced to do it.

Regular exercise requires more than just the temporary extra expenditure
of time required to establish most other positive lifestyle changes such as
engaging in healthy eating, achieving weight loss, and stopping cigarette
smoking. For example, all people spend time food shopping, cooking, and
eating. After learning about what changes to make, healthy eating requires only
that the time be spent differently.

After undergoing smoking cessation counseling and quitting tobacco use,

no extra time need be spent again, unless relapse occurs. In contrast, regular
exercise requires a permanent commitment of time that would be otherwise
spent doing something else. Of course, the maintenance of any successful
behavior change requires constant attention for the rest of one's life, to a
greater or lesser extent.
However, in order to be most effective in counseling their patients to
become regular exercisers, clinicians need to recognize the ongoing time
commitment that regular exercise requires.

Therefore, because of its special nature, exercise cannot be prescribed

like a drug. Rather, the clinician is recommending the effort to become a
regular exerciser. The clinician's goal should be to develop a respectful and
supportive partnership with their patients, using advice and counseling to assist
them in the decision-making process. The primary need is for the clinician to
spend time with patients communicating about regular exercise, recognizing
obstacles to success, and equipping patients with the tools to overcome them.
Risk Assessment
The clinician should assess every patient before recommending a regular
exercise program. Some will need a full medical examination. Many otherwise
healthy patients will not. According to the USPSTF, neither a resting
electrocardiogram nor an exercise stress test provides information helpful in
reducing the risk of an adverse outcome from regular exercise among
asymptomatic persons.

Although the USPSTF does not endorse them, these tests may be clinically
indicated for men older than 40 years with two or more risk factors for coronary
artery disease other than sedentary lifestyle. Coronary artery disease risk
factors include elevated serum cholesterol, history of cigarette smoking,
hypertension, diabetes, or a family
history of early-onset coronary artery disease

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 Furthermore, the clinician should conduct a thorough clinical evaluation of
patients for whom regular exercise presents a definite risk, before advising
these patients to start exercising. These high-risk patients may have a history
of one or more of the following diseases or conditions:
Previous myocardial infarction
Exceptional chest pain or pressure, or severe shortness of breath
Pulmonary disease, especially chronic obstructive pulmonary disease
Bone, joint or other musculoskeletal diseases or other limitations
These conditions are not necessarily contraindications to regular exercise,
but each patient's risk must be assessed on an individual basis.
Patients for whom regular exercise presents a possible risk may have a
history of one or more of the following diseases or conditions:
Hypertension
Cigarette smoking
Elevated serum cholesterol
Prescription medication used on a regular basis
Abuse of drugs or alcohol
Any other chronic illness, such as diabetes
Family history of heart disease
Overweight in excess of 20 lb
Current sedentary lifestyle

Regular exercise is very useful in the management of a number of these

diseases and conditions. For example, regular physical activity has been shown
to reduce the rate of progression of diabetes by more than 50%.

Goal Setting
In most cases, the first subject to discuss with patients is goal setting:
why is the patient thinking about regular exercise? It may be because the
clinician suggested it, but virtually no one becomes and remains a regular
exerciser simply because they are told to do so.

To succeed, the patient must mobilize internal motivation. What goals

does the patient want to achieve, and why? Specifically, does the patient want
to become fit, lose weight, look better and feel better, reduce future risk of
various diseases and conditions, or join a friend or family member in a race? In
both starting and staying with a regular exercise program, it is very helpful if
patients have a good grasp of just why they are doing it in the first place.

The same list can be used in the process of motivational interviewing with
patients who are not yet prepared to make health-promoting lifestyle changes.
For patients currently in the precontemplation or contemplation stages of
change, addressing the questions mentioned earlier may be helpful to patients
in advancing to the next stage.

Realism

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 The clinician should counsel patients to set realistic goals and define
success for themselves. A good formulation of this concept is to explore your
limits and recognize your limitations. Consider the example of endurance
versus speed. After some reasonable period of training, say 34 months, most
people can improve endurance, but they may not be able to improve their
speed. Speed is the product of speed-specific training plus natural ability.

