SOUTH AFRICAN LIFESTYLE MEDICINE ASSOCIATION

Exercise: The Gateway to Lifestyle Change

By Dr Megan Michaux

The implementation of behaviour changes associated with the pillars of lifestyle medicine is an effective way to improve health and wellbeing. However, bridging the gap between behaviour change theory and the practical ways to make the change happen can be overwhelming. To help our patients, lifestyle medicine needs to provide support, education, and a pragmatic approach to change.

One strategy to help your patient start making sustainable healthy lifestyle choices is to start with physical activity. Exercise and decreased sedentary time are both critical to improving health on a global scale. A 2005 study found that 15.2% of deaths in the USA could be attributed to physical inactivity and poor diet.1 While some lifestyle-change programs shy away from intentional and planned activity, recommending things like step counting instead, exercise might be even more valuable than it appears on the surface. Of course, increasing daily movement without exercise is also beneficial, and it is not a case of one or the other. But what if implementing an exercise program could help motivate a broader healthy lifestyle change?

Why is exercise valuable?

There are so many types of physical activity to choose from – aerobic exercise like running or cycling, resistance training at the gym, bodyweight-based training, like yoga – and almost all of them have proven health benefits. Exercise can lower blood pressure2, improve insulin sensitivity3, improve cardiovascular health4, improve body composition5, slow the rate of cognitive decline6, and improve the symptoms of depression7. Each pillar of lifestyle medicine is connected to the physical activity pillar through these positive effects, and this interlinking system highlights how lifestyle medicine principles unite to prevent, treat, and sometimes reverse chronic illness.

To reap the rewards of exercise, the global guidelines recommend aerobic exercise of 150 – 300 minutes per week of moderate intensity exercise, or 75 – 150 minutes of vigorous exercise, or some combination of the two, plus at least 2 days per week of muscle-strengthening exercise. 8 Those numbers can seem overwhelming to someone who has never done an exercise program. When introducing exercise to a patient, it is important to focus on patient-centred care which is highly valued in lifestyle medicine. Consider the patient in their own context. People have different fitness levels, different responsibilities at home and at work, and a different response to stress. Some people relish the challenge, others are nervous and need more support to get started. An important takeaway from the exercise guidelines is: “doing some physical activity is better than doing none”. 8 Starting off slowly, building up over time, and maintaining a regular exercise program in the long term, is far more effective than shooting for 150 minutes of vigorous exercise from day one and giving up after two weeks.

Another point to consider when initiating an exercise program: enjoyment! An effective exercise plan is likely to be challenging, and in some moments difficult. However, incorporating types of exercise that the patient enjoys is a great way to increase the chances of long-term success. For example, resistance training is recommended, but not everyone loves the idea of an hour in the gym lifting weights. Maybe a group class that uses some dumbbells is more fun, or an outdoor class with kettlebells. Body weight can also be effective, especially for people who have little experience with weight training. Maybe a few sessions with a personal trainer to learn some of the movements and build confidence could be the way to start. When it comes to aerobic exercise, some people love to go running, but others find it boring. Dance classes, martial arts, or skipping classes can be great aerobic exercise. Thinking outside the box can help people find a form of exercise that they love and are happy to show up for week after week, and the real benefits of exercise are seen in people who find that consistency.

Why is exercise a good starting point?

So, why is starting with the physical activity pillar an effective way to initiate a lifestyle change?  Research has found that exercise can be a gateway to other lifestyle changes. Implementing an enjoyable and sustainable exercise program can help people to start making changes in all six of the lifestyle medicine pillars, not only the physical activity pillar9. As the patient starts to identify as a person who exercises (or perhaps even as an athlete), the other aspects of fitness and health beckon to them. Incorporating exercise into your identity can be an important step in building a habit that sticks. In Atomic Habits, author James Clear describes this as deciding what you want to be (in this case, a person who exercises), and then proving it to yourself with small wins (each time you exercise) 10. This step could take some time, especially for someone who has no experience with exercise or sport.

