Do Adults Need Physicians to Tell Them to Exercise?

According to a new CDC report, only 1 in 3 doctors advise their adult patients to exercise. The survey-based findings are limited, in part, because they rely on people’s recollection of whether they’d visited a physician in the previous year and what they were told. Nonetheless, the study revealed some clear trends:

1. In 2010, 32.4% of adults who’d seen a health care professional were advised to begin or continue with exercise or other physical activity. That fraction’s up significantly from 2000, when a slim 22.6% of patients recalled their doctors telling them to get a move on.

2. Among folks over 85 years, nearly 29% say they were told to exercise. That number’s nearly doubled since 2000, when only 15.3% of elderly patients reportedly received this kind of advice.

3. Adults with diabetes were told to increase their activity more often than those with high blood pressure, cardiovascular disease and cancer. Compared with healthy weight adults, obese people were twice as likely to have been told to exercise by a physician or other health professional.

An underlying message is that doctors should be prodding their patients to exercise. From the report:

Research points to the benefits of physical activity for reducing the risk of chronic health conditions (1–4). Engaging in regular physical activity can reduce medication dependence, help maintain functional independence, and improve the quality of life for older adults (5,6). Physicians and other health professionals can be influential sources of health information, and exercise counseling by primary care physicians has been shown to increase patients’ participation in physical activity (6–9).

There was discussion about this yesterday on Twitter, stemming in part from a USA Today article on the report. And here’s the essence of the short-form debate:

Some suggested that doctors don’t tell patients to exercise because they, themselves, are overweight. Or it’s because they don’t feel comfortable recommending for others what they don’t do themselves. While this might explain some physicians’ behavior or discomfort with the topic, it can’t explain that of the majority.

So why don’t more doctors prescribe exercise for their patients?

Reasons I wonder about include a lack of time for “non-essential” communication, especially in clinics. In specialists’ offices, the omission of exercise could have to do with the visit’s purpose. A gastroenterologist or internist who evaluates a patient for a problem like diarrhea, say, might not think to ask about exercise. For some doctors it might be, problematically, an attitude issue – that they just don’t care that much, or think it would be a waste of time to discuss the matter of exercise.

Whatever the reasons are that most doctors don’t bring up the issue, one might ask this: Why do adults need doctors to tell them about the health benefits of regular exercise? After all, it’s common knowledge – the kind of thing taught in elementary school, like nutrition should be – that regular exercise is good for most people. As we age, being out of condition makes every task in life, like walking a few blocks, harder.

In an ideal world, we’d have most adults exercising regularly, and doctors who’d occasionally intervene and counsel patients about what they shouldn’t do because of a particular medical condition, like arthritis or heart limitation. I guess we’re not there yet –

All for this week,

ES

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Weight Loss Strategies – What Should Doctors Say to Patients?

Yesterday’s Times offered two distinct perspectives on weight loss. One, a detailed feature on gastric surgery by Anemona Hartocollis, details the plight of a young obese woman who opts for Lap-band surgery. In this procedure, surgeons wrap a constricting band of silicone around the stomach so that patients will feel full upon eating less food than they might otherwise. Allergan, the company that manufactures the device, admits to these complications on its website.

The other, a discussion of resolutions and will-power by John Tierney, considers strategies for sticking to diets, exercise regimens and other good intentions for the new year. Within this piece lies a distracting story of an obese (375 pound) hedge fund manager whose gastric band failed to keep his appetite in check. When he landed a project in Las Vegas and feared regaining weight, he aimed high – to lose 100 pounds, outfitted his hotel suite with a gym, and hired a personal trainer to stay nearby and keep him on track in terms of meals and exercise. This costly “outsourcing” of will-power is, obviously, not an option for most people.

Tierney does offer some reasonable suggestions – like setting realistic goals, weighing yourself daily, Tweeting your weight, logging into a weight-loss website, not freaking out if you blow your diet one day, etc.

Both articles are well-worth reading.

But here’s the thing – how do doctors fit into this picture? In the last few years that I was practicing hematology, I saw a few patients who had B12 deficiency after gastric bypass surgery. These patients turned out to have multiple problems after their stomachs were cut so they’d eat less food. For some it was helpful; I saw individuals who lost over 150 pounds. Still, the surgery was huge and risky. I can’t fathom having recommended it to a patient whom I cared for, unless perhaps I’d personally witnessed her struggling to lose weight for over, say, 8-10 years.

Because most people, if inspired or starved, can lose weight. This may sound cruel, but what if the doctors recommending the procedure don’t have sufficient confidence in their patients?

The Lap-band is sold as a safer alternative, but upon reading the story (an anecdote, but telling), you have to wonder what are patients’ expectations of the procedure, and how well do they understand the likely risks and benefits. Who are the doctors who tell them about the procedures, and what are their ties with industry (besides the obvious link of surgeons who do the surgery and recommend it).

