Exercise Prescriptions for Cardiometabolic Health

The alarm sounds at 6 am, and within the hour, you’re sitting in a car for a lengthy commute. You arrive at the office only to sit at a desk for another eight hours with short, intermittent standing and/or walking. At 5 pm, you’re back in the car for rush hour and arrive home to start the nightly routine—eating dinner (sitting), helping with homework (sitting), reading bedtime books (sitting), and relaxation (sitting) in front of the TV or reading a book before going to sleep. Does this sound familiar—either to you or your patients?

Now more than ever, both children and adults are spending copious amounts of time in sedentary behavior—defined as any waking behavior characterized by a low energy expenditure while in a sitting or reclining posture.1 Sedentary behavior, in and of itself, has emerged as a potential risk factor for cardiometabolic health, chronic disease, and mortality.1,2

And yet, for many, a sedentary lifestyle has become the norm. Throw in a 30-minute workout a few times a week, and the average individual may even consider themselves to be physically active. The medical community says this is not enough. Current health policy guidelines recommend at least 150 minutes of physical activity per week coupled with reduced daily sedentary behavior by interrupting prolonged sitting with bouts of light activity every 30 minutes to promote health and quality of life.3 Anything less is considered physical inactivity, which is one of the most prevalent major health risk factors, with 8 in 10 US adults not meeting aerobic and muscle-strengthening guidelines.4 Over 80% of adolescents do not do enough aerobic physical activity to meet the guidelines for youth; many children spend more than seven and a half hours a day in front of a screen.5

Recent data shows that physical inactivity accounts for more cardiovascular disease (CVD)–related deaths (37%) than smoking (19%) and hypertension (13%) combined, and that 15-17% of all premature deaths are attributable to low fitness.3 The American Health Association (AHA) promotes physical activity as part of its 2020 Impact Goals to improve cardiovascular health and reduce deaths caused by stroke and cardiovascular disease.4 In April 2018, the AHA issued a scientific statement recommending a “systems change” approach for ameliorating sedentary behavior, by imploring healthcare providers to call on others in the community like clinical and community care providers, fitness experts, health coaches, and other stakeholders to help get people moving.4

How can clinicians help patients modify sedentary behaviors—many of which are involuntary—and incorporate physical activity into their daily lives? Functional Medicine educators teach clinicians how to craft sustainable, personalized exercise prescriptions to reduce cardiometabolic risk for patients who are struggling with sedentary behavior and physical inactivity. “IFM has a wonderful tool in the toolkit that helps [clinicians] walk patients through the process of writing an exercise prescription,” says IFM educator Cheryl Montgomery, who offers Functional Medicine health coaching at the office of Shilpa Saxena, MD. “I think this is fantastic because when you tell your patient to go exercise, they are much more likely to do it if you hand them a piece of paper—just like if you write them a prescription for medication or a nutraceutical—they are more likely to do it if they have something in their hand.”

In the following video, IFM educator Elizabeth Boham, MD, MS, RD, talks about ways to improve a
patient’s health through exercise.

Dr. Elizabeth Boham is board certified in family medicine, with a strong background in nutrition and Functional Medicine. She speaks on topics ranging from women’s health and breast cancer prevention to insulin resistance and heart health.

A 2018 study suggests that sedentary time, higher intensity physical activity, and cardiorespiratory fitness should all be targeted with metabolic syndrome and diabetes status.6 Sedentary behavior (sitting time) and low physical activity levels are strongly associated with increased cardiovascular disease risk and cardiovascular-related mortality in major studies like the Nurses’ Health Study, the Lancet Sedentary Behavior Working Group, and the 45 and Up Study.1 One meta-analysis showed an increased risk for all-cause and cardiovascular disease mortality and incidence of type 2 diabetes with higher levels of total sitting as well as TV viewing time, independent of physical activity.7 A range of evidence supports the use of standing as a means for interrupting sitting time and optimizing blood glucose control and cardiometabolic health.3 Many workplaces now offer adjustable standing desks that allow employees to intermittently switch between standing and sitting throughout the day. Movement breaks can also be added into the day, alternating between five minutes of movement for every 30 minutes of sitting.

