In Brief Given that a physically active lifestyle is important to health and quality of life, health care professionals are faced with the challenge of guiding individuals as they attempt to increase their level of physical activity. To provide some insight into this challenge, several lifestyle interventionists (many of whom were part of the Diabetes Prevention Program) have shared stories of participants and patients whom they have encountered through the years. This collection of “fishing tips”is meant to help in the challenge of hooking an active, healthy lifestyle.
Diabetes and the Fishing Expedition
Over the past few years, encouraging findings of several efforts in diabetes prevention have been released.1–4 Lifestyle programs composed of diet, physical activity, and weight loss have been shown to be an effective strategy to prevent type 2 diabetes.5,6 Most importantly, this decrease in diabetes development was found in all age and ethnic groups and in both men and women, as suggested by the findings of the Diabetes Prevention Program.1
The benefits of a physically active lifestyle certainly do not stop at diabetes prevention. It has been well established that a cascade of health benefits can accompany an increase in physical activity, including reduction in body weight and fat mass, improvement in cholesterol, improvement in insulin sensitivity and glycemic control, and improvement in the function of the heart and cardiovascular system. (Readers are referred to the Handbook of Exercise in Diabetes7 and the American College of Sports Medicine [ACSM] exercise and diabetes position statement8 for more information on diabetes and exercise.) Regular physical activity is likely also beneficial for the treatment of individuals with type 2 diabetes.
Yet the benefits of an active lifestyle go far beyond diabetes. There is mounting evidence of the health benefits of physical activity, some of which were documented in the 1996 U.S. Surgeon General's Report on Physical Activity and Health.9
Despite the multitude of health and social benefits that can be gained by achieving and maintaining a physically active lifestyle, a substantial number of individuals with or at risk of developing diabetes continue to lead a sedentary lifestyle.9 These individuals remain inactive despite the fact that they are likely aware of the benefits of an active lifestyle. National surveys of physical activity indicate that > 25% of U.S. adults do not engage in any leisure-time physical activity and that this level of inactivity is higher among individuals with diabetes.10
In an attempt to address the critical problem of sedentary lifestyle throughout the nation, the Centers for Disease Control and Prevention and the ACSM joined forces in 1993 to review the pertinent scientific evidence and to develop a clear, concise public health message regarding physical activity. One of the important concerns identified at this meeting was the public misconception that health benefits from physical activity could only be gained through vigorous, continuous exercise.
The outcome of this meeting was a major revamping of the national public health recommendations for physical activity.11 The old exercise prescription was a structured series of criteria designed for athletes. Exercise then meant high-intensity activity and was associated with gyms, exercise equipment, and sweat. This type of exercise was also relatively costly, thereby limiting participation to those who could afford it. The old exercise prescription was also inflexible in terms of time demands, involving exercise routines that required large blocks of time each week.
In contrast, physical activity as defined by the new set of recommendations can be more easily incorporated into the daily routines of all individuals,regardless of their income or other individual factors. The major thrust of these recommendations is to encourage sedentary individuals of all ages,races, and ethnic backgrounds to increase their levels of moderate, feasible physical activity, such as walking for 20–30 minutes over the course of the day on most days of the week. Few individuals have large blocks of free time, but many are able to accumulate 20–30 minutes of activity by doing several short activity bouts.
In the children's book Swimmy by Leo Lionni, a large fish chases and eats some of the little fish, forcing those that survive the attack to stay inside their homes. Then one day, the little fish gather together, form the shape of the large predator fish, and collectively chase the enemy away. Interestingly, physical activity intervention over the years has followed a similar storyline. Health and exercise professionals used to insist that everyone had to exercise at a certain intensity for a certain amount of time. This “whale” of an exercise prescription scared most people away. As with any prescription, individuals had to follow it religiously or else the effort “didn't count.” But today, we are recommending that individuals focus on the “fish” rather than “whale.”The “fish” in this analogy would include activities such as taking a small walk at lunchtime or walking after dinner with your family. By the end of the week, individuals accumulating many smaller bouts of activity, or“fish,” will have gathered a “whale” worth of exercise.