However, once you start identifying as someone who exercises, that shift in perception can start a cascade of positive lifestyle changes. First in line is often nutrition11. After all, to perform well at your chosen sport, nutritious food is essential. Several studies have found that people who started to exercise spontaneously increased their vegetable intake and decreased their fat intake. 11 12 13 This might seem a small change, but this simple step in the direction of healthier, more plant-based nutrition sparks a positive feedback loop – better nutrition makes training feel better, which can inspire more training or training at a better effort level, which can inspire healthier food choices. Focussing on nutrition to fuel effective physical activity can also take away the negative associations a lot of us have with food, leading to a healthier relationship with food. This relieves some of the stress and anxiety that dieting and constant restriction can cause.

This leads us on to the next pillar – stress management. Exercise has a positive impact on mental health and can improve the symptoms of anxiety, depression, and stress as it has positive psychological and physiological effects. 7 14 It can become a part of a patient’s stress management arsenal, improving mood symptoms, helping with stressful workdays, and providing a safe space to step away from the pressures of daily life.

Another positive aspect of exercise can be the social connections it engenders. Joining an exercise class or signing up for a sports team is a great way to meet new people and build a social circle. Not every type of exercise is social, but even in more traditional gym settings, people often make friends with people that they see regularly. In some cases, these friends become a sort of accountability partner, but they also make the exercise session more enjoyable. Finding that connection and being able to spend time with people who also value exercise forms yet another positive feedback loop – these relationships increase the likelihood of the patient sustaining the behaviour. 15

Not sleeping well? Exercise is a good option for people with poor sleeping patterns. Regular exercise improves total sleep time, lessens the time taken to fall asleep, and increases the restfulness of the sleep. 16 17 The idea of identifying as a fit person, or an athlete, or just as someone who exercises can help sustain the initial behaviour, but it also makes you more likely to prioritise sleep. Knowing that you need a good night’s rest before the morning exercise session can lead to healthier choices – like an earlier bedtime, making sure there is enough time for a restful sleep, and spending more time developing good sleep hygiene.18

Lifestyle medicine promotes the avoidance of risky substances and behaviours, and some research has found that smoking and alcohol use is less frequent amongst people who exercise regularly. This could be related to the idea of identifying as a healthy person that exercises as well.19 More research is needed to find out the mechanisms that might explain this association, but people who want to do well athletically are likely to make more healthy choices in terms of substance use.

Prescribe physical activity

A lifestyle medicine practitioner should be comfortable with recommending physical activity to a patient as part of treatment plan. Many things come into consideration when prescribing exercise, for example:

  • Does my patient have any experience with exercise?
  • What type of physical activity does this patient enjoy?
  • What is the social context of this patient? Are resources available to help with access to physical activities?
  • Who will help support this patient? Perhaps the rest of the family or a friend can get involved!
  • Barriers to exercise: plan for any obstacles so that the patient knows how to handle them.
  • Remember that any physical activity is better than none. Start slowly, build up intensity over time, and focus on consistency.

This list is not exhaustive, and it is clear from the complexity of the prescription that simply telling a patient to “move more” is unhelpful.

Other aspects of prescribing exercise that are not covered here (for example, goal setting, physical examination to ensure the patient is safe, and motivational interviewing techniques that can help with getting patient on the right track) mean that exercise prescriptions are complicated, take time, and involve frequent follow-up with appropriate adjustments to the initial plan.

The time taken to discuss, plan, and implement an exercise routine with a patient during a lifestyle medicine consult is worth every moment and the rewards that it could bring – potentially an entire lifestyle overhaul – cannot be overstated.

Physical activity can change lives

While there is ample evidence to support the benefits of exercise, most people still do not meet the guidelines. A patient looking to improve their health through lifestyle changes needs support, encouragement, knowledge, and motivation. A lifestyle medicine consult is the perfect opportunity to bring this first step to our patients and to set up ongoing support for them as they get started on the journey to a healthier life. An exercise prescription can be that initial step that helps a lifestyle management plan get underway, and it can provide motivation to start and maintain multiple healthy lifestyle changes in the long term.