Many people will be able to train fairly easily for endurance, because for
most people endurance is not simply the product of natural ability. On the other
hand, because natural ability is such an important element in speed, many
exercisers will not be able to improve their speed no matter how hard they try.
Clinicians should stress this point to their patients in order to avoid frustration,
injury, and quitting. On the other hand, if patients are encouraged to explore
their limits gradually and carefully, they may discover abilities they never knew
they had.

Inner Motivation
The literature regarding positive lifestyle and behavior change clearly
shows that the only kind of motivation that works in the long run comes from
within. The patient says, I want to do this for me, because I want to look
better, feel better, and feel better about myself, not for anyone else. In
contrast, a patient who is externally motivated says, I'm doing this to make
my [spouse, boy/girl friend, children/parents, employer/coworkers] feel better,
but I don't anticipate getting much out of it for me. External motivation almost
invariably leads to guilt, anxiety, anger, frustration, and, quitting, and possibly
even injury.

Taking Control
Taking control is an important concept to stress with patients. In this
formulation, patients decide to engage in physical activity on a regular basis,
perhaps in a physical activity that they have never done before or even
contemplated doing. Many people find that taking control of the process for
themselves, thinking yes I can, because yes, I can do this is an important
motivator, both in starting a regular exercise program and sticking with it.
Gradual Change
Gradual change leads to permanent changes is another basic element
leading to success in becoming a regular exerciser, losing weight, and making
other lifestyle changes. It is recommended that the previously sedentary person
should start with ordinary walking, at a normal pace, for 10 minutes or so, three
times a week. After a couple of weeks, the patient can increase the length of
each session.

After several more weeks, the patient can increase the frequency of
sessions and the speed with which the exercise is performed. The hardier soul
may move through this program more quickly, but all should be counseled
against going out for an hour, at full tilt at the beginning. Too much, too soon
may lead to muscle pain, injury, and an increased likelihood of quitting. Once

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again, a gradual increase in time spent, distance covered, and speed are the
proven formula for adherence.

Getting Started: It is the Regular, Not the Exercise

Further, the clinician should recognize that, for most people, the first
challenge of becoming a regular exerciser is the regular, and not the
exercise. Indeed for most people who are regular exercisers, the hard part
remains the regular, not the exercise. Most people are aware that exercise is
good for them and that they will feel better and increase their self-esteem if
they begin exercising.

Despite these positive reinforcements, most people have busy schedules

and other demands that make it difficult for them to make room in their lives for
exercise on a regular basis.

The correct first step for many patients who are motivated to start
exercising is to discover that they can indeed find and make the time in their
lives for exercise on a regular basis. For most people, the focus of the first 24
weeks of an exercise program should include making the time to exercise and
walking instead of learning a new sport or athletic activity.

Patients who live in poor neighborhoods or who have limited resources

face special challenges in becoming physically active. They often lack a
conducive and convenient place in their built environment or safe surroundings
to engage in regular exercise of the type discussed here. Researchers and
urban planners are beginning to deal with this important issue.
Duration and Frequency
The original regular exercise recommendation should be performed
continuously for a minimum of 2060 minutes at least three times per week. As
of 2005, the ACSM recommendation was to exercise for 3060 minutes
(including warm-up and cooldown) three to five times per week.

This recommendation assumes that the exercise will be done at least at

the lower end of the aerobic level of intensity. Some guidelines encourage even
greater duration for daily exercise (e.g., 60 or more minutes). However, they
are problematic in terms of patient adherence and the heightened risk of
overuse injuries.

As previously noted, since the early 1990s it has been recognized that
physical activity, even at a moderate level of intensity, can also be beneficial to
health. The Centers for Disease Control and Prevention (CDC) and the ACSM
recommended that, for persons not engaging in regular aerobic exercise at the
ACSM standard, an accumulated 30 minutes daily of moderate-intensity
physical activity (below the aerobic level) should be performed on as many
days of the week as possible.

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 The so-called lifestyle approach to exercising regularly includes such
activities as ordinary walking, gardening, and housecleaning for a minimum of
10 minutes per session. The lifestyle approach can help some people get
started exercising regularly. Counting and recording short sessions and trying to
figure what does and does not count as exercise can become confusing and
time consuming.

Any amount of regular exercise at any level of intensity is better than no

exercise at all. Whatever the recommendations suggest, the amount of time
that an individual devotes to regular exercise must fit comfortably into that
individual's overall lifestyle, whether it is 2 hours a week or 12. Otherwise,
success is doubtful.