The flexibility in the type of physical activity now recommended is much more realistic for currently inactive people. In fact, these new recommendations were specifically designed for the currently sedentary. They say, in essence, for those who are sedentary, the time to move is now. And for those who are already active, keep up the good work.
The purpose of revamping the physical activity public health message was to make exercise more approachable and doable for the masses. But can this level of physical activity also make a difference in regards to the health of the masses? Based on the results of several landmark clinical trials of type 2 diabetes prevention, the answer is yes.FIG1
The Diabetes Prevention Program (DPP) was a clinical trial of diabetes prevention involving 3,234 overweight individuals aged 25–85 years with impaired glucose tolerance, a condition that often precedes diabetes. Of the participants enrolled in the DPP, 45% were from minority groups that suffer disproportionately from type 2 diabetes, including African Americans, Hispanic Americans, Asian Americans, Pacific Islanders, and American Indians.12 One of the treatments tested in this trial was a lifestyle modification program composed of nutrition and physical activity guidance. Participants who were part of the lifestyle intervention arm were asked to reduce their weight by 7%through a low-fat diet and to achieve 150 minutes/week of moderately intense physical activity similar to brisk walking. This activity goal was achieved by the majority of the DPP participants throughout the course of the program. Most importantly, the DPP demonstrated a significant decrease in the progression to type 2 diabetes in the lifestyle intervention group and was effective in both men and women of all ages and across all ethnic and racial groups.13
This physical activity goal was similar to the new public health recommendations.9 The DPP exercise goal was also remarkably similar to that prescribed in several other recent clinical trials in type 2 diabetes.2–4 Interestingly, all of these studies demonstrated a significant decrease in the development of type 2 diabetes in the lifestyle intervention groups that included physical activity, suggesting that this prescribed level of activity(150–210 minutes/week of moderate-intensity activity) was sufficient to prevent diabetes or to effect weight loss, which in turn prevented diabetes.5,6
Importantly, most participants were able to achieve the activity goal of the DPP. The activity program was, in general, appropriate, flexible, and realistic enough for each participant to become a winner. Given a minimum requirement of 150–175 minutes/week of moderate-intensity activity,exactly how to do it, where to do it, when to do it, and with whom to do it remains entirely up to the individual.
There are only two requirements. One is that it be done. The other requirement is that it continues to be done. It is important to remember that the benefits of a physically active lifestyle last as long as the physical activity does. A dentist friend, Gary, once said when asked about the necessity of flossing teeth, “You do not have to floss all of your teeth, just the teeth you want to keep.” In a way, the situation with physical activity is like that: just move the muscles you want to keep.
Given that activity is so important to health and quality of life, the next question becomes, how do we help guide individuals as they attempt to increase their levels of physical activity? To provide some insight into how individuals were able to achieve or maintain a physically active lifestyle,several lifestyle interventionists (many of whom were part of the Diabetes Prevention Program) were polled. They were asked to share any information they had regarding one or more of the following three key questions about their participants:
What benefits have your participants mentioned they have gained by becoming more active?
Can you tell us of any insightful or unique ways that your participants have found to increase the amount of physical activity they get in their day?
What creative methods have your participants found to overcome barriers to becoming more active?
Described below are the responses to these questions, provided by lifestyle coaches about participants and patients whom they have encountered through the years. The lifestyle interventions wisely included diet and activity for the purpose of both weight loss and fitness gain. Therefore, please keep in mind that the benefits mentioned are not specific to increases in physical activity alone.
Benefits: What good can come from “fishing”?
In addition to reports of improved fitness and lower body weight, some participants noted fewer hospital or doctor visits since adopting a healthy lifestyle. Other important health benefits mentioned included being able to decrease or discontinue medications (under their physician's guidance),especially those related to blood pressure, cholesterol, or diabetes treatment. Several participants reported being able to sleep better and attributed this, in part, to the weight loss and increased physical activity.
