FITTNESS Mnemonic for Physical Activity: Part 1 of 2

Lane Therrell FNP, MSN, RN, NP

Lifestyle change recommendations often involve a directive to "increase physical activity," but what kind of patient education best supports the patient's efforts to exercise more? I realized early on in my practice that helping patients who are ready to change by actually creating a useable, personalized, exercise plan that can be maintained over time was a complex task for which my nursing education alone had not adequately prepared me.

Without a formal background in exercise science, kinesiology, or personal training to draw upon, my solution was to identify the fundamental concepts of exercise, and boil them down into memorable categories so I could cover the important points in my patient education, and set the patient up for success. FITTNESS is a comprehensive mnemonic I came up with to help me keep the fundamentals of exercise in mind.

I first learned about FIT for diabetes care--FIT stands for frequency, intensity, and time-- from my 2007 copy of "Memory Notebook ofNursing." While FIT was a great place to start, it felt somewhat limited. Then,I learned about the F.I.T.T. principle for designing workouts, which built upon frequency, intensity and time by adding exercise type.While F.I.T.T. was somewhat more helpful than FIT, it still felt incomplete, because it failed to address the myriad practical realities that are necessary for patients to sustainably integrate increased physical activity into their daily lives. With that in mind, I added NESS-- nutrition, enjoyability/equipment, safety, and success-- to the F.I.T.T. concept.

The FITTNESS mnemonic can be applied clinically in multiple ways. One way is to pair evidence-based guidelines and age-appropriate recommendations in each fundamental category. However, I prefer to use FITTNESS as an empowerment tool as well as a prescriptive device. In other words, I spend more time asking the patient questions than giving the patient instructions or facts within each of the fundamental areas of physical activity.

Incidentally, the questions I like to ask are based on "directed thinking," which encourages the patient to articulate concrete actions he or she can take within each fundamental category, as opposed to enumerating the reasons why. By pairing FITTNESS with a coaching approach that emphasizes relevant individualized questions instead of general information and facts, I'm able to help the patient build motivation and a sustainable plan. In this way, the FITTNESS mnemonic helps me help my patients get maximum benefit from the time I spend with them discussing increased physical activity.

Frequency

Frequency addresses how often the patient exercises, and is usually quantified in term sof the number of workouts per week. There are many sources of guidelines for recommendations on exercise frequency, but ultimately, the appropriate number of workouts per week is determined by the patient's current fitness level and future fitness goals. Of course, the patient needs to have an active role in defining those goals.

I like to describe the concept of exercise frequency to my patients in terms of the importance of consistency: In other words, working out on weekends only and being sedentary during the rest of the week will not help you achieve fitness goals, nor is it a good way to enhance wellness over time. I like to ask my patients, "What can you do regularly above and beyond your existing daily routine?" with the goal of starting small, and building from there over time.If further suggestions are needed, I might offer something like: "Every other day, try a different form of movement, like stretching first thing after you get out of bed, or walking around the block after dinner... until you find something you like and want to make a habit of it."

Some key action-oriented questions you might ask your patient related to exercise frequency are: "How can you build some extra physical activity into your day?" "When can you add more activity?" "What are you going to do later today?Tomorrow? The rest of this week?"

Intensity

Intensity is all about how hard the patient works during a given exercise session. The idea of working hard during exercise need not equate to a steep learning curve, or a punishment. I like to encourage my patients to think of it in terms of how nearly the body is reaching its current performance capacity. Sweat can be an indicator, and heart rate can be a real-time objective measure.

Like frequency, intensity varies depending on the patient's fitness level and fitness goals. While there are specific guidelines in this regard, broadly speaking, the ideal intensity level provides challenge without injury. A classic example is that if you can carry on a conversation, or other activity such as reading or writing, while you are doing an activity, your body is probably not working hard enough to benefit from the exercise. I like to emphasize "no cheating" -- Cheating means getting on the treadmill for an hour and barely moving because you are reading the whole time, going slowly so you can see the words on the page.

It may help to remind patients that as they get into better shape, they will need to increase the intensity of their workouts. And as they start to get into better shape, they will start to feel better and will likely WANT to do more.

Some key action-oriented questions you might ask your patient related to intensity are: "How will you know you need to work harder?" "How can you modify your exercises so that your body will work harder?" "What other types of exercises are you interested in that might make you work harder?"

Time

The amount of time the patient dedicates to physical activity may seem straight forward, but this category can be deceiving because more time spent exercising is not always better. While specific recommendations exist about how much time the patient should be spending per day/per week exercising based on fitness goals and other factors, the big idea here is that any time spent exercising is better than no time spent exercising, and there is always time for physical activity if you're conscious and have made a sincere commitment. In other words, "I don't have time to exercise" is not a valid excuse.

This category, like others before it, is dependent on fitness level and goal, and is influenced by type of exercise. Additional factors that often get overlooked in this category include the personality and perceptions of the patient.

Some key action-oriented questions for frequency are: "How much time can you devote to working out per day or per week?" "How might you leverage your exercise time to get more benefits from it?" "What are the most effective workouts you can do during the time that you have available?" "How might you be able to build even more physical activity into your schedule?"

Type

This is all about the type of exercise the patient will be doing. In a prescriptive sense, some types of exercise may be more appropriate than others for certain patients depending on co-morbidities, health condition, disability and other limitations, all of which must be considered. Discussions in this category can be used as opportunities to change things up to keep exercise interesting. Varying the type of exercise from workout to workout also helps to avoid repetitive motion injuries and can help conquer weight loss plateaus.

Encourage the patient to choose various types of exercise to involve the whole body-ideally a combination of cardiovascular and musculoskeletal stimulation. Include various forms of weightbearing and non-weightbearing exercise for variety.Encourage the patient to keep it interesting and avoid doing the same thing all the time.

Some key action-oriented questions related to the type of exercise are: "What type of exercise is most appropriate for your current fitness goals?" "Are there things about that type of exercise that make you doubtful?" "How often will you change your routine?" "Is there a good variety of different types of exercise in the current plan?" Note: The type category of this mnemonic is closely related to the enjoyability/equipment category which will be discussed further in Part 2.

This concludes Part 1 of this article. Part 2 addresses the NESS components of the FITTNESS mnemonic for physical activity.