Exercise prescriptions

There is strong evidence that medical prescriptions for physical activity increase physical activity and improve physical fitness (Barrow 2019, Stoner 2019, Muller-Riemenschneider 2008, Senter 2013). Among adults with obesity, exercise prescriptions improve physical function, preserve muscle, support healthy weight loss, and may prevent osteoarthritis (Barrow 2019). Exercise prescriptions improve healthy weight loss and health outcomes among adolescents with obesity or higher weights (Stoner 2019). Prescriptions for physical activity, especially aerobic exercise and resistance training, have been shown to maintain mobility among older adults (Yeom 2009).

Exercise prescriptions increase the number of patients that meet recommended physical activity targets (Muller-Riemenschneider 2008). Exercise prescriptions combined with telephone counseling have been shown to increase physical activity and physical function, and improve mental health and health outcomes, especially for women who were previously physically inactive (Senter 2013). Prescriptions to walk 5-7 days/week can increase walking (Williams 2008). Brief interventions offered during visits with health care providers, such as exercise prescriptions, increase self-reported physical activity in the short-term (Lamming 2017).

Individually tailored exercise prescriptions are more effective than generic prescriptions (Maslov 2018, Muller-Riemenschneider 2008). Many successful interventions use exercise prescriptions in conjunction with exercise counseling, planning and activity logs, and exercise testing that allows prescriptions to target safe heart rate zones. Combining exercise prescriptions with additional interventions such as phone, mail, or email follow-up can improve prescription adherence and long-term effectiveness (Muller-Riemenschneider 2008). Using a multi-sector approach to exercise prescription implementation, including regulatory and policy action, partnerships with community organizations, and consultations with exercise professionals, can increase opportunities for follow-up, patient support, and prescription adherence (Whitsel 2021). Successful exercise prescriptions typically include suggested intensity, duration, and frequency, along with a variety of exercises using aerobic and resistance training, ideally with individually tailored recommendations (Taylor 2023, Barrow 2019). Exercise prescriptions are more effective when combined with nutrition advice and calorie restrictions (Stoner 2019). When exercises are perceived as fun, patients find it easier to adhere to the prescription (Burnet 2019). Medical schools that provide training and education on creating individual exercise prescriptions increase the use of exercise prescriptions among health care providers (Sprys-Tellner 2023, Pancio 2023). Training and education can change physician attitudes about exercise prescriptions, their usefulness, and prescription best practices; however, structural barriers remain in the limited time available to spend with patients, insurance coverage for physical activity counseling, and lack of referral services available (Omura 2018).

Exercise prescriptions can use mobile apps to improve communication, accountability, and data tracking of exercise completion; however, mobile apps can have technology issues, pose security concerns, and require electronic devices and broadband access that are not equally available for all patients (Gell 2024). Exercise prescription interventions that provide patients with wearable electronic devices (e.g., Fitbits) increase data recording, communication, and physical activity (Gao 2023). During the COVID-19 pandemic, some exercise prescriptions offered virtual exercise programming when in-person meetings were not possible; however, individuals without stable internet access could not participate (Wonders 2021).

Exercise prescriptions can be tailored for patients with medical conditions such as coronary artery disease, congenital heart disease, osteoporosis, diabetes, or hypertension through consultations with certified exercise specialists (Leone 2023, Taylor 2023, Lui 2021, Senter 2013). Exercise prescriptions are a suggested strategy to improve the health of patients with diabetes who can safely exercise, since supervised exercise can improve blood pressure control, lower LDL cholesterol levels, and elevate HDL cholesterol levels for diabetic patients (Hayashino 2012). Exercise prescriptions are a suggested strategy to increase physical activity, which can improve mental health outcomes, for patients with psychiatric conditions, including anxiety, depression, schizophrenia, bipolar disorder, and more (Escobar-Roldan 2021).

Exercise prescriptions and supports for exercise adherence may be a cost-effective way to reduce medical costs for treating obesity in the U.S., which total more than $147 billion annually (Stoner 2019). Estimates suggest that population physical inactivity alone creates about $117 billion in health care costs every year in the U.S. (Whitsel 2021). Several studies suggest that exercise prescriptions are cost-effective when treating patients with heart disease and related risk factors (Oldridge 2020).

