– Written by Robert Sallis, USA
A PILL CALLED EXERCISE
Imagine there was a pill that conferred the proven health benefits of exercise. It is certain that physicians would widely prescribe it to patients and healthcare systems would see to it that every patient had access to such a wonder drug. Yet despite the fact that most clinical guidelines recommend exercise as a first-line therapy for both the treatment and prevention of virtually every chronic disease, little has been done in an organised fashion to try and help patients get the exercise they need. Instead, there has been a continued overemphasis on an expanding array of high-priced and often marginally effective pills and procedures as the only answer most healthcare providers offer to patients. The evidence suggests healthcare systems around the world should provide more than just ‘lip service’ regarding the importance of exercise to health and begin to utilise exercise as a therapy that has been proven to prevent and treat a variety of chronic diseases.
Nations around the world have a lot at stake in getting citizens more active. The World Health Organization recently recognised physical inactivity as the fourth leading risk factor for global morbidity and premature mortality1. The cost of medical care for inactive patients dwarfs that required to care for active ones2. Further, we may be looking at a current generation of children who are much less fit than their parents and with the potential to be the first not to live longer than their parents. Where will we get our next generation of policemen, firemen and military personnel with the fitness and strength needed for these demanding jobs? Physical inactivity has become possibly the greatest public health problem of our time, which will get worse if organised medicine does not take action.
To stem this tide, physicians must become advocates for exercise. They should ask about it at every patient visit and a patient’s activity level should be looked at as a vital sign, because it is arguably the single best indicator of a person’s health and longevity. Physicians should prescribe 30 minutes of moderate exercise (such as a brisk walk) on most (5 or more) days each week as first-line therapy to both prevent and treat disease. This prescription should be the same regardless of provider or specialty. Further, we need to bring about a merging of the fitness and healthcare industries. As physicians, we should be able to refer our patients to a fitness professional that can help them achieve their goals for exercise. Exercise is a free medication that all patients need to take and the time has come for organised medicine to actively promote health by advising our patients to meet the guidelines for physical activity. The benefits, in terms of individual quality of life and public health, are just too great to ignore.
THE 'EXERCISE IS MEDICINE' INITIATIVE
Addressing these issues has been the vision of the Exercise is Medicine™ (EIM) initiative, a 6-year-old programme developed by the American College of Sports Medicine (ACSM) in conjunction the American Medical Association, and supported by the US Surgeon General and the US President’s Council on Physical Fitness and Sports3. The goal of EIM is to make a physical activity assessment and exercise prescription a standard part of the disease prevention and treatment paradigm for all patients in the USA and around the world. EIM is committed to changing the physician–patient dynamic by educating healthcare providers about the benefits of advising patients to participate in at least 30 minutes of physical activity on 5 days each week. The guidelines and tools to successfully conduct this discussion can be found at www.exerciseismedicine.org.
OBESITY VS INACTIVITY: WHAT IS MORE IMPORTANT TO PUBLIC HEALTH?
There has been growing concern and publicity around the world about the global epidemic of obesity. Unfortunately, obesity is a nebulous diagnosis that is most often defined by body mass index (BMI), which is essentially a ratio of one’s weight to height. This is really a rather poor measure that fails to take into account a person’s body composition and therefore extra muscle will raise BMI in a similar fashion to extra fat. In fact, using BMI as a measure of obesity labels more than one-third of US Americans and 56% of NFL football players with a chronic disease! This hardly makes sense and it is a stretch to think that assigning such a label is going to improve health outcomes when it is widely acknowledged that using BMI as the gauge for obesity is fraught with error.
More concerning is the fact that there are currently only three funded medical treatments for obesity: bariatric surgery, weight loss drugs and nutritional counselling. It is interesting to note that the most expensive obesity treatment by far (bariatric surgery) is also by far the one most often covered by health insurance. Is stapling the stomachs of obese patients really the best way to spend healthcare dollars? I certainly do not think so and given the proven effect of exercise in helping to prevent obesity and more importantly mitigating its harmful effects, why is it not funded as a medical treatment at all?
The problem lies in the fact that, in general, a healthcare system’s approach to dealing with most diseases is to simply prescribe a pill or a procedure. As a physician, I have seen first-hand the limited utility of weight loss pills and procedures: while they may help in the short term, the long-term effects are rarely significant. I have also observed the utter failure of public health messaging on obesity over the past couple of decades. Efforts to inform the public just how fat they are, to blame food companies and to push short-term, feel-good solutions such as bans and taxes have got us nowhere but fatter.