Like patients with cancer, patients with obesity may feel desperate. But unlike cancer, obesity is almost always a function of choices we make, and for which I think we have to hold people responsible.

Doctors, maybe, should expect more of their patients. “Yes, you can lose 30 pounds over the next 2 years,” one might say. And they might talk about strategies, Tierney-style or otherwise, based on the patient’s preferences and personality. “Come into my office once each month for a weigh-in” might be very effective in persuading patients to shed pounds. A technician could do the monthly measurement in the office or medical home, and the doctor or nurse might follow-up with an encouraging email. Imagine that!

So why don’t more general practitioners, including pediatricians, offer this sort of weight-loss approach? Is it too simple a strategy that doctors don’t find it interesting? Or not sufficiently profitable for the office or medical center?

No answers, just thoughts upon reading, for today –

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On Deaths in the New York City Triathlon, and Pushing Ourselves to Limits

Yesterday some 3900 people swam, biked and ran in New York City’s 11th annual triathlon in what might be a celebratory event of human strength and perseverance.

According to this morning’s paper, a 40-year-old woman suffered a heart attack during the 1500 meter swim in the Hudson. She was hospitalized and said to be in stable condition. A man, aged 64, became unconscious mid-way through the swim and was pronounced dead. The man’s death was the second in the history of NYC’s triathlon; three years ago someone else didn’t make it through the water segment.

In March, 2009, the LA Times ran a piece on Death by Triathlon. Most who died in triathlons were men between the ages of 35 and 55 years. Most of the deaths occurred during the swimming portion of the race.

Triathlon (Wikimedia Commons image)

At the pool where I swim, I see people training for the triathlon, and I admire them.

Still, you have to wonder, do people not know their own limits? Or do they choose to ignore them?

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Get Off My Case

In my inbox this morning, via ASCO‘s “Cancer in the News” feed:

The UK’s Telegraph (5/6, Beckford) reported that as “many as 20,000 British women could avoid developing” breast cancer “each year, if they took more exercise, drank less and ate better.” Latest figures “suggest that 47,600 women developed breast cancer in 2008,” and the World Cancer Research Fund estimates that estimates that “42 per cent of these cases…would be preventable if women developed healthier lifestyles.” The WCRF’s “10 Recommendations for Cancer Prevention include being ‘as lean as possible without becoming underweight’; keeping fit; limiting consumption of fatty, salty and sugary food and drink; eating fruit, vegetables and pulses; eating less red meat and processed meat; drinking less and choosing a balanced diet rather than vitamin supplements.”

This follows numerous reports that women may develop breast cancer or suffer recurrences because they eat too much, drink too much, work too much or fret too much. (But don’t relax and put down your vacuums, girls – there’s striking evidence that household chores can reduce your risk!)

Of course it’s wise from a general medical perspective – think in terms of heart disease, osteoarthritis, type 2 diabetes and other ailments prevalent in our too-developed world – to be slender instead of fat, exercise regularly and eat a balanced diet.

I’m tired of the press trumpeting poorly-done trials that feed into a stereotypic conception of how women should behave. Yes, diet and stress could play a role in any hormone-driven disease, but so do a lot of things. As for alcohol, maybe consumption is a surrogate for wealth and living in a place like the U.S. where people drink freely, where breast cancer rates are unseemly.

We should be sure of the facts before pronouncing these fatal flaws in our ways of existence and being. Plenty of women feel badly about their tumors and disfigurement without this added layer of insult.

And what did you eat for dinner last night, big brother?

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Another Brooklyn (and how I feel when I look in the mirror)

The image of Brooklyn Decker, a real woman and model from Middletown OH, streamed through my Google news feed this morning. I have to admire any person named Brooklyn, the place where I was born.

From a post on my BlogHer health RSS:

Brooklyn Decker on the cover of Sports Illustrated, in 2010

The BlogHer subject is Decker’s diet and exercise secrets: “…no matter how wealthy or famous you are, Decker says the only thing that really works is exercise, eating healthy and accepting your body for what it is that will make you succeed.”

Got it.

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After Breast Cancer, Get a Gym Membership!

Earlier this month the Journal of the American Medical Association (JAMA) published a myth-busting paper on weight lifting for women at risk for lymphedema after breast cancer treatment.  The study was neither large (154 patients at max, whittled down to 134 at analysis) nor high-tech (interventions involved gym memberships, weight training and lifting in neighborhood facilities like YMCAs).

The results were clear: working out with hand-held weights, carefully, is good for most women who’ve had surgery for breast cancer (BC).

Lymphedema, or swelling due to a damaged gland, can develop in a patient’s arm after removal of lymph nodes in the armpit. The uncomfortable condition can be disabling by impairing arm or hand movements. It affects a significant number of BC patients: among women who’ve had have just a sentinel lymph node removed, lymphedema affects roughly 6%; for those who’ve had complete axillary (armpit) lymph node dissection, the incidence is around 30%. There are roughly 2.5 million women living in the U.S. after a breast cancer diagnosis; most are at elevated risk for lymphedema.