It is unclear what impact exercise prescriptions alone may have on disparities in physical activity and health outcomes.

Exercise prescriptions that also support access to safe places for physical activity with passes, participation fee waivers, or memberships to gyms, community centers, fitness classes, and pools; provide equipment (e.g., fitness trackers, bicycles and helmets, resistance bands, etc.) to support exercise; or appointments with physical activity professionals may have the potential to decrease disparities in physical activity and health outcomes experienced by people of color and individuals with lower incomes, compared to white people and individuals with higher incomes (Jaworski 2019). Experts suggest that increasing access to community-based programs and facilities can help individuals with exercise prescriptions adhere to prescribed exercise (Jaworski 2019, Jordan 2018). Exercise prescriptions that use virtual meetings or programming and mobile apps can provide electronic devices and apps; however, these features require broadband access and stable internet, which is not equally available to all patients (Gell 2024, Gao 2023, Wonders 2021).

Populations with lower incomes and Hispanic, Black, Native Americans, and Alaska Natives are less likely to engage in leisure time physical activity than those with higher incomes and white and Asian adults (Hawes 2019, ACSM AFI-Sallis 2019, CDC-API), likely due in part to living in neighborhoods with less access to safe places for physical activity and lack of supports for active lifestyles (CDC-Equitable access). Overall, communities whose residents are primarily people of color and have lower incomes have less access to parks and recreational facilities for physical activity than neighborhoods with white and higher income residents (ALR-Disparities 2011), though the quality of parks and the built environment can vary widely at the local level (ACSM AFI-Sallis 2019).

Throughout U.S. history, discriminatory housing, lending, and exclusionary zoning policies entrenched racial residential segregation and concentrated poverty (Zdenek 2017, Kaplan 2007). The built environment in under-resourced communities is a significant contributor to health inequities for people of color with low incomes (Prochnow 2022, McAndrews 2022, Brookings-Semmelroth 2020). Disinvestment in and unequal distribution of recreational facilities, parks, and green space means that communities with low incomes and communities of color have fewer places to engage in outdoor activities, have less access to cooling shade, and experience poorer air quality (CAP-Rowland-Shea 2020, TPL-Chapman 2021, Braveman 2022). The Federal Housing Administration’s residential redlining practices also resulted in fewer health care facilities, resources, and funding in urban areas with largely Black populations (Lee 2023, Lee 2022c).

Disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods that are primarily Black and low income (Lee 2023). People with one or more chronic diseases are at greater risk for disability, death, poor functional status, unnecessary hospitalizations, and many other challenges (Bleich 2015). Individuals from minoritized racial backgrounds (Price 2013), from rural areas (RHIhub-Chronic Disease), and those with low incomes are disproportionately more likely to have one or more chronic diseases (Eyler 2019). Rural areas also lack adequate access to physicians; approximately 20% of the U.S. population resides in rural areas, but only 10% of physicians provide care there (Arredondo 2023).

The health benefits of physical activity are well-established and support treatment and prevention for many diseases; however, as of 2009 and 2010, several surveys suggest that many patients have not received exercise or physical activity recommendations from their health care providers (Jaworski 2019). The American Medical Association and American College of Sports Medicine created the Exercise is Medicine (EIM) initiative in 2007 to establish physical activity assessments and prescriptions as a standard in health care globally (Jaworski 2019). In 2018, the World Health Organization (WHO) launched “More Active People for a Healthier World,” a global initiative to decrease physical inactivity by 15% by 2030 (Jaworski 2019). The U.S. Department of Health and Human Services (US DHHS) emphasizes the importance of physical activity for everyone with the Physical Activity Guidelines for Americans (US DHHS-PAG). Updated WHO and US DHHS recommendations include goals to increase the use of exercise prescriptions by health care providers (Jaworski 2019).