Many participants described having more energy and improved physical condition, which allowed them to keep up with the fast pace of daily life more effectively. They appeared better able to meet the challenges of getting through a busy day. “I can do things now that I could not do before” was a frequent response that included a range of accomplishments from being able to tie their own shoes to finally being able to keep up with their spouse, friends, or grandchildren. A lifestyle coach noted that“one participant recounted a time in the past when a visit to his brother required an hour-long effort to climb the single flight of stairs to a second floor apartment. He said he used to get tired walking 100 feet over flat ground to get to the gym. Now he can walk up three flights of stairs with moderate effort.” This example also supports the notion of the need to take care of oneself in order to take care of others. And it suggests that the time individuals spend participating in activity to become more fit sometimes pays off in time saved when they can tackle other tasks more quickly or efficiently.
One less mentioned benefit of an active lifestyle is the fact that, while striving to improve health and physical condition, individuals also serve as role models to others. One lifestyle coach noted, “One of the striking characteristics of one of my participants was her ability to influence others to take action toward a healthier lifestyle.” In a way, it is like a healthy virus, spreading across an individual's personal health, family,career, and community and improving quality of life for all who come into its path.
Motivation: Creative ways to catch fish
One unique story involved a participant who had built an unusual reenforcement into her daily walk to help her sustain this healthy routine.“This participant walks very early in the morning and covers the same unusual route,” the respondent noted. “She makes it a point to walk around the area of the drive-throughs of local fast-food restaurants and to search for money that may have fallen. You see, people sometimes drop some of their change as it's handed to them, and it falls to the ground. For a nickel or dime, some people won't bother to get out of the car to retrieve it. This participant, early in the morning, picks up the leftover change on the ground from all those drive-through orders. Talk about the early bird getting the worm! She now has a group of lady friends that have begun walking and“collecting” with her. Throughout the year, they gather their treasures and donate the pot of money at the end of the year to a charitable organization. They donate in excess of $100 every year thanks to their walks and their sharp eyes. It's a win-win situation: the women improve their health, and the charities improve their pocketbooks.”
Some people have found ways to build activity into their day as a way to get to where they need to go while saving money in the meantime. Where possible, walking or biking part or all of the way to work can replace taking the bus or family car and results in a solid activity program nicely built into the work day. Including a friend or colleague makes it more fun. Money saved on bus fare or gasoline can be used to buy something special as a reward.
Not all stories are generalizable to the majority of people, but they do serve as a reminder that individuals need to do what they can to help themselves maintain an active lifestyle. One participant sought an active job.“She was having trouble finding time for activity due to intense family responsibilities with kids, spouse, and caring for her ill mother,” the respondent said. “For financial reasons, she needed to find a part time job. She chose an active job that required a lot of walking—working at a hospital doing valet parking. She wore her pedometer and was thrilled with the number of steps she got walking between the hospital and the parking lot throughout the course of the day. She also packed healthy meals to take to work so that she was not forced to purchase food at a fast-food joint.”
Some people have managed to tie physical activity with their daily religious activities. One participant does her 45-minute prayers each morning while walking on the treadmill. A second goes on “rosary walks”around the neighborhood on a regular basis, with the walk continuing until the rosary prayers are completed. Talk about a double blessing.
Barriers: Handling sharks that could get in the way
When challenged, it is often our nature as human beings to get discouraged and “throw in the towel.” Typical examples of barriers or obstacles (the “sharks”) to participating in physical activity include but are not limited to:
illness and other physical limitations (whether permanent or temporary)
lack of time
demands from family, friends, or the job
lack of motivation
The challenge to individuals seeking a more active lifestyle is to refuse to let these obstacles permanently stop them. For most barriers, there are ways to get past them. These are found through trial, error, and perseverance. In some cases, we cannot get over them and must instead get around them. Below are some examples of these barriers (“sharks”) and the ways participants have found to get over or around them.
The number-one barrier to exercise for most people is lack of time. Building activity into the day in clever ways is one way over this obstacle.“I could not find anyone to baby-sit my children, so now they walk with me each night as a family event” is one way to address both commitment to family and the need to keep active. Including family in daily physical activity is the perfect way to kill two birds with one very healthy stone.
