If You're Recommending Exercise As Medicine...

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As research has repeatedly shown that movement (aka exercise, cardiorespiratory fitness, physical activity) can have health benefits, there has been a push to treat movement as medicine. There can be a number of issues with this that must be dealt with if this concept is to be applied ethically by healthcare practitioners and other health and fitness professionals.

As always, a reminder that “health” and “healthy habits” (including movement) are amorphous and multi-factorial concepts, are not an obligation or barometer of worthiness, and are not entirely within our control.

Understanding that, here are some things to consider before utilizing movement as medicine:

Beware of false assumptions

Full disclosure: I am someone who has a lot of privilege in this area, including receiving “good fatty” privilege (better treatment from those who believe that fat people who participate in “healthy behaviors” by whatever definition are better/deserve better treatment than fat people who don’t.) I want to state in the clearest terms: that is absolutely wrong and should not happen. Participation in fitness is a personal choice that is impacted by privilege and access and does not make those who participate better, or deserving of better treatment, than those who do not participate, regardless of the reasons.

For those who have always enjoyed fitness and/or always felt welcome in fitness spaces, it can be difficult to conceptualize that others don’t/can’t have those experiences. Someone who started running and found that they loved it can make the mistake of assuming that everyone who tries running will love it (perhaps if they just keep trying…) Someone who feels comfortable walking into a gym may make the mistake of thinking that everyone can do that.

This can lead to the dismissal of patient experiences, which can be made worse if the provider is also operating out of extrinsic or intrinsic weight stigma, racism, homophobia, transphobia et al.

If a healthcare provider is operating from erroneous assumptions and/or a place of privilege, then they can easily harm their patients with inappropriate discussions around movement.

Language

Language can be important here because of the ways that it can re-engage past harm. I use “movement” throughout since both “exercise” and “fitness” are often used in contexts that are harmful in multiple ways, including as part of diet culture and weight stigma.

Also, beware of ableist language. For example, messages like “sitting is the new smoking” can stigmatize wheelchair users (and is, at the very least, a questionable comparison but that’s a topic for another day.)

Always use language that is blame-free, shame-free, and future-oriented.

Weight Neutrality

One important thing to understand is that movement has been shown to improve health without a change in body size. Often fat people are misinformed (often by health professionals who have also been misinformed,) that exercise causes weight loss and that weight loss is what improves health, so care should be taken to clear up this misconception. Weight loss fails the vast majority of the time, and the notion that small amounts of weight loss improve health is not supported by the research.  If movement is being prescribed as medicine, it should be prescribed as a weight-neutral intervention.

In the same vein, it should be prescribed with equity across body sizes. Don’t assume that fat patients aren’t already involved in movement, don’t assume that thin patients are. Don’t prescribe medication to thin patients but movement to fat patients with the same symptoms/diagnoses.

Contraindications

One thing I’ve seen repeatedly is the suggestion that movement should be prescribed to all patients. In fact, movement is not an appropriate recommendation for all patients for a number of reasons.

There are people with chronic pain issues, health issues, injuries, and disabilities for whom movement can be contraindicated, or only specific recommendations are appropriate (which may be out of scope for a given provider.)

Many people, of all sizes, have faced significant harm and trauma around the concept of exercise. They may have had messy breakups with exercise due to everything from mistreatment at the hands of physical education teachers and coaches, to experiences of weight stigma, racism, homophobia, transphobia and more at any time, and possibly many times, throughout their lives. This kind of harm and trauma can be belittled or shrugged off, especially by people who have not experienced it. That is a mistake that ends up re-harming/re-traumatizing the patient, so please don’t make it.

Many people have relationships with movement that have become disordered due to their repeated exposure to diet culture and/or because of eating disorders, contraindicating a prescription of movement, or at least without assured access to appropriate support.

Practice medicine, not stereotypes. And allow the patient/client the option to consent to the discussion. Don’t assume that patients are, or are not, involved in movement. Before recommending it, ask patients if they are already involved. Consider saying something like “there are a lot of options for [supporting your health/managing this health issue] one of them is through physical movement, is that something you’d like to discuss?” And then respect their answer.

Treat it like a medication

Movement as “medicine” can often be confusing since movement can both help support general health, and assist with various health issues. Make sure that you are clear in your explanation of this to your patients. If you are offering movement as one of the many options to support general health (which should also include things like rest and social connection, and a clear discussion about social determinants of health and ways that health is not entirely within our control) then make sure that is understood. If you are suggesting it as an intervention for a specific health issue (for example, high blood pressure or blood sugar management) be clear about that, and the fact that people’s bodies react differently and so this is something to try, and if it doesn’t provide the hoped-for benefit, that’s not the patient’s fault.  

If movement is being prescribed/used as one might prescribe/use a medication, it should be treated like other medications. So, for example, you can offer movement as a possible option for blood sugar management, but be clear that it’s only one of the options that are available. Inform the patient that the choice of which intervention to use (whether it’s movement and/or a medication or something else) isn’t a moral one, and (even beyond the contraindications from above) movement isn’t the right choice for everyone.  

For example, imagine a single mother, working two jobs and caring for her children, who is experiencing high blood sugar. She may know that it is much more likely that she can consistently take a medication than that she can consistently work out. But if she has the sense that choosing movement over medication makes her a better person, or that if she chooses medication she will disappoint her healthcare provider, she may choose movement to the detriment of her health.

Explain to patients that the goal should be, for example, blood sugar management, in the way that works best for the patient whether that’s movement, medication, or something else.