• What education or training does your community offer to health care providers to support their use of exercise prescriptions? What community programs or facilities are available for use by those with exercise prescriptions? Are these spaces for physical activity available for free? If not, why?
• What resources, funding, or collaborations are available in your community to enhance exercise prescriptions by expanding access to safe places for physical activity by offering passes, participation fee waivers, or memberships to gyms, community centers, fitness classes, and pools? How can your community provide equipment (e.g., fitness trackers, bicycles and helmets, resistance bands, etc.) to patients along with their exercise prescriptions?
• Are there local coalitions or partnerships that can champion expanded appointment times so health care providers can offer counseling and referrals to develop individually tailored exercise prescriptions? Which groups have the power to influence health insurance policies to pay for physician’s time and any additional costs associated with exercise prescriptions?

In many areas of the country, physicians use prescriptions to refer patients to local Exercise is Medicine programs, for example, in Pinehurst, North Carolina (FirstHealth-EIM); Wesley Chapel, Florida (Florida hospital-EIM); East Texas (UT East Texas-EIM); and Indianapolis, Indiana (IGG-Park prescriptions). Many cities also support health care provider exercise prescription programs, as in Chicago, Illinois with the Chicago Exercise Prescription Fitness Center Waiver program (IGG-Park prescriptions).

Through the Prescribing Parks program, health care practitioners prescribe healthy outdoor activities to adults and children; examples include Baltimore, Maryland; Greenville, South Carolina; Portland, Oregon; the County of San Diego, California; Washington, D.C. (NRPA-Prescribing parks); and the Quad Cities in Iowa and Illinois (IGG-Park prescriptions). Exercise prescriptions are also supported by the Prescription Trails Program in New Mexico (IGG-Park prescriptions) and the Prescribe a Bike Program in Boston (BMC-Prescribe a bike).

Partnerships can also support efforts to prescribe exercise and refer patients to places for physical activity (IGG-Park prescriptions). Similarly, the Walk with a Doc program is an international program that fosters community partnerships through physician-led walks and conversations around current health topics (Walk with a Doc).

The Centers for Disease Control and Prevention (CDC), the Institute at the Golden Gate, and the National Recreation and Park Association are collaborating to evaluate and refine best practices for park prescriptions and related programs (ALR-Wheeler 2014).

ACSM-EIM - American College of Sports Medicine (ACSM), Exercise is Medicine (EIM) Initiative. Exercise is medicine: Your prescription for health.

MBC-Health care toolkit - Mary Bridge Children’s (MBC) Hospital-Clinics-Foundation. Family wellness toolkit: Ready, set, go! 5210.

PAA - Physical Activity Alliance (PAA). Move with us.

ParkRx - ParkRx. What are park prescriptions? The park prescription toolkit, and the 2020 ParkRx Census.

Walk with a Doc - Walk with a Doc. Inspiring communities through movement and conversation.

* Journal subscription may be required for access.

ACSM AFI-Sallis 2019 - Sallis J. Disparities in the quality of physical activity environments. American College of Sports Medicine (ACSM) American fitness index. 2019.

ALR-Disparities 2011 - Active Living Research (ALR). Do all children have places to be active? Disparities in access to physical activity environments in racial and ethnic minority and lower-income communities. Princeton: Robert Wood Johnson Foundation (RWJF); 2011.

ALR-Wheeler 2014 - Wheeler K, Razani N, Bashir Z. Park prescriptions in practice: The community driven way. 2014 Active Living Research (ALR) Annual Conference. 2014.

Arredondo 2023 - Arredondo K, Touchett HN, Khan S, Vincenti M, Watts BV. Current programs and incentives to overcome rural physician shortages in the United States: A narrative review. Journal of General Internal Medicine. 2023;38:916-922.

Barrow 2019 - Barrow DR, Abbate LM, Paquette MR, et al. Exercise prescription for weight management in obese adults at risk for osteoarthritis: Synthesis from a systematic review. BMC Musculoskeletal Disorders. 2019;20(1):1-9.

Bleich 2015 - Bleich SN, Sherrod C, Chiang A, et al. Systematic review of programs treating high-need and high-cost people with multiple chronic diseases or disabilities in the United States, 2008–2014. Preventing Chronic Disease. 2015;12:150275.

BMC-Prescribe a bike - Boston Medical Center (BMC). America's Essential Hospitals: Prescribe-a-Bike gives patients control over access, exercise.

Braveman 2022 - Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.

Brookings-Semmelroth 2020 - Semmelroth L. How Wilmington, Del. is revitalizing vacant land to rebuild community trust. Washington, D.C.: Brookings Institution; 2020.