Choosing the Activity or Sport

Once the patient deals successfully with the problem of making exercise a
regular activity, the patient will need to focus on choosing a specific sport or
activity. The first point the clinician should stress is that regular aerobic exercise
is not limited to running and aerobic dance.

There is a wide range of activities or sports that can be used for regular
exercise, whether aerobic or nonaerobic. There are the tried and true sports,
such as running, fast walking, bicycling, and aerobic dance. These are sports to
which most people have ready access at home, where they may even exercise
to the accompaniment of a video or television show.

Less widely available are activities that often require an athletic facility,
such as running and walking on a treadmill or indoor track, swimming, and
group aerobic dance classes. Exercise machines such as treadmills, stair
climbers, ellipticals, and stationary bicycles can be purchased for home use.

For cycling, there are also indoor trainer devices on which road bicycles
can be mounted for riding in place. Certain individual and team skill sports are
often played at aerobic intensity and are useful for regular exercise.

These sports include singles tennis, squash, racquetball, handball, and

full-court basketball. They require an athletic facility with courts and at least
one partner. Weight training, with free weights or a machine, can be done at
home or in the gym and can also be performed aerobically.

As contrasted with weight training for strength and bulk, aerobic routines
stress
lighter resistance, more repetitions and sets (groups of repetitions) of each
program component, and less time between sets to keep the heart rate in the
training range. Some health clubs feature circuit training, utilizing a set of
machines and stations offering different muscle resistance levels.

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 Aerobic exercises are performed by participants in a series, following a
timed schedule established by a prerecorded set of instructions broadcast in
the circuit training room over the loudspeaker.

The heart and muscles do not know what sport the exerciser is
performing. If the activity increases heart rate and muscle oxygen uptake to a
given level, the benefit will be the same, regardless of the sport. For example,
pace walkingfast walking with a strong arm swing is equivalent to running if
each is done to the same level of aerobic intensity.

Pace walking with a strong arm swing at a rate of 1112 minutes per mile
is usually as demanding on the cardiovascular system as running 89 minutes
per mile.

After learning the regular part by engaging in ordinary walking, it is

then time for the patient to choose a sport or other physical activity that he or
she will enjoy. In fact, the likelihood of remaining a regular exerciser will be
increased if the patient chooses two different sports or activities (e.g., going to
the health club once or twice a week for low-impact aerobic dance, and pace
walking once or twice a week).

Making Exercise Fun

When contemplating regular exercise, many patients will say, Well, I

know I should exercise, but I know it just isn't going to be fun. In fact, some
people find to their surprise that exercise is enjoyable, in and of itself. For those
exercisers whose enjoyment from exercise lie in between, there are some
techniques for making exercise more fun. Over the long run, the following
techniques may also help all exercisers maintain the fun level: fun

Let it be fun: positive anticipation is very important.

Set appropriate goals, and avoid doing too much, too soon, as discussed
previously.
For the distance sports, train by minutes, not miles (see later in this
chapter).
Recognize that, in those distance sports in which concentration on
technique is not required, exercise time is uniquely private and great for
thinking.

Listen to music, the news, or radio talk shows through a headset.

(Appropriate safety measures must be taken, however. Outdoor use of in-the-
ear headphones can block out the sounds of traffic, animals, and other
individuals approaching. Rather, sponge phones mounted on the temple in front
of the auditory canal should be used. Outdoor cyclists should never use
headsets.)

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 Set nonexercise-related goals like getting an errand or two completed in
the course of a workout.
Periodically, reward oneself with a new piece of clothing or a long-denied
snack treat.
Enjoy the rhythm, being outdoors, and the seasonal variation that is part
of many of the sports done for aerobic exercise.

Many regular exercisers find that a very useful way to stay on a program
and enjoy it is to engage occasionally in racing, not for speed but for
participation and feelings of personal achievement in terms of distance covered
or time spent.
Be sure to take a week or two off when needed, at least one to two times
per year.

Generic Training Program

Tables present a generic training program from the beginning phase

through regular maintenance, at all levels up to the training level required for
racing on a regular basis. Note that the workouts are measured in minutes
instead of miles. Time rather than distance is a better way to define the
workout because, in the end, what counts is the duration and not the speed: the
mental and physical stressor of speed is not a factor for distance sports.