In matters of illness and physical limitations, individuals often must change the types of physical activities they participate in temporarily or sometimes permanently. One lifestyle coach said, “An elderly participant broke her foot and changed her treadmill walking program to one that was composed of sitting exercises. Although it took her foot several months to heal, she maintained her activity routine throughout this time. Now that she is fully ambulatory, she exercises to videotapes, since her treadmill broke down.” From broken foot to broken treadmill, this participant kept modifying her activity program to keep it working for her.
Many sedentary adults grew up as sedentary kids and have a negative attitude towards activity. Their vision of fishing is one of a body of water filled with sharks and whales. They have little hope of catching any fish and no plans to try. “This participant was extremely skeptical of her ability to ever become more active,” a respondent said. “The most active she ever remembers being was as a youth playing hopscotch and jump-rope. She recalls growing up in a family with an overprotective and watchful mother who hovered over her, resulting in her remaining quite sedentary. Her only real programmed physical activity was during one time in her life when, as a young woman, she lost a lot of weight and attended aerobics classes regularly. Once she regained all of her weight back, she was reluctant to return to high-impact classes. She later developed severe osteoarthritis in both knees.”
So how did her lifestyle coach help her to see the fish through this image of a whale? “This participant was encouraged to begin very slowly with a walking program. The initial program was a brief walk across a bridge and back during her lunch break at work. She added a minute or two to her routine each day. Although she was walking extremely slowly, this participant started to feel twinges of discomfort in her body, and that scared her. Her lifestyle coach suggested that this “shark” may just be a sign that her body was working and urged her to just continue her activity at the same level. Much to the participant's surprise, she felt better with the continued physical activity, not worse. She progressed with this activity and expressed a great deal of satisfaction when she was able to walk across the bridge and back several times per week at lunch.” The whale no longer scared her once she was taught to fish in waters she could handle.
One of the best fishing stories, however, involves a statistician who was involved with the Diabetes Prevention Program at the study coordinating center. She was responsible for analyzing the data and was therefore the first to see the benefits of the lifestyle intervention of the study. As a result of what she saw, she changed her own lifestyle, became active, and lost weight.“My resolve has remained, mostly due to the improvement I feel in my everyday life,” she noted. “I have more energy, I sleep fewer hours, I can keep up with my children and my hectic lifestyle, and I can fit into all of my clothes now. I work at it every day, I never take it for granted, but it's been worth it.”
Another successful fishing story. Isn't it time we all cast out our lines?
Andrea Kriska, PhD, is an associate professor in the Department of Epidemiology at the Graduate School of Public Health; Amy Otto, PhD, RD, LDN,is a research assistant professor and the assistant director of the Physical Activity and Weight Management Research Center; Kelley Pettee, MS, is a doctoral student in the Epidemiology Department; Linda Nelson Semler, MS, RD,LDN, is a dietitian in both the Diabetes Prevention Program Outcomes Study(DPPOS) and the Physical Activity and Weight Management Research Center;Elizabeth M. Venditti, PhD, is an assistant professor of psychiatry and director of the Lifestyle Resource Core DPPOS; and Donna Wolf, MS, is an exercise physiologist in the Department of Medicine, Division of Endocrinology/Metabolism, all at the University of Pittsburgh in Pittsburgh,Pa. Linda Delahanty, MS, RD, is chief dietitian and director of nutrition and behavioral research at Massachusetts General Hospital Diabetes Center in Boston. Mary Hoskin, MS, is the DPPOS program coordinator for the Arizona sites of the Southwest American Indian Center at the National Institute of Diabetes and Digestive and Kidney Diseases/Phoenix Epidemiology and Clinical Research Branch in Phoenix. Margie Matulik, RN, is the program coordinator for the DPPOS at the University of Chicago. Connie Pepe, MS, RD, LDN, is a case manager in the DPPOS in the Department of Medicine, Division of Endocrinology at Thomas Jefferson University in Philadelphia, Pa. Jeremy Pomeroy, MS, RCEP,is director of a diabetes primary prevention demonstration project at Gila River Healthcare Corporation in Sacaton, Ariz. Lisa Testaverde, MS, is a program coordinator at the University of Colorado at Denver Health Sciences Center.
The authors would like to acknowledge all those participants who have not given up trying to catch fish, no matter how murky the waters get. We would also like to acknowledge Donna Miller for her amazing whale creation.