In 2017, the recommendation to interrupt prolonged sitting was added to the American Diabetes Association’s standards of care.8 A 2017 cross-sectional analysis of adults at risk of type 2 diabetes found that intermittent standing or stepping may improve two-hour fasting glucose and two-hour insulin and insulin sensitivity.1 This is important for heart patients because people with diabetes are two to three times more likely to die of a cardiovascular event.3 A recent study of middle-aged adults who were working full-time found that personalized interventions increased daily walking and active time by helping them develop concrete plans to increase activity on a daily basis.9 The use of specific intentions, such as planning when, where, and how to increase daily walking, also increased participants’ confidence that they would engage in physical activity even under perceived time constraints.9

Some working patients could be encouraged to hold “walking meetings” throughout the day; a 2015 exploratory survey of 150 working US adults found that those who participate in walking meetings are 5.25% more likely to report being creative at their jobs than those who do not. Additionally, the responses suggest that walking meetings support cognitive engagement, or focus, on the job. Those who participate in walking meetings are 8.5% more likely to report high levels of engagement.10

What other types of physical activity are recommended for patients with cardiometabolic disease and related complications? A 2018 review of yoga therapy shows improved cardiovascular and quality of life outcomes for heart failure patients, who typically have comorbidities that prevent them from participating in traditional exercise programs.11 Cardiac patients are encouraged to stay active for multiple benefits, including improvement of inflammatory markers and vascular reactivity; the metabolic demand of yoga is flexible, ranging from chair-based to continuous flow as well as rigorous forms that combine several postures.11

The Functional Medicine model emphasizes the importance of helping cardiovascular and other patients to identify what types of physical activity they enjoy the most to maintain a higher level of adherence to exercise prescriptions. To be truly effective, a Functional Medicine exercise prescription must not only help the patient develop an exercise routine but also help them replace a certain amount of sitting time each day with standing, stepping, or walking.

To learn more about ways to craft personalized exercise prescriptions for cardiometabolic patients, consider IFM’s Cardiometabolic Advanced Practice Module. In this in-person or live-stream course, clinicians will learn to evaluate and utilize specific nutrients, phytonutrients, botanicals, pharmaceuticals, dietary plans, stress reduction techniques, and lifestyle interventions to improve the prevention and management of patients with hypertension, cardiovascular disease, metabolic syndrome, and type 2 diabetes.

Explore more articles about cardiometabolic conditions


  1. Edwardson CL, Henson J, Bodicoat DH, et al. Associations of reallocating sitting time into standing or stepping with glucose, insulin and insulin sensitivity: a cross-sectional analysis of adults at risk of type 2 diabetes. BMJ Open. 2017;7(1):e014267. doi:10.1136/bmjopen-2016-014267.
  2. Hamilton MT, Healy GN, Dunstan DW, Zderic TW, Owen N. Too little exercise and too much sitting: inactivity physiology and the need for new recommendations on sedentary behavior. Curr Cardiovasc Risk Rep. 2008;2(4):292-298. doi:10.1007/s12170-008-0054-8.
  3. Solomon TPJ, Eves FF, Laye MJ. Targeting postprandial hyperglycemia with physical activity may reduce cardiovascular disease risk. But what should we do, and when is the right time to move? Front Cardiovasc Med. 2018;5:99. doi:10.3389/fcvm.2018.00099.
  4. Lobelo F, Rohm YD, Sallis R, et al. Routine assessment and promotion of physical activity in healthcare settings: a scientific statement from the American Heart Association. Circulation. 2018;137(18):e495-e522. doi:10.1161/CIR.0000000000000559.
  5. President’s Council on Sports, Fitness & Nutrition. Facts & statistics: physical activity. US Department of Health & Human Services. Updated January 26, 2017. Accessed September 24, 2018.
  6. van der Velde JHPM, Schaper NC, Stehouwer CDA, et al. Which is more important for cardiometabolic health: sedentary time, higher intensity physical activity or cardiorespiratory fitness? The Maastricht Study [published online September 10, 2018]. Diabetologia. doi:10.1007/s00125-018-4719-7.
  7. Patterson R, McNamara E, Tainio M, et al. Sedentary behavior and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis. Eur J Epidemiol. 2018;33(9):811-829. doi:10.1007/s10654-018-0380-1.
  8. Colberg SR. Key points from the updated guidelines on exercise and diabetes. Front Endocrinol. 2017;8:33. doi:10.3389/fendo.2017.00033.
  9. Lachman ME, Lipsitz L, Lubben J, Castaneda-Sceppa D, Jette AM. When adults don’t exercise: behavioral strategies to increase physical activity in sedentary middle-aged and older adults. Innov Aging. 2018;2(1):igy007. doi:10.1093/geroni/igy007.
  10. Clayton R, Thomas C, Smothers J. How to do walking meetings right. Harv Bus Rev. Published August 5, 2015. Accessed October 8, 2018.
  11. Pullen PR, Seffens WS, Thompson WR. Yoga for heart failure: a review and future research. Int J Yoga. 2018;11(2):91-98. doi:10.4103/ijoy.IJOY_24_17.

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