Exercise Counseling for Women
January 2000; Volume 2: 3-6
By Charlea T. Massion, MD and Adriane Fugh-Berman, MD
For humans, exercise is essential for physical, mental and, probably, emotional vitality. Humans are no more solely designed to sit in traffic or in front of a computer screen than fish were solely designed just to tread water or birds solely to perch. Not only is regular exercise associated with lower mortality rates for both women and men, but consistent exercise decreases rates of diabetes, hypertension, osteoporosis, and myocardial infarction (MI), and can lessen stress, dysmenorrhea, sleep disorders, and premenstrual syndrome symptoms.1
However, despite concerted public health campaigns, Americans are bigger and better couch potatoes than ever. According to recent surveys, more than 60% of adults do not exercise consistently and 25% spend none of their leisure time in physical activities. Most people spend 10-15 hours daily sitting in a car, at a desk or computer terminal, or watching television. As expected, children mirror adult activities, spending many hours transfixed by television (and eating the junk food advertised there) and computer games. Vigorous physical exercise is lowest among young girls, non-Hispanic blacks, and Mexican Americans.2
Sedentary women are twice as likely as regular exercisers to have an acute MI. The relative risk of inactivity and coronary heart disease ranges from 1.3 to 1.9. Total physical activity is inversely related to the risks of fatal coronary heart disease and first MI.1
A recent report from the National Health Interview Survey found that of 9,299 respondents, 34% were counseled about exercise during their last physician visit. Physicians were more likely to counsel patients over the age of 30, those with incomes over $50,000, those with higher levels of physical activity, college graduates, overweight patients, and patients with cardiac disease or diabetes.3 We should counsel all of our patients to start or continue exercising; it is the one alternative therapy that almost everyone has the resources to do, and may be the most important for disease prevention and health promotion.
So what can physicians do to help their sedentary women patients transmogrify into ones who exercise regularly? Note: Although this article is aimed at counseling women patients, physicians also literally need to "walk their talk," despite all pleas of being "too busy to exercise." Dr. Massion tells patients that if the president can find time to jog, surely we can do so also.
Exercise that is fun is the easiest to do consistently. We tell our patients that they will exercise "when you find the exercise that is right for you," and that to exercise regularly, they probably will need to do something that they have not yet tried. If they have a treadmill that has been a clothes rack for two years, most likely they will not suddenly begin to use it, but they may be able to get motivated by something radically different—like ballroom or folk dancing, salsa aerobics, or African dance. Hatha yoga, t’ai chi, or qi gong are gentle exercises that can be particularly beneficial for those with physical limitations or who are out of shape.
Tennis again, anyone? For women who have played sports earlier in their lives (tennis, softball, volleyball, etc.) but whose work and/or family obligations have interrupted their athletic endeavors, reconnecting them with their sport may be relatively easy. A physician’s encouragement, perhaps bolstered by the specter of having to start antihypertensive medication, may provide them the impetus to resume exercise.
For those who have always aimed to be as inactive as possible (e.g., circling the parking lot until the space next to the handicapped spot is free) different strategies may be needed. Starting an exercise program at a feasible level is essential for eventual success, and lofty goals need to be discouraged, at least initially. A physician can help a woman set realistic (i.e., low) goals. Tieraona Low Dog, MD, member of the Alternative Therapies in Women’s Health editorial advisory board, asks her patients to commit to one minute of daily exercise. They often protest that they can do more than that. She agrees, but still asks them to commit to one minute each day.
We both have had a lot of success with writing prescriptions for walking programs. Walking is easy, inexpensive, and most people can do it. It is important to detail the "when and where" options, e.g., the high school track near home or work, an after-dinner stroll with a spouse or a neighbor (if one’s neighborhood is safe enough), or the mall. One of Dr. Massion’s patients, a 65-year-old Japanese American woman with diabetes and foot problems, just passed her 400-mile mark at a shopping mall in Santa Cruz, CA. Walking only requires adequate shoes and can be done while traveling or visiting. Regular activities can be adjusted to get more walking in: Editorial advisory board member John Pan, MD suggests that those who take public transportation get off a stop earlier on the way to work and back. And for golfers, walking and carrying ones bag instead of using a cart can burn 300 calories an hour; Dr. Pan recommends a double strap carrying system. A round of golf can involve walking four miles with a 25-lb load.
Many people do better when they ritualize exercise and include other people, whether family, friends, or strangers. Showing up for a Jazzercise or aerobics class three times a week can be much easier than deciding by oneself when and where each exercise session will be. However, health clubs can be intimidating places for those with more than 3% body fat and whose exercise wardrobe consists of sweats and tattered T-shirts rather than Lycra jumpsuits. Health clubs do vary a lot in their clientele’s age range, dress, and tolerance of new and/or unfit members. Physicians can benefit their patients by knowing their community’s resources and offering practical advice. For example, Washington, DC has a club exclusively for those 55 and older.
