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Exercise referral: giving patients the right advice

Heidi Waters
BA (Hons) PG Dip
Weight Management Services Manager
City Health Care Partnership

In this article, Heidi Waters explores an effective intervention for helping overweight, inactive patients to adopt healthier lifestyles, and offers practice nurses some practical tips to promote physical activity.

The benefits of an active lifestyle on physical and mental health are well documented. For adults, achieving 30 minutes of moderate-intensity physical activity at least five days a week helps prevent and manage over 20 chronic conditions, including coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal conditions. There is a clear link between physical activity and chronic disease.

The strength of the relationship between physical activity and health outcomes persists across the life course, and highlights the potential health gains that can be achieved if individuals are supported to become more active.1

Inactive lifestyles in England are twice as prevalent as smoking, hypertension or high cholesterol. Evidence shows that the health impact of inactivity in terms of coronary heart disease, for example, is comparable to that of smoking, and almost as great as that of high cholesterol levels. However, despite the multiple health gains associated with a physically active lifestyle, only 40% of adult men and 28% of adult women do sufficient activity to benefit their health. That equates to 27 million adults in England alone not doing enough.2

Most people know that physical activity is good for them, but many don't have the motivation to change their lifestyle, or know where to start. Approximately 25% of people would become more active if they were advised to do so by their doctor or nurse; and with three out of four people visiting their GP surgery each year, practice nurses in primary care are well placed to raise the issue of an active lifestyle with
their patients.3

Promoting physical activity
Exercise referral (also known as exercise on prescription) usually involves a GP or practice nurse referring a patient to a short-term exercise programme in a local gym or leisure centre. Significant improvements in patients' wellbeing have been observed as they learn to enjoy the structure of a gym programme or the routine of regularly attending their preferred exercise class.4 However, this is usually limited to the patients who are motivated and have the confidence to turn up in the first place. For the most inactive, unfit, older and overweight individuals, this sort of exercise regimen is perceived (by themselves) as being unsuitable. Therefore, they may drop out during or after the scheme finishes, and some never turn up in the first place.5

According to experts, greater emphasis needs to be placed on the promotion of moderate-intensity physical activity, such as walking, cycling, taking the stairs, and not being dependent on leisure-based facilities. The use of goal-setting, self-monitoring, and being offered regular, ongoing contact with a physical activity advisor is also important for exercise adherence.4

The traditional "exercise on prescription" model was popular in Kingston-upon-Hull 10 years ago. GPs and practice nurses could refer their inactive patients onto a number of different exercise schemes, such as organised walking groups, exercise classes, or gyms. Each scheme had its own paperwork and referral forms to complete, and many practice nurses didn't have the time to spend discussing each programme that was on offer to the patients. Some also didn't feel that they were the right specialists to be giving out specific physical activity advice. They suggested that a more streamlined approach (where they could refer all their patients in need and wanting physical activity advice) would be the best way forward.

In 2003, Hull Primary Care Trust commissioned a new physical activity service called Active Lifestyles to operate as the umbrella service for all the different exercise referral schemes in the city. Still in operation today, practice nurses and GPs can refer their patients (aged >12) who want to develop lifelong healthier lifestyles and lose weight by becoming more physically active. Specifically designed for those needing
motivational support for behaviour change, sedentary patients with a range of physical and (low-to-moderate) mental health needs are supported by Active Lifestyles Advisors (ALAs).

All the ALAs working for the service have a background in physical activity and health, and are trained in motivational interviewing. This technique has been found to be increasingly effective for supporting patients to change lifestyle behaviour, as it helps them to explore and resolve any ambivalence they may have. It selectively elicits and reinforces the patient's own arguments and motivations to change, rather than imposing reasons for change upon them.6

How the Active Lifestyles service benefits patients: case study
In January 2009, Jane had her 55th birthday. At the time she weighed 16 stones, and at 5'1" tall was classed as being clinically obese according to her body mass index (BMI) of 42. Ever since she could remember she had been unhappy with her weight and dieted on-and-off for most of her adult life, with limited success. She had never tried to lose weight through exercise as she had always felt embarrassed about her body. She also doubted her fitness level, as she used to get out of breath very easily when shopping or climbing a flight of stairs. The thought of exercising in public at a gym or swimming pool horrified her.