Psychologically, it is much easier to pace walk regularly for 40 minutes at

a stretch than it is to cover 3 or 4 measured miles. If the person is feeling good
and the weather is nice, he or she will go faster and cover more ground. A bit of
stiffness on a given day will lead to a slower workout and therefore less
distance covered.

The benefit of focusing on time is that the workouts can be used for any
sport or activity the patient decides to undertake. The minutes formula allows
the person to easily mix and match sports or activities in a single program. The
periodicity and duration of the sessions comprising the program recommended
in these tables are based on the assumption that the person will be engaging in
a regular exercise program, at a level of intensity eventually reaching the
aerobic range.

The objective is to help patients become regular exercisers at a comfort

level that works for them.
The Introductory Program starts with ordinary walking and concludes with
pace walking. This program leads up to engaging in 1.5 hours of exercise per
week.

The Developmental Program provides for up to 3 hours of exercise per

week. There are two Maintenance Programs: the program in Table 6.3 provides
an average of 2 hours per week over a 13-week period, whereas that in Table
6.4 provides an average of 3 hours per week. The latter is the equivalent of 15
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20 miles of running per week, which is all that is required to gain the maximum
health benefits from regular exercise. Musculoskeletal fitness increases with
exercise intensity, time, and distance, up to approximately 75 miles of running
per week.

Correct pace walking gait and arm swing

As noted, the current (2006) ACSM recommendation encourages working

out 35 days per week. The total weekly allotted time for each pace walking
program in the tables is distributed over 34 days per week. Obviously, the
suggested times can be redistributed over 45 days per week, with shorter
sessions for each workout. Some stretching after a brief warm-up is
recommended. There are books devoted entirely to stretching.

Some sport-specific books also contain a section on stretching. Note that,

once a 4-day-per-week level is reached, in either Phase II or Phase III B, more
than half of the total workout time is scheduled for the weekends, making the
program more convenient for most people. Phase III A is an every-other-day
program, requiring an average of only 2 hours per week. These programs
provide the framework in which virtually any motivated patient can become a
regular exerciserslowly, gradually, and without the need to make an
overwhelming time commitment.

Technique
The clinician need not be a technical expert in the sports or activities
suitable for regular exercise. There are many good books written for the layman
on the subject. If exercise counseling becomes a regular part of the practice,
the clinician may benefit from periodic visits to local bookshops and/or the
popular web-based booksellers for an update on available books.
The technique for pace walking, the recommended starting sport, is very
simple.

How to Pace Walk:

Walk fast with a purposeful stride of medium length. With each step, land
on your heel, then roll forward along the outside (lateral aspect) of your foot,
and push off with your toes. Try to keep your feet pointed straight ahead,
walking along an imaginary white line. This will help your balance and rhythm,
and will allow you to increase your speed. Your back should be comfortably
straight, but not rigidly so.

Your shoulders should be dropped and relaxed, your head up. Swing your
arms forward and back, strongly, with your elbows comfortably bent. (The
elbow bend prevents the accumulation of fluid in the hands, which will happen
if you swing your arms strongly while keeping them straight.) At the end of the
back swing, you should feel a tug in your shoulder. On the fore swing, your hand
should come up no further than mid-chest level. To stay in balance and
maintain a smooth forward motion from the hips down, concentrate on the back
swing, not the fore swing.

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 For most people, it is the strong arm swing that makes pace walking
aerobic. If a person has been completely sedentary for some time, just walking
quickly without the strong arm swing will most likely raise the heart rate into
the aerobic range. When the exerciser has been working out more regularly
though, walking fast alone will not be sufficient to raise the heart rate into the
aerobic range. That is why if walking is to be used as the aerobic exercise on an
ongoing basis (and many regular exercisers do so use it), a second major
muscle group must be brought into play (i.e., swinging the arms strongly as in
pace walking).

Equipment

Common to most regular exercise sports or activities is the need for

properly fitting shoes in order to achieve success and avoid injury. Proper fit
means that the shoe should conform to the shape of the exerciser's foot by
touching the foot in as many places as possible, except over the toes. The shoe
should be flexible under the ball of the foot, and it should have a firm vertical
heel counter at the back end of the shoe to keep the heel down in the shoe.

