1. A presentation at Active Lives:
Transforming Ourselves and Our
Patients 11/10/12 (delivered by Dr Edward Phillips)
Stephan Esser MD
www.esserhealth.com

2. Filling the Exercise Prescription
Stephan Esser USPTA, MD
November 2012

3. Disclosures
• Co-creator of ABEforfitness.com

4. This Weekend
• Physical Activity and Fitness Assessment
• Exercise Prescription Implementation
• Physician Health
• Business of Lifestyle Medicine
– Filling the Exercise Prescription
• Motivation

5. You …….After this Weekend
• Inspired
• Motivated
• Ready to Change Lives
• A brain full of exciting new stuff

6. Possible Patient Concerns Remain
• I don’t know where to exercise
• I don’t know how to exercise
• I don’t have time to exercise
• It costs too much to exercise

7. Goal
• Action-able
• Rubber hits the Road
• Introduce you to ideas/opportunities
• Equip you with the tools to transform lives
• Stimulate your creative Juices

8. Day #1
• In the Clinic…3rd patient of the day
– Mr Yulepsi is a 62 y/o gentleman back for follow
up of his BP. He is feeling more fatigued, and
having some lightheadedness, but his BP’s are still
borderline.
– He says he wants other options than medx…..

9. Day #1
• Your mind RACES…..nutrition…exercise…stress
• You harness your motivational interviewing
skills and after more dialogue you know he is
in a preparation/action stage and would
prefer to start an exercise program while also
trying to eat a little better
• He has previously received appropriate ACSM
screening and is cleared for moderate
intensity activity

10. Day #1
• More mature individual
• Known cardiovascular dysfunction
• Was cleared with exercise stress test
• Motivated to start an exercise program

11. What do you do?
• What does he want to do ?
• What are his resources?
– What can you offer him?
• What are his options?
– Do you know your community options?

12. Our Goals
• Fill that Prescription
– People
– Programs
– Places
– Products
– Etc…..

13. People
• Structured:
– Your Office: Trainer, Wellness Coach
– Physical Therapy
– Training:
• Personal Trainers
• Group Classes

14. Physical Therapy
• Common:
– Post-injury/Pre or Post Surgery
– Therapeutic Exercise, Modalities
• Often Available:
– Therapeutic Exercise Training
– Use of Equipment

15. Physical Therapy
• Pros:
– Highly trained
– Significant Experience
– Certified/Insured/Credentialed
– Established mechanism of communication
• Cons:
– Require a medical diagnosis
– Co-Pays ($20-40)
– Limited # of visits paid by insurance
– Time/training in therapeutic exercise

16. Trainers
• Personal Trainers
• Group Trainers
• Heath Coaches
• Life Coaches

17. Trainers
• Pros:
– Accessibility
– Variety
• Private sessions, group classes
• Strength training, Yoga, Kick-Boxing, Pilates…etc
– Price:
• Privates: Variable ($20-$200)
• Groups: included in memberships or $8-$15/hr

18. Trainers
• Cons:
– Cost: private pay
– Variable experience/knowledge
– Variable insured status
– No “established” method of communication
– Certification?

19. Trainer Certification
• Many Types:
– 7 Certified
– National Commission for Certifying Agencies NCCA
• American College of Sports Medicine (ACSM)
• American Council on Exercise (ACE)
• National Academy of Sports Medicine (NASM)
• National Strength and Conditioning Association (NSCA)
• National Council on Strength and Fitness (NCSF)
• National Federation of Professional Trainers (NFPT)
• National Exercise and Sports Trainers Association (NESTA)

20. Selecting a Trainer
• Certification
– ACSM > NASM > ACE > NSCA > NCSF > NFPT >
NESTA
• Affiliation
– Independent/National Gym
• Insured
• Interview
• Word of Mouth
• Patient Report

21. People
• Unstructured:
– Friends
– Family
– Work-Out Buddy
– Neighborhood: Pick up Ball, Park sports etc
– Meet up

22. Programs

23. Programs
• National Physical Activity Plan
– http://www.physicalactivityplan.org
– Collaborative: to achieve HP 2020, PA 2008 CDC
– “One day, all Americans will be physically active
and they will live, work, and play in environments
that facilitate regular physical activity.”
– Sectors: Business, Health Care, Industry,
Education, Media, Parks/Recreation, Public
Health, Transportation, Volunteer