Many women struggle with exercising at home (for many women after work, there’s homework, dinner to prepare, etc.), and new exercisers should be discouraged from buying expensive equipment. A whole resale industry has sprung up for used (actually mostly unused) equipment; this may be ideal for some, such as someone who walks outdoors during two or three seasons, but needs a treadmill at home during the darker, colder months. Audio or visual distractions can help: Editorial advisory board member Ward Cates, MD, MPH can only use his cross-country ski machine if there is a game on TV—a good excuse to subscribe to ESPN. Another editorial advisory board member, Freddie Ann Hoffman, MD, listens to a talk show she finds offensive while on her treadmill; she finds fury useful fuel for working out harder.
In 1995, the American College of Sports Medicine (ACSM) and the Centers for Disease Control and Prevention issued guidelines for the exercise levels necessary for health promotion and disease prevention, i.e., 20 min/session on three nonconsecutive days with target heart rates in the 70-85% maximal range. Many people assumed that if they were unable to meet those specifics, they were wasting their time. However, in 1998 ACSM updated the recommendations, noting that research now indicates that three 10-min sessions/d provide almost identical improvements in fitness, cardiovascular risk, body weight, and fat stores as a 30-min continuous workout.4
Also, even better news for the seriously deconditioned, is that moderate-intensity exercise, e.g., brisk walking at less than 3 miles/hour, cycling at less than 10 miles/hour, and swimming relatively slowly, also has significant benefits. Those who opt for this moderate level of activity, however, are advised to exercise 5-7 times/week.5
Special considerations should be applied to women with specific health conditions:
Pregnancy: Women who have exercised prior to pregnancy can safely continue most of their same exercise routines. Some studies show that women who exercise during pregnancy may tolerate labor better, have shorter labors and deliveries, and have less postpartum blood loss. Swimming may be an ideal exercise for pregnant women. Pregnant patients should avoid high heart rates, prolonged sessions especially during hot weather, and exercise that has a risk of abdominal impact, especially during the third trimester. Hydration before, during, and after exercise is especially important for pregnant women.6
The American College of Obstetrics and Gynecology advises against deep knee bends, full sit-ups, double leg raises, and straight-leg toe touches because during pregnancy these exercises are more likely to injure connective tissues. After about 20 weeks, women should also avoid any exercise that involves lying flat on their back for more than several minutes.7
Heart disease: A physician should consider a woman’s current medications, e.g., beta-blockers may slow heart rate and mask ischemic symptoms. Despite lower resting and exercise heart rates, however, the patients on these medications have as much to gain as do others with heart disease. During peak exercise their heart rates should be at least 10 beats less than their anginal threshold. High-intensity exercise (e.g., sprinting) should be discouraged, especially at the end of a workout.
Diabetes: Since exercise can induce hypoglycemia, women with diabetes should carry juice, crackers, or other supplies for immediate use. They should avoid insulin injections in an area that will be used actively during their exercise session because increased blood flow to that area will increase the rate of insulin absorption , e.g., runners should not use injection sites in their legs before a run. For diabetics, more frequent exercise sessions, especially if consistent, will help to regulate glucose levels, and may decrease body weight and the fat stores that increase insulin resistance.
Elderly women: Even in the extremely frail, e.g., for whom walking down the hall can be like running around a track for someone younger, exercise still can have very positive effects. A study of 10 nursing home residents, ages 86-96, indicated that in eight weeks of high-intensity resistance training (weight-lifting), their strength increased 174%, their walking speed 48%, and their lower extremity strength from 61% to 374%.8
Encouraging patients to exercise may be the most important preventive medicine intervention we can do for our patients. And making time in our own lives for exercise will not only help us stay healthy, but will help us manage the stress of taking care of patients.
References
1. Eaton CB, Menard LM. A systematic review of physical activity promotion in primary care office settings. Br J Sports Med 1998;32:11-16.
2. Andersen RE, et al. Relationship of physical activity and television watching with body weight and level of fatness among children: Results from the Third National Health and Nutrition Examination Survey. JAMA 1998;279:938-942.
3. Wee CC, et al. Physician counseling about exercise. JAMA 1999;282:1583-1588.
4. Pate RR, et al. Physical activity and public health. A recommendation from the Centers of Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-407.
5. American College of Sports Medicine position stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30:975-991.
6. Trotto. Exercise for optimum health. Pat Care 1999;33:97-112.
7. Carlson, et al. Exercise. In: The Harvard Guide to Women’s Health. Cambridge, MA: Harvard University Press; 1996;237-241.
8. Fiatarone MA, et al. High-intensity training in non-agenarians: Effects on skeletal muscle. JAMA 1990;263:3029-3034.
January 2000; Volume 2: 3-6
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