Writing prescriptions to exercise does better than merely discussing the benefits with patients

St. Louis Post-Dispatch (MCT) - Dr. George Kichura looked at Marc Leeke and his blood tests last fall and diagnosed him with metabolic syndrome.

Leeke, 50, of Ballwin, Mo., weighed 258 pounds (too heavy), had triglyceride levels near 300 (twice what they should be) and low HDL levels (that's the good cholesterol). He was also complaining of becoming tired and winded while working in his yard.

Kichura, an interventional cardiologist and clinical lipidologist at St. John's Mercy Heart Hospital, worried that Leeke might also become diabetic.

So he pulled out a notepad and wrote a prescription. Kichura scribbled out a detailed plan for something cheap but effective: dietary changes and a walking program that increased the number of steps Leeke was walking by 10 percent each week.

Now, three or four times a week, Leeke heads to the Ballwin Rec Center before sunrise and walks for 10 minutes then whirs away on the elliptical trainer for 20 minutes. He estimates that, on those days, he walks 5,000 to 7,000 steps, about three times more than he once did in a typical day.

Leeke has lost 17 pounds, lowered his triglyceride levels to 180 and raised his HDL levels.

Kichura was not surprised. He's prescribed exercise before, and when patients cooperate, it works.

Doctors have long prescribed exercise as part of rehabilitative programs for patients who've had heart attacks, undergone coronary bypass surgery or experienced other cardiac problems. Insurance usually covers that rehabilitation for a few weeks.

But a growing number of doctors, here and nationwide, are prescribing detailed exercise plans as a preventive measure before the health of high-risk patients deteriorates. And they'd like to see insurance cover those patients as well.

"I'm not an economist, but from a health standpoint, exercise is invaluable," said Dr. Mike Cannon, assistant professor in department of family and community medicine at St. Louis University. "Prescribing it is a very effective way of preventing chronic disease, which is not only having a profound effect on the quality of our lives but it's also bankrupting our health care systems."

COSTS LESS THAN DRUGS

The Agency for Healthcare Research and Quality reports that in 2006, Americans older than 18 spent $38 billion on prescription drugs that lower cholesterol and control weight and diabetes. They spent an additional $33 billion on cardiovascular drugs such as blood pressure medicine. Both drug categories top the list of most money spent on prescription medicines, accounting for 34 percent of the $208.1 billion spent in 2006.

Dr. Cynetra McNeil, assistant professor of pharmacy practice at St. Louis College of Pharmacy, said more than 47 million of those people have metabolic syndrome like Leeke. They have three out of five of the following risk factors: excess abdominal fat, abnormal triglyceride levels, elevated blood sugar levels, high blood pressure and diabetes.

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McNeil estimates that each of those patients spends more than $300 a month on prescriptions, such as a simvastatin for cholesterol, ACE inhibitor for blood pressure, metformin for blood sugar.

"They're also sometimes on insulin if their diabetes is advanced," she said. "Of course exercise is always good, too. Most people who have metabolic syndrome are overweight or obese, and a 5 percent weight loss will help lower the amount of medication they need."

Kichura notes how popping pills is easy. But they're costly and don't reverse underlying problems. Exercise does.

Writing itemized prescriptions to, say, walk 15 minutes a day and do specific strength training exercises has proved more successful than merely discussing the benefits of exercise with patients.

To begin, Kichura gives patients a blank diary, instructs them to buy a pedometer and record the number of steps they take each day. Then he works with them to increase those steps by 10 percent a week and has them send their daily logs to him.

"It forces patients to at least make an effort, and it also makes them a part of their own health care plan," he said.

It also lowers the risk of injuries and complications of diseases so patients can successfully maintain their fitness program.

Cannon teaches his students how to prescribe exercise. He gives them a template that helps them learn patients' goals, as well as find out if they've exercised before or ever been injured during exercise.

He's found that patients often want different results from exercise than their doctors do. For instance, patients simply want to lose weight when they should be working toward lowering lipid levels and raising their levels of fitness.

Prescribing exercise for some patients, such as diabetics, is complicated, Cannon says. At first, their sugar levels go up with exercise; after a few minutes, those levels can drop too far. And because they sometimes have loss of feeling in their feet, they run the risk of developing sores or losing their balance while walking.

"Diabetics don't have any room for error," Cannon said. "They need to do it right in order to do well over time."

That's where physical therapists and programs like Fitness First at St. John's Mercy Heart Hospital can play a role.

Fitness First is for anyone who has risk factors for heart disease or could benefit from a cardiovascular exercise program. A health care team of exercise specialists and nurses helps patients build confidence and teach them to exercise effectively and safely. Patients must get a doctor's order to join Fitness First, which costs $45 a month and is not covered by all insurance plans.

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INSURANCE INDUSTRY'S ROLE

That's not to say that the insurance industry as a whole is ignoring exercise as preventive medicine.

"Over 70 percent of health care costs go to diseases that are the result of unhealthy behaviors such as overeating, sedentary lifestyle and smoking," says Robert Zirkelbach of America's Health Insurance Plans, an association that represents nearly 1,300 health insurance providers. "So there is a growing recognition of this, and you are seeing the health insurance industry implementing programs to encourage people to take better care of their health."

Last year AHIP issued a report recommending lifestyle programs that could save as much as $47 billion on health care spending between now and 2015. The programs AHIP points to as successful examples put a high premium on fitness. For instance, PrimeWest Health, a nonprofit health plan that provides coverage to low-income people in rural Minnesota, contracts with exercise specialists who work with members to increase physical activity and exercise.

Members receive individual fitness plans and up to 28 visits with a fitness professional over a year, depending on needs and goals.

Experts agree that individual attention helps eliminate obstacles such as fear. People who have never exercised aren't used to the feelings of discomfort that come with exertion.

Mary Mercer, supervisor of the rehab unit at St. John's Mercy Heart Hospital, sees this a lot with patients who've had cardiopulmonary illnesses. Mercer says she points to the Pulse Oxymeter measuring their heart rate and oxygen saturation and tells them, "I know you're winded, but look, your oxygen saturation is at 98 percent, so you're OK."

Soon, the same amount of exercise feels easier, so they can go farther, faster.

Leeke now finds himself subconsciously walking more even during work hours. Rather than sitting at his desk at lunch time as he used to, he walks at a nearby mall or home improvement centers or outside.

He wasn't surprised when Kichura prescribed exercise.

"What did surprise me was if I didn't see results in the first three months, he was going to put me on medication which I was really scared of. But it's been working," Leeke says. "And we decided last time I would continue this course and try to take off another 15 pounds if possible, which means I'll have to increase my number of steps a day."

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© 2009, St. Louis Post-Dispatch.