Years ago, doctors commonly advised patients not to lift weights or perform strenuous exercises with their arms after a mastectomy or lumpectomy with lymph node dissection. To a lesser extent, this happens still today. As reported in the JAMA article:

Breast cancer survivors at risk for lymphedema alter activity, limit activity, or both from fear and uncertainty about their personal risk level, and upon guidance advising them to avoid lifting children, heavy bags, or other objects with the at-risk arm.9,10 Such guidance that deconditions the arm, increasing the potential for injury, overuse, and, ironically, lymphedema onset.11 Adherence to these precautions may limit physical recovery after breast cancer and, for some women, result in lost employment. Furthermore, activity avoidance may deter survivors from performing regular exercise…

The researchers recruited women in the Philadelphia area who’d undergone surgery for localized, unilateral breast cancer sometime between 1 and 5 years before the study. Each had at least 2 lymph nodes removed in surgery. The median age was around 55 years. The women were divided into two balanced groups before randomization – they received a year’s membership at a gym and a trainer for the first 13 weeks, or not.

So it’s good news that the women in “weight lifting intervention” group developed less lymphedema. What’s more, those women became stronger and sported a lower percentage of body fat. All of these differences were statistically meaningful and, for the most part, quite strong. Perhaps more remarkably, in a pre-planned subset analysis of women who’d had 5 or more lymph nodes removed, the proportion who experienced lymphedema in the weight-lifting group was only 7%, compared with 22% in the controls. That difference was highly significant, with a p-value of 0.003. The findings, in sum, show that it’s safe for women who’ve had breast cancer surgery to work out in a way that includes a careful, progressive upper body strengthening.

About a week ago, I was alerted to this article by Dr. Ramona Bates, a plastic surgeon who authors Suture for a Living. She’s had several recent, excellent pieces on this subject including a post on lymphedema and the JAMA report. I chose to write on this, in part, because it meshes with my professional and medical history.

In my case, I got conflicting advice on the matter. I wanted to continue swimming because it helps my scoliotic back. But some colleagues suggested that arm-intense strokes might be best avoided after mastectomies. A cosmetic surgeon rightly told me that some strokes might have untoward effects on implants. So I relied on my judgment: I chose to swim because it made me feel better and stronger. In the past year, I’ve started lifting a few small weights, carefully and slowly.

In the end, this is a story of a small clinical trial and the value of common sense in medicine. Weight lifting is not only safe; it can reduce the incidence of lymphedema in women at risk. But “old wives’ tales” still persist in some doctors’ minds; these need be dispelled. Finally, I can’t help but wonder what would happen if every woman could have a year’s membership at a local gym –

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An Ordinary Day

If there’s one obvious thing I didn’t learn until I was well into my forties it’s this:

Don’t let a day go by without doing something you feel good about.

This message is not unusual, cryptic or even interesting. It’s simple, really so trite you could find it in most any “how having cancer changed my life” book available in bookstores and on-line.

Why say it again? Everyone knows we should relax and enjoy sunny weekend days like this.

Because it’s a reminder to myself, as much as for some readers and maybe a few fledgling doctors out there. One of my biggest regrets, during and after so many medical hurdles, is that I was overly ambitious. I am, probably still, one of those people who’s hard-wired to achieve. At work, when I was a young physician-hematologist-oncologist-cancer researcher-pregnant wife, I worked long, long hours. After dinner in our apartment, I’d stay up late, reading, and get up early enough to read the paper and have some breakfast before morning rounds. Later, as my career matured, I used extra hours for research, presentations, grant proposals and, of course, more reading. I loved my work as much as anyone I’ve ever known, wishing I could put more time into it, not less.

Illness places real limits on people’s capabilities. I refused to accept this. I just kept pushing. No excuses.

Looking back, I see that I should have slowed down earlier in my career and made more time for my family and for myself. I needed physical therapy and an occasional day off. Even while I had breast cancer, undergoing treatments, I worked in the clinic, took on administrative responsibilities at the hospital (in lieu of being on-call), and continued to write and review manuscripts, besides teach. After my back operation, a huge, painful and bloody affair, I returned to work and took call like everyone else. It took me too long to realize that I should pull back.

So I think it’s a lesson, or at least it’s one for me. It has to do with the Passover story of Exodus. Making sure to enjoy life, taking some time of each day and week to focus on what you choose, is the privilege of not being a slave.

An unfortunate reality is that many people work long hours because they must, due to financial necessity or because they have no choice. But for those who aren’t so strapped that they must work 16 hour days, who do it for pleasure as much as for wages or for riches, maybe it’s a reminder to take care. Sometimes it takes discipline to know when to shut out the light, or even call it quits. Less is more, sometimes even better.

It shouldn’t take a catastrophic illness to get this message through. Maybe just a good night’s sleep, or another sunny day tomorrow.

Take it easy.

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