Dosage

The CDC guidelines are 150 minutes of moderate movement or 75 minutes of vigorous movement, or an equivalent combination (as well as 2 strength training workouts per week.)

A recent study suggests that people who do more than that (two to four times more) had better health outcomes. I haven’t had a chance to do a deep dive but, glaringly to me, they do not appear to have controlled for all the variables (socioeconomic and otherwise) that would allow people to have that kind of time (300 to 599 minutes a week for moderate exercisers) to engage in “leisure time physical activity.”

Often people, even healthcare providers and fitness professionals, mistakenly believe that amounts less than that don’t have benefits, or that it has to be done in significant amounts of time (for example, at least 30-minute sessions.)

First, even if someone is aiming for the CDC guidelines, their movement doesn’t need to be done all at once each day, it can be broken down into increments of five minutes and still deliver benefits.

Also, even if a shared decision-making process leads to the client having goals based on these guidelines, depending on the patient’s situation it may be prudent to suggest that they start out at far less than that and then build up over time.

Beyond that, research has shown that health benefits can be achieved at amounts far less than the CDC guidelines. (A reminder that if studies come from a place of weight-bias or use biased language I do not provide links, but do provide enough information so that they can be googled.)

Matheson et. al. 2012 showed benefits with “leisure-time physical activities” more than twelve times per month.  

A study of those between 65 and 75 years old by Dr Babraj at Abertay University found that ten 6-second hard pedals on stationary bikes (with resting in between) done once a week improved glucose function and mobility.

Hupin’s study of older people found that “15 minutes of light activity” per day could reduce mortality.

A study showed that people performed at ten minute workout three times a week on a stationary bike consisting of a two-minute warmup on the bike; 20-second high-intensity pedaling; two-minute moderate-intensity recovery; 20-second high-intensity pedaling; two-minute moderate-intensity recovery; 20-second high-intensity pedaling; and three-minute cool-down on the bike had similar health benefits to cis men who did three 45 minute moderate intensity rides a week.

Other studies have shown that between 20 and 60 minutes of moderate movement one or two times a week can provide health benefits.

As an example of health management, some people find that five minutes of movement after a meal can help even out post-meal blood sugar spikes.

So in general, and especially if you are just recommending movement as a health-supporting behavior, let patients know that small amounts of movement have benefits.  

The Treatment

One of the main differences between medications and movement is that meds are a specific pill, liquid, etc, while movement comes with a lot of options. The pillars of movement are strength, stamina, flexibility, mind/body work, and technique.

When the CDC talks about the 150/75 minutes of movement, they are talking about cardiovascular movement. This can include anything that can get someone’s heart rate up – which may be anything from dancing around their space, to gardening, to structured fitness classes etc.

There are a couple of seriously harmful mistakes that healthcare practitioners often make around these recommendations. The first is recommending walking to all patients, there is a full piece here that explains the issues with this. The other is a blanket recommendation of “joyful movement.” This piece goes into an explanation of the issues with this.

Helping people choose the movement that is right for their needs/goals/situations may be out of your scope, at which point you would want to refer to a weight-neutral fitness professional. This fitness finder is a place to start looking.

Side Effects

I’ve heard people say that movement is preferable to medication because movement has “no side effects.” That’s not actually true. Side effects can include:

Loss of time:
Taking medication takes a minute, movement requires a greater time investment, especially if someone has to travel to and from their workout.

Loss of money:
If someone has access to insurance, medication may be covered, but their preferred movement option is likely not. (This is where the people pushing movement often suggest that someone should just do a type of movement that they don’t enjoy but, remember, this is a shared decision-making process and if the patient feels that this side effect is worse than the possible side-effects of medication or other interventions that is a valid choice.)

Discomfort/Pain:
Whether due to trauma or other factors, many people (of all sizes) find movement physically and or psychologically uncomfortable. Whether it’s the feeling of sweating during the workout, or soreness afterward. Others have conditions that mean that movement creates or exacerbates pain, either during or after.

Stigma/Harassment/Oppression:
Fat people risk experiencing weight stigma any time they go out in public. I can tell you that, in my experience, the worst harassment I’ve experienced has been when I’ve been participating in fitness activities. Racism is a constant threat that was drawn into sharp relief by the murder of Ahmaud Arbery. When I interviewed Martinus Evans for my series in US News and World Report, he talked about how, as a Black man, he was stopped by police for “looking suspicious” while he was simply running in running clothes. Trans and nonbinary people can face stigma including laws and policies that prevent them from having access to basic facilities like bathrooms and locker rooms. For these reasons and many more someone might choose not to participate in movement, and that’s a valid choice and one they get to make for themselves.

Efficacy/Expectations

Be sure to explain to patients that all bodies work differently, and so movement might not give them the hoped-for benefits. Be clear, from the beginning, that if that’s what happens, it’s not a failure - it’s just helpful information and once you have a sense of whether movement is creating the benefits desired, you can work with them to decide if they want to continue with movement and/or try something else.

Also, note that some people find that consistent movement isn’t something that works for them for any number of reasons, and that there’s no shame or failure in trying it and deciding that it’s not the right intervention for you. Emphasize that the goal is supporting their health, so if movement isn’t the right medicine, you’ll be happy to discuss other options for them.

Even if you’re thinking of movement as “medicine,” it’s definitely not the right prescription for every patient.

Want more support around this? My workshop for this month is “Getting Jiggly With It - Movement in a Fat Body” It’s open to people of all sizes as well as health and fitness pros. Fat experiences will be centered. There is a pay-what-you-can-afford option so money isn’t a barrier. Get details and register here!

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.