The design should be suited to the sport for which it will be used: that is,
shoes for pace walking or running should facilitate forward motion, shoes for
tennis or aerobic dance should facilitate lateral motion. Referral to a sports
medicine orthopedist or podiatrist may be necessary for orthotics or special
shoes in patients with a lower extremity disorder or a known foot deformity
such as hallux valgus. In general, a person should be advised to buy equipment
in a pro shop rather than in a department store.

A pro shop is a store other than a sports superstore that is dedicated to

sports equipment. In general, the more sport specific the focus of the store, the
more likely the buyer will come away with suitable equipment. In a pro shop,
the buyer is more likely to find salespeople who are knowledgeable about the
sport for which they are selling equipment and more likely to actually engage in
the sport themselves. Although good buys and high quality equipment can be
found at sports superstores, the quality of the advice received can be highly
variable, if available at all.

The cost of equipment for the regular exerciser can range from nothing
(the person decides to pace walk or jog, and their wardrobe already includes an
adequate pair of shoes and the necessary clothing), to hundreds or even
several thousand dollars for a health club membership, high-performance
athletic shoes, or a top-of-the-line bicycle. The best recommendation for
beginners is to spend as little as possible, except on buying a good pair of
shoes if they lack a pair, until they are convinced they are going to stay with
the sport.
Office and Clinic Organization

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 These principles must be reduced to a counseling package that can be
used successfully in clinical practice. First, of course, clinicians must decide
whether exercise counseling is important for some or all of their patients. To do
that, the clinician should follow the same goal-setting process that the potential
exerciser undertakes as his or her first step.

Is exercise promotion important in my practice? Why? For which patients?

What are the goals, for the patients, the practice, and the clinician?
Who should do the counseling: medical professionals or other staff
members?
How is exercise counseling going to be paid for?
Is counseling groups of patients (group visits) a strategy worth trying?
If so, when will they be offered and under what fee arrangements?

How should the practice use community resources (e.g., classes offered
by health systems and community centers, health clubs, sports clubs, gyms,
pools, tracks, bicycle routes, walking or running trails, courts, and pro shops), if
at all?
Are there other resources, such as Internet or telephone coaching
services, which can be used in concert with the clinician?
Is role modeling important?
How should I learn the specifics of regular exercise counseling and
incorporate them into my own knowledge base and skills?
How much time am I willing to invest in developing an exercise promotion
component in my practice?

It should be noted that asking and answering these questions for oneself,
with certain variations to be sure, applies to the consideration of adding any
health behavior counseling program/protocol to one's practice. In particular the
list applies to weight management efforts for which a regular exercise
component should surely be included. In many practices, group programs for
promoting both regular exercise and healthy weight management will be at
least in part integrated. Practices face opportunity costs in setting up a group
class for every behavior, and therefore some parsimony is required.

Although a practice would likely run separate group classes for smoking
cessation or healthy sexual practices, an integrated program for exercise and
weight management might come naturally because regular exercise is so
central to effective weight management and because so many persons who
first seek help with regular exercise are trying to lose weight. Indeed it would
make sense for a practice to have an integrated approach to the triad of
exercise, diet, and weight management, at least for beginners. More
advanced classes that focus on exercise might be considered for patients going
on to higher levels of regular exercise for its own sake and perhaps competitive
sports (e.g., racing).

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 Further, if it is decided to incorporate exercise promotion into one's
routine clinical practice, it is worth spending time to learn about and evaluate
the various community resources for promoting both regular exercise and
weight management. This will save time and provides substantive assistance to
patients. The clinician can consider setting up a formal referral relationship with
respected community facilities and establishing convenient in-office systems
(e.g., fax referral forms, automated referrals using an electronic health record)
to facilitate the process (see Chapter 21 for more details on making use of
these resources).

By whatever method exercise counseling is accomplished the clinician

should make it a regular part of the practice and be sure to document the
exercise counseling in the patient's medical record. Finally, although not
essential, clinicians who regularly exercise themselves can set examples for
patients. Such clinicians can draw on their own experiences to counsel patients
on the benefits and the drawbacks of being a regular exerciser.

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