Burnet 2019* - Burnet K, Kelsch E, Zieff G, Moore JB, Stoner L. How fitting is F.I.T.T.?: A perspective on a transition from the sole use of frequency, intensity, time, and type in exercise prescription. Physiology and Behavior. 2019;199:33-34.

CAP-Rowland-Shea 2020 - Rowland-Shea J, Doshi S, Edberg S, Fanger R. The nature gap: Confronting racial and economic disparities in the destruction and protection of nature in America. Washington, D.C.: Center for American Progress (CAP); 2020.

CDC-API - Centers for Disease Control and Prevention (CDC). Adult physical inactivity outside of work.

CDC-Equitable access - Centers for Disease Control and Prevention (CDC). Physical activity: Equitable and inclusive access.

Escobar-Roldan 2021 - Escobar-Roldan ID, Babyak MA, Blumenthal JA. Exercise prescription practices to improve mental health. Journal of Psychiatric Practice. 2021;27(4):273-282.

Eyler 2019 - Eyler AA, Valko CA, Marti M, et al. Adjusting the equity lens: Gaps in addressing health equity in state chronic disease prevention. Health Equity. 2019;3(1):86-91.

FirstHealth-EIM - FirstHealth Fitness. Exercise is medicine (EIM).

Florida hospital-EIM - Florida Hospital Wesley Chapel. Health classes, events, and programs: Special health programs: Exercise is medicine (EIM).

Gao 2023* - Gao Z, Ryu S, Zhou W, et al. Effects of personalized exercise prescriptions and social media delivered through mobile health on cancer survivors’ physical activity and quality of life. Journal of Sport and Health Science. 2023;12(6):705-714.

Gell 2024 - Gell NM, Smith PA, Wingood M. Physical therapist and patient perspectives on mobile technology to support home exercise prescription for people with arthritis: A qualitative study. Cureus. 2024;16(3).

Hawes 2019 - Hawes AM, Smith GS, McGinty E, et al. Disentangling race, poverty, and place in disparities in physical activity. International Journal of Environmental Research and Public Health. 2019;16(7):1193-1205.

Hayashino 2012* - Hayashino Y, Jackson JL, Fukumori N, Nakamura F, Fukuhara S. Effects of supervised exercise on lipid profiles and blood pressure control in people with type 2 diabetes mellitus: A meta-analysis of randomized controlled trials. Diabetes Research and Clinical Practice. 2012;98(3):349-360.

IGG-Park prescriptions - Institute at the Golden Gate (IGG). Park prescriptions: Profiles and resources.

Jaworski 2019 - Jaworski CA. Combating physical inactivity: The role of health care providers. ACSM’s Health and Fitness Journal. 2019;23(5):39-44.

Jordan 2018* - Jordan CR, Butler J, Myers J, Albert MA. Exercise prescription for a healthy heart. Current Cardiovascular Risk Reports. 2018;12(7).

Kaplan 2007* - Kaplan J, Valls A. Housing discrimination as a basis for Black reparations. Public Affairs Quarterly. 2007;21(3):255-273.

Lamming 2017 - Lamming L, Pears S, Mason D, et al. What do we know about brief interventions for physical activity that could be delivered in primary care consultations? A systematic review of reviews. Preventive Medicine. 2017;99:152-163.

Lee 2022c* - Lee EK, Donley G, Ciesielski TH, et al. Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis. Social Science and Medicine. 2022;294:114696.

Lee 2023* - Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Social Science and Medicine. 2023;328:116009.

Leone 2023* - Leone D, Buber J, Shafer K. Exercise as medicine: Evaluation and prescription for adults with congenital heart disease. Current Cardiology Reports. 2023;25(12):1909-1919.

Lui 2021 - Lui GK, Moons P. Exercise prescription as medicine. International Journal of Cardiology Congenital Heart Disease. 2021;5.

Maslov 2018 - Maslov PZ, Schulman A, Lavie CJ, Narula J. Personalized exercise dose prescription. European Heart Journal. 2018;39:2346-2355.

McAndrews 2022* - McAndrews C, Schneider RJ, Yang Y, et al. Toward a gender-inclusive Complete Streets movement. Journal of Planning Literature. 2022;38(1):3-18.