24. Programs
• The President’s Challenge
– www.presidentschallenge.org
– Online resources, testing, awards
• Let’s Move
– www.letsmove.gov

25. Programs
• Walk With A Doc: www.walkwithadoc.org

26. Programs
• Silver Sneakers: www.silversneakers.com
• Physical Activity insurance benefit to seniors
• Provides gym memberships and fitness classes
at 11,000 locations
• Multiple Insurance providers involved

27. Worksite Wellness

28. Motorola
• Cost ≈ $6 mil/yr on wellness and work/life programs
• Offerings: Health Screenings, Education, gym access
etc
• Cost-effectiveness:
– ROI=$3.93
– Participating employees = 2.4% increase vs 18%
increase for non-participants
– $6.5 million yearly savings in medical expenses for
lifestyle-related diagnoses (e.g., obesity,
hypertension, stress)

29. DaimlerChrysler
• National Wellness Program
– Targeted education programs, one-time workshops, multi-session
classes, individual counseling, and self-directed modules, on-site
services
• Savings of: $16 per employee per month
• The more health assessment completed= the more saved
• Employees who had completed at least one health risk
assessment and participated in an additional wellness
activity had an average cost savings of $200.35 per year.

30. Union Pacific
• 1990: 29% spending on LR disease, $40mill.
• The “Health Track Program”: Health Risk Assessment, a
Smoking Cessation Program called Butt Out and Breathe,
over 500 contracted Fitness Facilities, an incentive
program
• 10 yr healthcare costs per employee decreased by 16%
• 10% decrease in Health Care Costs due to Lifestyle
Related Factors

31. Caterpillar
• Healthy Balance Program: health assessment, risk
stratification, individualized interventions, disease
management phone counseling; serial tracking, online
resources
• Projected healthcare cost savings of $700 million by 2015.
• Participants who completed the high-risk program reduced
their doctor office visits by 17%, and hospital days by 28%.

32. Northeast Utilities
• 17% healthcare costs = Lifestyle related disease
• WellAware program: financial incentives, employees and spouses
eligible, a health risk assessment, phone contact and Internet site
access at work and home, and a toll free hotline for materials and
questions.
• Participants demonstrated: 31% decrease in smoking, a 29% decrease
in lack of exercise, a 16% decrease in mental health risk, a 11%
decrease in cholesterol risk, an 10% improvement in eating habits, and
a 5% decrease in stress.

33. Common Ground
• Health Assessments
• Risk Stratification
• “High Touch”
• High Tech and Low Tech
• Family/Spouse Participation
• Incentivization

34. Web based programs

35. Web-Based Health Programs
• Virgin Health Mile: $5 for Employer
– HealthZone kiosks at Employer sponsored fitness
center (computer terminal that tracks weight, blood
pressure, & body fat)
– Go Zone pedometer (track online)
– LifeZone Website (track activity, questionniares)
– Challenges
– Employee receives gift cards (Target, Best Buy)

36. Virgin Health Miles
• Pros:
- A fun easy way to work toward improving
your health and earning money while doing it.
- Virgin Health Miles is quick to respond to
customer inquiries and sends items ordered
from their website within days of the request.
- Relatively easy with moderate activity to earn
back your investment.

37. Virgin Health Miles
• Cons:
- Pedometer reliability has been mixed.
- Walking style and user's size appear to
impact the ability of the pedometer to register
steps.
- HealthZone Kiosks are time consuming to use
and could be inconveniently located for you.
- GoZone Challenges haven't yet figured a way
to eliminate cheating.

38. Limeade

39. Limeade
• Hired by Employer
• Establish Personal Health Goals
• Achieve them using
– Includes in-person meetings, webinars,
newsletters, home mailings on-site signage,
mobile apps & devices
• Offer rewards

40. Red-Brick Health
• www.redbrickhealth.com
• Health assessments
• Health coaching, resources, challenges
• Rewards: Reduced premiums, 401k deposits,
gift cards etc.
• Personalized Programs, & individual rewards.

