The subject of lifestyle physical activity and its effects on health is a hot topic in the journals at present. Increasingly, the focus is being placed on understanding the barriers that people may face which prevent them from engaging in activity or exercise (see also: FitPro, Research Update, pp 36 37, June/July 1999.).

Writing in The Physician & Sportsmedicine, Dr Ross Andersen has reviewed the role of exercise and activity in the management of obesity. Andersen notes the prevalence of the problem in the United States, where an estimated 33.3% of men and 36.4% of women have a body mass index (BMI) of 27 (kg per metre squared) or greater. A BMI under 26 is considered healthy. More worryingly, reports Andersen, 14.4% of American men and 16.2% of women are now considered obese using a BMI value of 30 or greater. And the problem is not confined to the adult population since 26% of American children are overweight with 10% being severely overweight.

Inactivity

Researchers in several countries have reported that the prevalence of obesity is matched by a decreased level of physical activity in the general population. For example, Andersen cites some of his own work, which found a very strong relationship between television watching and fatness (Andersen 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 (12): 938 - 942). Yet can increasing the levels of physical activity or exercise in the overweight individual reverse this trend? As Andersen points out, Americans spend billions of dollars annually on diet books, exercise equipment and weight loss programs. Unfortunately, losing weight is difficult for most patients and most of those who do lose weight ultimately regain it. These well-publicised statistics may leave physicians wondering how to counsel their overweight patients or if it is even worth trying.

Current Evidence

The evidence with respect to the role of exercise and physical activity in successful weight management is compelling. Andersen notes that the most favourable body composition changes can be expected with appropriate, combined diet and activity programmes. For example, 20 24% of weight loss will come from fat-free mass in the non-exercising dieter, compared with 11 - 13% in the exercising dieter (Ballor & Poehlman, a meta-analysis of the effects of exercise and/or dietary restriction on resting metabolic rate. Eur J Appl. Physiol 1995; 71 (6): 535 542)). This loss of lean tissue would seriously affect the long-term success of such a programme. Andersen quotes other research to show that, 90% of women who have lost weight and kept it off report exercising on a regular basis.

Increased levels of physical activity and exercise are of benefit even if weight is not lost. Again in a review of the relevant literature Andersen comments that, unfit lean men had a higher risk of all-cause and cardiovascular disease mortality than did men who were fit and obese. Furthermore, patients who exercise regularly are likely to be less depressed, have higher self-esteem and have an improved body image, states Andersen in a summary of the psychological effects of exercise.

Barriers to Activity

The paradox is that people know that regular exercise and physical activity are important for both health and weight management. So why do so many people do so little of either?

Andersen and his colleagues have attempted to answer this question by surveying 52 overweight, sedentary patients who were beginning a weight loss programme. This group reported that the four greatest barriers to regular physical activity were:

1) Lack of time

2) Embarrassment at taking part in activity 3) Inability to exercise vigorously

4) Lack of enjoyment of exercise.

Because a lack of time is consistently reported as the greatest obstacle to being active, many authorities in this field are now recommending lifestyle activity and the accumulation of 30 minutes or more of moderate intensity physical activity on most (preferably all) days of the week. This message is obviously that of the American College of Sports Medicine, the Centres for Disease Control and Prevention, the National Institute of Health and the US Surgeon General. Indeed, it is the message of our own Health Education Authority.

According to Andersen, the concept of lifestyle activity encourages patients to look for everyday opportunities to increase energy expenditure. Patients are encouraged to work short bouts of activity into their daily routines which may fit more easily into busy schedules. In essence, any physical activity counts (gardening, climbing stairs wherever possible, walking, etc.) The effectiveness of such lifestyle activity interventions has been discussed in detail in a previous Research Update (FitPro, April/May 1999). Practically, Andersen recommends a Daily Physical Activity Log in which patients record the number of minutes of physical activity, plus any relevant comments.

It is noteworthy that Andersen sees lifestyle activity as a potential gateway to more traditional exercise programmes. As ever, when writing the exercise prescription, Andersen emphasises the importance of assessing the individuals exercise history, current health and fitness status and exercise enjoyment. This helps ensure that any programme is tailored to fit the individual and therefore more likely to be successful.

Overcoming Exercise Barriers in Older Adults

On a different but related theme, Drs Dunlap and Barry have reviewed and commented upon the barriers to exercise that older adults may face (Overcoming exercise barriers in older adults, The Physician & Sportsmedicine, Vol. 27, No. 11, October 15 (Special Issue), pp 69 75), 1999).

Some of the barriers reported are familiar. They include; lack of time, exercise discomfort, fear of injury, inertia, isolation and misconception regarding exercise and physical activity. However, whilst they might be recognisable, they may well be more substantial to the older individual. For example, a fear of injury and potential loss of functional independence is a considerable barrier to an older person who may have friends who have fallen and broken a hip.

Dunlap and Barry provide a list of ten counselling guidelines. Briefly these are:

1. Frame the teaching to match the individuals perceptions

2. Help the individual set goals

3. Inform them of the expected benefits and the time to achieve them

4. Suggest small changes rather than large ones

5. Provide specific, informative instructions

6. Keep in mind that adding new behaviours is sometimes easier than eliminating established behaviours

7. Link new behaviours to old behaviours

8. Use the power of your profession

9. Get specific commitments

10. Use a combination of strategies

The authors also review the familiar stages of change model and the strategies that may be deployed at each stage. Most interestingly, they provide a table of strategies to overcome objections to exercise.

Finally, Dunlap and Barry note that long-term compliance is the desired goal. Key exercise programme characteristics that are associated with long-term compliance are listed as:

1. Low probability of injury

2. Group participation

3. Emphasis on variety and fun

4. Use of personal goals and contracts

5. Assessment of training response

6. Support network

7. Monitoring of progress

8. Use of music

9. Positive feedback

10. Enthusiastic leadership and role models.