Another important factor to consider is the fact that a patient who has a normal BMI and develops a chronic disease (such as cancer, heart disease or diabetes) generally does not live as long as one with the same disease that is overweight or obese. Researchers have termed this the ‘obesity paradox’ and though its causes are not quite clear, it is evidence that being thin is not always healthy4. In fact, there has been ongoing debate about the relative importance of ‘fitness vs fatness’.
The evidence is clear that a person is better off being fit and fat, than skinny and unfit. To put that another way, being sedentary is a bigger risk factor for morbidity and mortality than mild to moderate levels of obesity.
More importantly, the evidence proves that the best way to combat the harmful health effects of obesity is to get these patients to be more active, rather than just getting them to lose weight. Exercise is medicine for obese patients and getting more active is a much more positive and easy-to-achieve goal than losing weight. Let’s face it, though not everyone can lose weight, almost everyone can go for a walk. I believe we have got to shift the public health focus away from obesity and towards physical activity. We have got to give the world permission to be fat and still be healthy. This is possible; the way to do it is by increasing physical activity.
HOW MUCH EXERCISE DO YOU NEED?
It is well established that regular exercise confers tremendous health benefits and helps us live longer and healthier lives. Exercise has also been shown to reduce depression and anxiety, while at the same time giving us more energy and helping our self-esteem. People who are fit miss less work and are more productive. It is clear that exercise is good for most ailments. So how much and how often do you need to exercise to gain these benefits?
The most important answer to that question is that any amount of physical activity is better than none and no matter what your age or ability, you will benefit from being more active. Notice the use of the phrase ‘physical activity’, rather than ‘exercise’. It is important to remember that doing vigorous activities like mowing the lawn or cleaning the house are as good for your health as playing tennis or jogging. Although doing household chores may not be as fun, knowing these activities are doing your body good might just make them easier to tackle and whether you are a child or a senior citizen, it is never too late to start an exercise programme and gain the benefits.
For adults, most of the health benefits are realised by doing 2 hours and 30 minutes (150 minutes) per week of moderate intensity physical activity, like a brisk walk. That works out to just 30 minutes on 5 days each week. Research shows you do not have to get your exercise all in one session and breaking it into several 10-minute bouts of exercise is just as good as one long session5. This is nice to know when you are on a tight schedule and do not have a large block of time to get your exercise in.
We also know that you can exercise for a shorter time at higher intensity and get the same benefit. So by doing vigorous exercise (like jogging or running) for 1 hour and 15 minutes (75 minutes) per week, you get similar benefits to doing 150 minutes per week of moderate exercise (walking)5. When you are pressed for time, it is nice to know you can get maximum benefits in less time by cranking up the intensity of your workout or activity.
During moderate exercise, your heart rate will rise and you will develop a light sweat, but you can still carry on a conversation, whereas during vigorous exercise your heart rate and breathing are rapid, you work up a good sweat and it is hard to say more than a few words without pausing to breathe. You can gauge moderate exercise by using the ‘sing-talk’ test: the intensity is moderate if you are going so hard you cannot sing while exercising, but not so hard that you cannot talk6.
Children need more exercise than adults and at a higher intensity level. They should set a goal of at least 1 hour of physical activity each day that should be mostly aerobic, but they also need to include activities that will help strengthen their muscle and bones. A good regimen for kids would be at least 3 days per week of aerobic activity such as swimming or riding a bike, while also getting at least 3 days of muscle strengthening activity such as push-ups or sit-ups, along with 3 days of bone strengthening activities such as skipping or running7. Most active kids easily meet these minimum exercise requirements and common youth sports like basketball or soccer provide the bulk of the activity they need to strengthen the heart, muscle and bones.
THE PRESCRIPTION FOR EXERCISE
As mentioned previously, if physicians had a pill that provided the benefits of exercise, they would undoubtedly recommend it to every patient. The EIM action plan addresses how to refine the trusted relationship between physician and patient so that prescribing exercise has the same status as pharmacological intervention. The powerful effects of physical activity cannot be emphasised enough, as it relates to the treatment and prevention of the leading causes of death today, such as diabetes, heart disease and cancer. Physicians have a responsibility to inform patients about the benefits of exercise and the risks of being sedentary, and encourage them to take steps towards a healthier lifestyle.
Providing an exercise prescription is easy to do by remembering to just ‘think FITT’ (see Table 1). This pneumonic is an easy way for physicians to remember how to prescribe exercise to their patients. The ‘F’ stands for frequency, which is most (5 or more) days per week. The ‘I’ stands for intensity, which should be moderate (judged by the sing-talk test). The ‘T’s stand for type of exercise and that includes anything that works major muscle groups and gets the heart pumping, and for time, which is recommended to be 30 minutes. Thus, the default exercise prescription would be advising your patient to walk at a brisk pace for 30 minutes on 5 or more days each week.