41. Tangerine
• www.tangerinewellness.com
• Outsourced weight loss and health solutions
• Create advertisements to the employees
• Health Assessments
• Enroll employees in 3 month cycles
• Offer incentives and reimbursement for
success

42. Web-based programs
• Free Programs (exercise, fitness etc)
– ABEforfitness.com
– Workoutz.com
– PhysicalFitNet.com
– www.sparkpeople.com
– Kids: GetSweaty.com
– JumpWithJill.com

43. Real Time Decreasing
Sedentary Time

44. Activity Desks
• Decreasing Sedentary Time
• Increase activity during and at work
• Up to 100kcal/hr
• Treadmill and Bikes
• Cost: $500-$2000
http://www.trekdesk.com/

45. Places

47. Parks
• “Free”
• Various options
– Walking trails, “Heart Trails,” Sports fields, Tennis
and Basketball Courts, Open Fields, Pools
– Hiking Trails, Nature preserves, Bike trails etc.

48. Gyms

50. What your patient wants
• Cost
• Location
• Hours
• Size
• Amenities
– Pool, Sauna, Climbing Wall, Raquetball Courts
• Classes
• Other: Childcare

51. Planet Fitness
• $10/month
• Resistance/Cardiovascular Equipment
• No group classes

52. Bailey’s Powerhouse Gym
• $25-$40/month
• 27 States
• Medium to Large
• Resistance/Cardiovascular Equipment
• Classes

53. Gold’s Gym
• $50- $150 Initiation Fee/ $10- $40 per month
• 37 States
• Pros: Low price, Plenty of equipment, Child
care
• Cons: Crowded, Small locker rooms, Lack of
customer service, Lack of cleanliness

54. Lifetime Fitness
- $190 Initiation Fee/ $60 per month
- 105 locations in US & Canada (some 24/7)
- Pros: Variety of Classes, Tennis, Basketball,
Squash, Mixed Combat Arts, Swimming
- Healthy Café, Spa & Salon
- Family oriented with child care, rock climbing,
swimming lessons, and camps

55. CrossFit
• Cost: $100-150/month unlimited group
classes
• Over 2,135 US locations
- “Old School”: weights, bars, balls, tires, boxes
- Pros: Minimal equipment (ropes, boxes,
bodyweight exercises)
- Cons: “Universal workouts for elderly
individuals with heart disease and
professional cage fighters”

56. 24 Hour Fitness
• 420 locations in 14 states
• Costs: Vary based on location & club type
(high-end Ultra Sport locations $150 Initiation
Fee/ $90 per month)
• Pros: Free weeklong pass; reduced rate
options for family members; many locations
open 24 hours; large exercise rooms; variety
of classes (Active Aging; Aqua; Mind/Body)
• Cons: No money-back guarantee

57. Boutique/Unique
• Tru Fit Personal Fitness
• Boxing Bunnies Women’s Boxing Club
• Focus Fitness

58. Apps

59. Map my run

60. Fitness Pro
- Cost: Free
- Electronically log your workouts
- Offers tips for newbies on types of cardio and proper form
- Select exercises by individual muscle
- Can create a
personalized routine
- Need gym equipment
- Maps running
- Flexible way to add new
exercises to workouts
- Can be used with
nutritional apps for
weight loss
https://itunes.apple.com/us/app/fitness-pro/id336826731?mt=8

61. GymGoal ABC
-Cost: $0.99
- Free version offers 280 exercises with animations
- Provides proper form instruction for
newbies
- Can add your own images to any
exercise
- Calculates target heart rate, BMI,
BMR, and body fat percentage
- Integrated body map of muscles to
focus on exercises designed for that
muscle group
- Need gym equipment
- $2.99 to record and track workouts

62. Fitness Builder
- Cost: $9.99
- 5600+ images/videos, 750+targeted fitness routines as well as
individual exercises;
- Location (gym, hotel room) and goal (core, flexibility) oriented
- Tracks completed workouts
by date
- Includes a variety of
calculators and stat trackers
- Complex app with
slideshows
- Experienced fitness goers
who want a large variety of
fitness routines and the
feeling of using a personal
trainer
https://itunes.apple.com/us/app/fitnessbuilder/id306287984?mt=8

63. iTreadmill
- Cost: $0.99
- Similar to pedometer to tracks steps, distance, and
average speed while in a hand, strapped to an arm, or
carried in a pocket or purse
- Sensor and stride calibrators help you ensure the
utmost accuracy
- Includes a calorie counter
and a pacer for setting
speed goals
- Calorie counter is based
on weight alone
- Does not detect incline

64. Cleveland Clinic’s Tip of the Day
- Cost: Free
- Daily wellness reminders
-Example: Drink your juice cloudy! Apple juice with
more pulp has 4x as many disease-fighting
polyphenols (antioxidants) as clear apple juice. And
keeping your
brain healthy and
happy (by volunteering,
for example) makes
it more likely you'll
stick with that gym
routine.