Jane knew friends who went to slimming groups and others who took diet pills, but was reluctant to buy into these interventions. She kept telling herself "I'll start exercising and my new diet on Monday". But the Mondays came and went, and by Wednesday she'd be thinking about starting again on Monday as she had eaten something she though she ought not to. She decided to book an appointment with her practice nurse because she wanted to do something about her weight soon, but didn't know what would be best for her. The nurse explained how the Active Lifestyles Service worked and said she would refer her (see Box 1). She agreed in principle to give it a go but was a bit sceptical having never enjoyed exercising in the past.

[[Box 1 referral]]

Within a week of being referred she received a letter asking her to call the Active Lifestyles service to arrange an appointment. She chose an appointment two weeks after that call and for the days leading up to the appointment felt really nervous about going. In fact, on the morning of the consultation she told her husband that she didn't want to go through with it. He persuaded her to attend as it was only around the corner in her local doctor's surgery, so she went.
There she met Wendy - her Active Lifestyles Advisor.

Jane's appointment lasted nearly an hour, during which she was encouraged to speak openly about her previous activity habits (or lack of them), about any potential barriers to exercise that she may face and about anything that she wanted to try out. Wendy went through a Physical Activity Readiness Questionnaire and some other forms (SF36v2) that asked her questions about her general wellbeing and suitability to begin being more active. She was weighed and blood pressure was measured, and towards the end of the consultation Wendy worked with Jane to set some short-term, realistic physical activity goals for Jane for the next few weeks.
These consisted of walking the dog three times a week for 20 minutes, doing the five-minute home workout poster twice a week and attending an exercise referral aqua aerobics class once a week.

She was assured that the aqua aerobics class would be suitable for her as it was a referral-only class at a low level with many other people who were also trying to lose weight. Wendy encouraged Jane to start that very Thursday as she knew the longer she left it, the less chance there was that she would start - Monday was too far away!

Three hours after her Active Lifestyles consultation Jane took her dog out for a walk. For the first time in a while she felt motivated and listened to. She didn't feel judged or embarrassed about talking about her weight, in fact she felt proud that she had began doing something about it and had the right support behind her.

After a few weeks, she got really into the aqua aerobics class and started going twice a week with her new class friends. Walking the dog became a habit and part of her routine; she would come in from work and before settling in front of the TV she would go out for the walk. She didn't weigh herself regularly as in the past this had led to feelings of shame and self-pity (and often binge eating) but she was noticing that her clothes were feeling a little slacker.

After seeing Wendy for six months Jane had lost over a stone in weight. She was taking every opportunity to be active and her self-confidence had increased enormously! On reflection, Jane felt that the secret to her successful change in lifestyle and weight loss was largely down to the support and encouragement of her ALA. She found it gratifying to speak with someone who listened to her, set realistic suitable targets and didn't judge her for being overweight.

Wendy provided the motivation and empowered Jane to get started and keep being active. The other positive knock-on effects of exercise led Jane to focus on a healthy eating plan and away from the yo-yo dieting that she became accustomed to. Jane doesn't "diet" now, but uses "The eatwell plate" as a guide to understand the types and proportions of foods she needs for a healthy and balanced diet.7

She never thought she was the type of person to enjoy exercise, but now doesn't view it as something gruelling and unpleasant, rather something that is part of her everyday lifestyle and makes her feel great!

[[pract point referral]]

1. Chief Medical Officer (CMO). At least five a week: Evidence on the impact of physical activity and its relationship to health. London: Department of Health; 2004.
2. Craig R, Mindell J. Health Survey for England 2006: CVD and risk factors adults, obesity and risk factors children. London: NHS Information Centre; 2008.
3. Department of Health. Let's Get Moving: Commissioning Guidance: A new physical activity care pathway for the NHS. London: DH; 2009.
4. Hillsdon M, Foster C, Cavill N, Crombie H, Naidoo B. The Effectiveness of Public Health Interventions for Increasing Physical Activity among Adults: A Review of Reviews. 2nd ed. London: Health Development Agency; 2005.
5. Riddoch C, Puig-Ribera A, Cooper A. Effectiveness of Physical Activity Promotion Schemes in Primary Care: A Review. London: Health Education Authority; 1998.
6. Martins RK, McNeil DW. Review of motivational Interviewing in promoting health behaviors. Clin Psychol Rev 2009;29(4):283-93.
7. Food Standards Agency. The Eatwell Plate. Available at:
8. Wormald H, Waters H, Sleap M, Ingle L. Participants' perceptions of a lifestyle approach to promoting physical activity: targeting deprived communities in Kingston-Upon-Hull. BMC Public Health 2006;6:202.