Muller-Riemenschneider 2008* - Müller-Riemenschneider F, Reinhold T, Nocon M, Willich SN. Long-term effectiveness of interventions promoting physical activity: A systematic review. Preventive Medicine. 2008;47(4):354-368.

NRPA-Prescribing parks - National Recreation and Park Association (NRPA). Prescribing parks for better health: Success stories.

Oldridge 2020* - Oldridge N, Taylor RS. Cost-effectiveness of exercise therapy in patients with coronary heart disease, chronic heart failure and associated risk factors: A systematic review of economic evaluations of randomized clinical trials. European Journal of Preventive Cardiology. 2020;27(10):1045-1055.

Omura 2018* - Omura JD, Bellissimo MP, Watson KB, et al. Primary care providers’ physical activity counseling and referral practices and barriers for cardiovascular disease prevention. Prevention Medicine. 2018;108:115-122.

Pancio 2023 - Pancio G, Kern N, Ankam N, Zhang XC. Impact of exercise prescription education on medical student confidence and knowledge in generating exercise recommendations. Cureus. 2023;15(12).

Price 2013 - Price JH, Khubchandani J, McKinney M, Braun R. Racial/ethnic disparities in chronic diseases of youths and access to health care in the United States. BioMed Research International. 2013:787616.

Prochnow 2022* - Prochnow T, Valdez D, Curran LS, et al. Multifaceted scoping review of Black/African American transportation and land use expert recommendations on activity-friendly routes to everyday destinations. Health Promotion Practice. 2022.

RHIhub-Chronic Disease - Rural Health Information Hub (RHIhub). Chronic disease in rural America.

Senter 2013* - Senter C, Appelle N, Behera SK. Prescribing exercise for women. Current Reviews in Musculoskeletal Medicine. 2013;6(2):164-172.

Sprys-Tellner 2023 - Sprys-Tellner T, Levine D, Kagzi A. The application of exercise prescription education in medical training. Journal of Medical Education and Curricular Development. 2023;10.

Stoner 2019* - Stoner L, Beets MW, Brazendale K, Moore JB, Weaver RG. Exercise dose and weight loss in adolescents with overweight–obesity: A meta-regression. Sports Medicine. 2019;49(1):83-94.

Taylor 2023* - Taylor JL, Myers J, Bonikowske AR. Practical guidelines for exercise prescription in patients with chronic heart failure. Heart Failure Reviews. 2023;28(6):1285-1296.

TPL-Chapman 2021 - Chapman R, Foderaro L, Hwang L, et al. Parks and an equitable recovery. San Francisco, CA: The Trust for Public Land (TPL); 2021.

US DHHS-PAG - U.S. Department of Health and Human Services (U.S. DHHS). Physical activity guidelines for Americans (PAG).

UT East Texas-EIM - UT Health East Texas. Medical fitness programs: Exercise is medicine (EIM).

Walk with a Doc - Walk with a Doc. Inspiring communities through movement and conversation.

Whitsel 2021* - Whitsel LP, Bantham A, Jarrin R, Sanders L, Stoutenberg M. Physical activity assessment, prescription and referral in U.S. healthcare: How do we make this a standard of clinical practice? Progress in Cardiovascular Diseases. 2021;64:88-95.

Williams 2008 - Williams DM, Matthews C, Rutt C, Napolitano MA, Marcus BH. Interventions to increase walking behaviour. Medicine and Science in Sports and Exercise, 2008;40(7):S567-S573.

Wonders 2021 - Wonders KY, Gnau K, Schmitz KH. Measuring the feasibility and effectiveness of an individualized exercise program delivered virtually to cancer survivors. Current Sports Medicine Reports. 2021;20(5):271-276.

Yeom 2009* - Yeom HA, Keller C, Fleury J. Interventions for promoting mobility in community-dwelling older adults. Journal of the American Academy of Nurse Practitioners. 2009;21(2):95-100.

Zdenek 2017 - Zdenek RO, Walsh D. Navigating community development: Harnessing comparative advantages to create strategic partnerships. Chapter: The background and history of community development organizations. New York: Palgrave Macmillan; 2017.