Taking the "Ex" Out of Exercise
Motivation tactics should be part of every exercise prescription.
By Gary Scheiner, CDE

Instilling and maintaining behavior change is rarely easy. If in doubt, think about your last three or four New Year's resolutions. How many are you still keeping? (A quick look at your office desk should negate the "be neat and organized" resolution!)

From a clinical standpoint, engaging in regular physical activity is desirable for virtually everyone with diabetes. Physical activity improves insulin sensitivity, helps to control weight, reduces cardiovascular risks, and brings a number of mental health gains. For those just starting a physical activity program, however, it usually takes a month or more for those new behaviors to become ingrained in a person's lifestyle. How, then, are we to motivate our clients to start exercising and maintain the increased activity long enough for it to take root?

Even though true motivation comes from within, there are many tactics that we as health care providers can employ to increase the odds that our clients will begin and maintain a physical activity program. For our purposes, motivational tactics for exercise come in three categories: (1) information, (2) inspiration, and (3) implementation.

MOTIVATION THROUGH INFORMATION
According to Richard Weil, MEd, CDE, an exercise physiologist and Director of the Weight Loss Program at the New York Obesity Research at St. Luke's Hospital, New York, NY, one of the keys to motivation is the belief that a behavior will help to achieve a desired outcome. In other words, "Will it help me?" Simply prescribing exercise or telling someone that they should exercise is not enough. Explain why, explore the barriers to change É and then collaborate with the individual on designing a plan that is realistic.

If the patient is interested in reducing or avoiding medication for diabetes, blood pressure, or cholesterol, then structure the plan realistically with the patient to increase his or her aerobic activity to three to five times per week for 20 to 30 minutes. If weight loss is the goal, then explain that exercise will help keep the weight off and burn extra calories, but that attention to calorie intake is also important. If improvement in daily function is the goal, especially in elderly patients, then balance and strength training exercises 4 to 5 days a week will help.

Remember, increasing physical activity takes effort, so make certain your patients know exactly how much they stand to gain.

MOTIVATION THROUGH INSPIRATION
You? An inspiration? That's right. Your patients look up to you and respect what you have to say. Use your well-earned position to its full advantage:

• Lend encouragement by following up your recommendations with a letter, phone call, or e-mail.
• Create a "wall of fame" in your office, honoring those who have successfully increased their physical activity.
• Incentivize your patients with token rewards such as pedometers, t-shirts, and squeeze bottles.
• Organize a network of your patients who are working on increasing their physical activity. Peer support can be a powerful thing. If possible, pair up patients with similar backgrounds and needs, or provide weekly or monthly support in a group format (online or in person).
• Challenge each individual to a long-term goal such as walking a certain number of miles, participating in a local event, or engaging in a certain number of workouts. Allow your patients to call, fax or e-mail their workouts, and use stickers to track each person's progress.
• Lead by example—be active yourself! Share your personal fitness experiences, successes as well as failures, and how you overcame them.

MOTIVATION THROUGH IMPLEMENTATION
Even the best intentions will go to waste without a good plan. Planning will help to overcome initial obstacles and avoid many of the common pitfalls that keep people from maintaining their workout routine.

Develop a specific plan or exercise prescription. Vague recommendations are followed less often than a structured plan. For example, telling someone to "walk more" is less effective than instructing them to "walk for 30 minutes at a moderate pace after breakfast five days per week." The more structure you can build into the plan, the better. For example, taking a regularly scheduled fitness class at a local YMCA, community center, or health club is often better for long-term compliance than working out at home. Provide specific recommendations regarding (1) activity type, (2) frequency, (3) duration, (4) timing in relation to meals, (5) intensity, (6) progression, (7) adjustments to insulin/oral hypoglycemic agents, and (8) motivational strategies.

Create responsibility. Some people are more interested in doing things for others than they are in helping themselves. For these folks, a dog (to walk), a house/yard (to tend to), a child/children (to care for), or seeking out an active job may be the answer.

Accomplish two things at once. For those with limited time, look for ways to make productive use of the workout time. Stationary exercise equipment allows for reading, TV watching, net surfing, or listening to music while exercising. People can also talk on the phone, spend time with friends/family/business associates, or just enjoy some solitude while they work out. For those with erratic schedules, carving out workout times in a calendar (written or electronic) at the beginning of each week helps ensure that other activities won't get in the way.

Start out easy. Making someone sore and exhausted will not motivate him or her to continue. Pain is also discouraging. For those who are new to exercise, it doesn't take much to get the heart rate up. It is fine to start out with short, easy bouts of activity, but provide a progression plan (such as adding a minute each day) so that the activity eventually morphs into a more beneficial exercise session.

Make it fun. Don't just assume that everyone likes to walk, bike, or swim. Ask people what they like to do, or what they used to like to do. Even if you can't match their preference exactly due to physical or access limitations, find something similar, or start moving them in the direction of their favorite activities.

Manage the medications. Fear/risk of hypoglycemia keeps many people from enjoying physical exercise. Give your clients specific advice on how to prevent hypoglycemia during and after exercise through adjustments to insulin/medication and, if necessary, extra snacks.

Keep the routine from getting routine. Variety in a workout program provides for greater enjoyment, better-rounded fitness, and less risk for overuse injuries. Two or three different types of activities performed on a rotating basis are ideal for most people. Try to include indoor as well as outdoor activities to accommodate for climate and weather conditions.

Gary Scheiner, CDE, is also an exercise physiologist with a private practice near Philadelphia. He is a member of the Review of Endocrinology Editorial Board. He and his staff provide diabetes self-management education and blood glucose control consulting for individuals worldwide through his Web site www.integrateddiabetes.com and toll-free hotline 877-735-3648.