65. Devices

66. Pedometers
http://media.komonews.com/images/123011_pedometers.jpg

67. Accelerometers
• Measure: change in velocity with respect to
time
• With Calculations…equations = usable data
• 1990’s: Increased interest, use, validation
• Pros: Portable
• Cons: Cost ($100-$300-1000+), On the waist
do not capture upper body movement or
cycling, and underestimate walking on an
incline or carrying heavy loads
http://www.cdc.gov/nchs/tutorials/under_constr6/PhysicalActivity/SurveyOrientation/images/DataOverview_accelerometer.jpg

68. Koko Fitness
• Cost: $70-90
• Fitness Studios
• Unique electronic set up/Virtual trainer
• Identify Goals/ Select Plan/ 30 minute
workouts
• Key-Fob: Plugs in to each machine, uploads
personalized goals, weights, monitors your
pace, coaches you etc..
http://www.kokofitclub.com/

69. Technogym Wellness Key
• Establish Personal Goals
• Select plans/Programs
• USB Key Fob: plugs into equipment, guides
user thru activity
http://www.technogym.com/gb/products/software-hardware/software-applications/wellness-system/682

70. Jawbone Up
• Cost: $99
• Wristband & iPhone, iPad or iPod Touch App work together to:
• Track Activity
- Steps, distance, calories burned, pace, intensity, level, GPS routes
- Active vs. inactive time: reminds you to move if inactive for too long
• Sleep Patterns
- Hours slept, deep vs. light sleep, awake time and overall sleep quality
- Smart Alarm: vibrates on wrist at the ideal moment in your natural sleep cycle
• Meals
- Snap a photo as a food journal and
respond with how you feel
• Challenges to reach goals
- Individual or team based to support,
compete, and collaborate

71. FitBit
• Cost: $99.95
• Clips onto pocket
• Activity:
- 3-D motion sensor tracks steps, distance,
calories burned
- Altimeter tracks floors climbed
• Sleep:
- Slip tracker into FitBit sleep wristband and
automatically uploads how many times and
how long you wake up during the night
• Logs workouts & meals:
- 100,000+ food items
-Yoga, Pilates, Elliptical, Boot Camp, Spinning,
Kickboxing & Wii Games
• Overall Stats:
- Sync with other apps (LoseIt! & RunKeeper)
- Daily and overall progress
- Individual score or compare with others in
your age and fitness range
- Track weight, blood pressure, glucose, & HR

72. Fitbug
• Fitbug Air
- Bluetooth with wireless to send to a desktop,
smartphone, tablet, iPhone & iPad
- Cost: $64.99 with 12 months of coaching or
$29.99 with first month’s coaching & $3.99/mth
• Fitbug Go
- USB connection to a desktop, smartphone or tablet
- Cost: $59.99 or $24.99 & $3.99/mth
• Pedometer tracks steps
• Individuals:
-85% of active members lost weight over the first
6 months
- Offers tailored set of goals in first week. Plus online daily
health tips and recipes
• Employers:
- 81% of employees made positive lifestyle changes
- 32% reduction in health insurance claims by users
- Create challenges for employees with rewards

73. Nike + Fuel Band
• Cost: $149
• Wristband displays your goal, calories,
steps, fuel, and local time
• Personalize your day with an emotion and
notes
• Accelerometer tracks running, walking,
dancing, basketball and everyday activities
• Syncs wirelessly to track overall progress,
share results and compete with others on
facebook and twitter

74. Stuff

75. Stuff
www.power-systems.com/

76. Pen and Paper

77. Old Fashioned
• Handouts
• Tracking Logs
• Calendars
• Sticky Notes…
http://www.personal-nutrition-guide.com/support-files/printable_workout_log.pdf

78. Our Goals
• Fill that Prescription
– People
– Programs
– Places
– Products
– Etc…..

79. Tomorrow
• You are Ready to Fill the Exercise Prescription
• Good ideas to support and empower your
patients and your self to achieve their/your
BEST health

80. Remember
• Ask what they want to do?
• Provide VALUE
• Develop Resources
• Follow up
• Adapt

81. Thank You!