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Doctors’ new prescription: ‘Don’t just exercise, do it outside’

It’s become commonplace for San Francisco physician Daphne Miller to write prescriptions that look like this:

Drug: Exercise in Glen Canyon Park
Dose: 45 minutes of walking or running
Directions: Monday, Wednesday, Friday and Saturday at 7am
Refills: Unlimited

She estimates she has now written hundreds of prescriptions for outdoor activity. “For some reason, it is much easier to keep up a movement or exercise regimen when it’s outdoors,” Miller says.

Perhaps it’s because of the varying scenery, the fact that monthly dues and expensive Spandex outfits aren’t required, or even because of what she calls “the camaraderie of the trail”.

Miller’s not alone. Faced with mounting obesity rates and a stubbornly sedentary population, physicians – especially pediatricians – are refining their exhortations that patients need to get more exercise.

Nationwide, they are dispensing thousands of prescriptions with specific instructions – not just going to a gym, but exercising in nature, at a park, along a trail. They’re literally telling their patients to take a hike.

“This is a lot more than getting people physically active. This is about getting them outdoors,” says Zarnaaz Bashir, director of health initiatives for the National Recreation and Park Association, a group that melds parks, recreation, the environment and now, health.

When terms like “park prescriptions” began popping up in 2008 or so, many experts viewed it as a niche idea.

“It was a quirky, fun play on words. I don’t think a lot of people thought there was going to be much substance,” says Kristin Wheeler, program director at the nonprofit parks advocacy group, Institute at the Golden Gate, in San Francisco. “Now, it’s been validated.”

The number of programs has risen steadily. Officials have identified at least 50 specific programs in the US, Wheeler says, but smaller ones may be under their radar, and new programs are popping up all the time.

The trend is spreading to other countries as well – including Australia, where a conference was recently held to discuss the health and medical benefits the country’s natural parks can offer.

In the UK, doctors are prescribing visits to Green Gyms, outdoor sessions run by a conservation group. The idea is to not only improve health and stamina through exercise and activities, such as planting trees, but also to benefit local green spaces.

A result of the green-prescriptions movement has been the unlikely teaming up of otherwise unrelated groups. The Appalachian Mountain Club, for example, forged a partnership in 2013 with MassGeneral Hospital for Children to prescribe regular outdoor physical activity for children.

“With so many proven benefits to getting active outdoors, AMC can help families take the first step in trying out new activities, finding places to explore, and making these outings fun for kids,” club CEO John Judge says.

An early proponent was Robert Zarr, a physician with Unity Health Care in Washington DC who quizzes patients about their interests, checks a searchable database for information on parks in or near their zip code, and then writes a script for specific activities. He told one obese teen to skip one of the two buses she takes to school and walk through a park instead. She ended up losing weight and feeling happier.

“We’ve really got this down,” he told attendees at a conference last year in Philadelphia. “I see this as no different from prescribing medicine for asthma or an ear infection.”

Across the continent in San Francisco, Miller says she has learned that formalizing her recommendation to get out in nature by writing it as a prescription is highly effective. “Well over 80% of patients try it, and many stick to it,” she says.

Mounting evidence shows benefits of being out and active in green spaces: less tension and stress, lower blood pressure, improved immune system responses, and milder ADHD symptoms in children. Japanese researchers have found that adherents to Shinrin-yoku – “forest bathing” – have lower levels of the stress hormone cortisol than study subjects who walk the same distance in a lab.

Beyond that, simply spending more time outdoors – versus in front of the TV screen or computer monitor – equates to an overall increase in physical activity.

Proponents say the nature prescriptions shift the focus of medicine from illness to wellness, leading to the potential for widespread changes in medical care.

Diana Allen, chief of the US National Park Service’s “Healthy Parks, Healthy People” initiative, is seeing mergers of medical schools and parks programs. “That’s wild,” she said. “I think there are going to be some new fields of practice.”

She acknowledges possible opposition from traditional practitioners and drug companies – “this goes against the money machine.” And patients who simply want to pop pills for whatever ails them also may balk.

Other than the doubtless eye-rolling of some physicians who may view the programs as gimmicky, participants in the Philadelphia conference had more practical concerns. Were the parks they would send children to safe? Would weather be an issue? Would lack of transportation be a barrier?

While early adopters of the philosophy simply leapt in without much of plan – it made intuitive sense, after all – organizers now aim to standardize programs so other communities can basically plug and play.

In Philadelphia, more than two dozen partners, including The Children’s Hospital of Philadelphia, are developing Nature Rx, a comprehensive plan aimed at ensuring that when kids show up at a park to “fill” their prescriptions, the staff is ready to welcome them with specific activities.

Gail Farmer, director of education for the 340-acre Schuylkill Center for Environmental Education and one of the organizers, says park audits will start this spring and physicians will begin writing prescriptions come summer.

Adopting standards also will help researchers who are moving to the data-gathering stage. Is it really working? Do people follow the prescriptions? And does their health improve as a result?

Wheeler has just finished an economic benefits analysis for the parks of San Francisco, which put the figure at $1bn a year.

“A piece of it is what we’ve known for a long time. People prefer liveable, walkable communities,” she says. “The big new piece is health benefits.” Those, they pegged at $50m in avoided health care costs.