 

References:

 

  1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Correction: actual causes of death in the United States, 2000. JAMA. 2005;293(3):293-294. doi:10.1001/jama.293.3.293
  2. Edwards JJ, Deenmamode AHP, Griffiths M, et al. Exercise training and resting blood pressure: a large-scale pairwise and network meta-analysis of randomised controlled trials. Br J Sports Med. 2023;57(20):1317-1326. doi:10.1136/bjsports-2022-106503
  3. Sampath Kumar A, Maiya AG, Shastry BA, et al. Exercise and insulin resistance in type 2 diabetes mellitus: A systematic review and meta-analysis. Ann Phys Rehabil Med. 2019;62(2):98-103. doi:10.1016/j.rehab.2018.11.001
  4. Lin X, Zhang X, Guo J, et al. Effects of Exercise Training on Cardiorespiratory Fitness and Biomarkers of Cardiometabolic Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc. 2015;4(7):e002014. Published 2015 Jun 26. doi:10.1161/JAHA.115.002014
  5. Lopez P, Taaffe DR, Galvão DA, et al. Resistance training effectiveness on body composition and body weight outcomes in individuals with overweight and obesity across the lifespan: A systematic review and meta-analysis. Obes Rev. 2022;23(5):e13428. doi:10.1111/obr.13428
  6. Huang X, Zhao X, Li B, et al. Comparative efficacy of various exercise interventions on cognitive function in patients with mild cognitive impairment or dementia: A systematic review and network meta-analysis. J Sport Health Sci. 2022;11(2):212-223. doi:10.1016/j.jshs.2021.05.003
  7. Heissel A, Heinen D, Brokmeier LL, et al. Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression. Br J Sports Med. 2023;57(16):1049-1057. doi:10.1136/bjsports-2022-106282
  8. WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva: World Health Organization; 2020.
  9. Sevild CH, Niemiec CP, Bru LE, Dyrstad SM, Husebø AML. Initiation and maintenance of lifestyle changes among participants in a healthy life centre: a qualitative study. BMC Public Health. 2020;20(1):1006. Published 2020 Jun 26. doi:10.1186/s12889-020-09111-8
  10. Clear, J. (2019). Atomic habits: an easy & proven way to build good habits & break bad ones. New York, NY, Penguin Audio, an imprint of the Penguin Random House Audio Publishing Group.
  11. Hajat C, Kotzen D, Stein E, Yach D. Physical activity is associated with improvements in other lifestyle behaviours. BMJ Open Sport Exerc Med. 2019;5(1):e000500. Published 2019 Nov 28. doi:10.1136/bmjsem-2018-000500
  12. Alakaam AAH, Lemacks JL. Fruit and Vegetable Consumption, Fat Intake, and Physical Activity Participation in Relation to Socio-demographic Factors Among Medically Underserved Adults. AIMS Public Health. 2015;2(3):402-410. Published 2015 Jul 30. doi:10.3934/publichealth.2015.3.402
  13. van der Avoort CMT, Ten Haaf DSM, de Vries JHM, et al. Higher Levels of Physical Activity Are Associated with Greater Fruit and Vegetable intake in Older Adults. J Nutr Health Aging. 2021;25(2):230-241. doi:10.1007/s12603-020-1520-3
  14. Stubbs B, Vancampfort D, Rosenbaum S, et al. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Res. 2017;249:102-108. doi:10.1016/j.psychres.2016.12.020
  15. Martin JE, Dubbert PM, Katell AD, et al. Behavioral control of exercise in sedentary adults: studies 1 through 6. J Consult Clin Psychol. 1984;52(5):795-811. doi:10.1037//0022-006x.52.5.795
  16. Kelley GA, Kelley KS. Exercise and sleep: a systematic review of previous meta-analyses. J Evid Based Med. 2017;10(1):26-36. doi:10.1111/jebm.12236
  17. De Nys L, Anderson K, Ofosu EF, Ryde GC, Connelly J, Whittaker AC. The effects of physical activity on cortisol and sleep: A systematic review and meta-analysis. Psychoneuroendocrinology. 2022;143:105843. doi:10.1016/j.psyneuen.2022.105843
  18. Kline CE. The bidirectional relationship between exercise and sleep: Implications for exercise adherence and sleep improvement. Am J Lifestyle Med. 2014;8(6):375-379. doi:10.1177/1559827614544437
  19. Thompson TP, Horrell J, Taylor AH, et al. Physical activity and the prevention, reduction, and treatment of alcohol and other drug use across the lifespan (The PHASE review): A systematic review. Ment Health Phys Act. 2020;19:100360. doi:10.1016/j.mhpa.2020.100360

 

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