THE EXERCISE VITAL SIGN
One of the basic tenets of the EIM initiative is that a patient’s minutes of physical activity should be regarded as a vital sign. It is suggested that every patient should have their physical activity habits assessed and documented and then be given a proper exercise prescription. The ‘exercise vital sign’ (EVS) is a simple way to do this and to also get the topic of exercise into the exam room with every patient8.
Kaiser Permanente, one of the biggest healthcare organisations in the US, has effectively used an EVS in their Southern California region since October 2009. Since that time the EVS has also been rolled out to all the other Kaiser regions. The EVS at Kaiser is administered by the medical assistant as part of their assessment of the traditional vital signs of blood pressure, pulse, respirations and temperature. To assess the EVS, the patient’s numerical response to two simple questions is recorded: “On average how many days per week do you engage in at least moderate to vigorous physical activity like a brisk walk?” and “On those days, how many minutes do you engage in physical activity at this level?” The two responses are multiplied to give the number of self-reported minutes per week of moderate to vigorous physical activity (MVPA) done by that patient. The Kaiser electronic medical record automatically displays the MVPA and flags adults doing less than 150 minutes per week of MVPA, with an alert that they should be counselled to get more active.
The Kaiser Permanente EVS has gained remarkable acceptance in the nearly 6 years that it is been used in Southern California and currently well over 90% of adult patients have an EVS recorded on their chart. More importantly, in looking at patients over the age of 65 years we found that 96% had an EVS on their chart, which is significant because elderly patients stand to benefit the most from doing regular exercise8. We also found that like most other populations studied, Kaiser patients often are not meeting US Physical Activity Guidelines. In fact our data showed that 36% of patients report they are completely sedentary and doing no physical activity on a typical week. We also found that 33% were insufficiently active, reporting they typically engage in between 10 and 149 minutes per week of MVPA. Only 31% of patients currently are meeting the guidelines of 150 minutes per week or more of MVPA8.
WALKING: THE DEFAULT EXERCISE PRESCRIPTION
Walking should be considered the default exercise prescription for many reasons, foremost of which is the fact that walking is extremely accessible for all ages, fitness levels and abilities. It can be done alone or in groups in almost any setting. Walking is also low cost and does not require a gym or specialised equipment. It is also easy to measure walking using a pedometer, a stopwatch or by distance. Walking is also the most common form of adult activity and generally has good long-term adherence. Walking is also a proven form of exercise with multiple studies showing its benefits to health. Finally, walking is cost-saving in terms of healthcare costs and fossil fuel consumption and hence has a positive effect on the environment and can be considered a very ‘green’ endeavour.
In 2011, Kaiser Permanente started a public awareness project called Every Body Walk!. This was conceived by then chairman and CEO George Halvorson. The aim of the Every Body Walk! campaign has been to inform the US public about the tremendous health benefits of walking and help motivate them to get out and do it. At the centre of the campaign is a walking hub –www.everybodywalk.org – that contains news and resources on walking, health information, walking maps and places to share stories about how walking has helped people get healthy and stay that way. The campaign has been a tremendous success by every measure and the website has had over 1.3 million views. Its success has been a testament to both the importance of the walking message and how open the public is to hearing about it.
TAKE THE FIRST STEP
The evidence is clear that exercise is a very powerful tool to treat and prevent chronic disease, to mitigate the harmful effects of obesity and lower mortality rates. In addition, exercise has a powerful effect on functional capacity and quality of life. In effect, exercise is medicine and many experts consider physical inactivity to be the major public health problem of our time. For these reasons, physicians have a responsibility to assess physical activity habits in their patients, inform them of the risk of being inactive and provide a proper exercise prescription. The easiest way to do this is by using an EVS to assess the minutes per week of moderate or greater exercise each patient is doing. Based on the EVS, a physician should either congratulate their patient on meeting current physical activity guidelines (150 minutes of moderate or greater physical activity each week) or encourage their inactive patients to try and meet these guidelines. Typically, walking is considered to be the default exercise prescription, although the type of exercise in which patients engage is not so important. Sports and exercise medicine professionals have the training and background necessary to lead the effort to promote exercise as a medicine and connect fitness with healthcare.
References
1. The Lancet. Physical activity, 2012. From http://www.thelancet.com/series/physical-activity Accessed July 2012.
2. World Health Organization. Mortality and Burden of Disease Estimates for WHO Member States in 2004. World Health Organization, Geneva 2009.
3. Anderson LH, Martinson BC, Crain AL. Health care charges associated with physical inactivity, overweight, and obesity. Prev Chronic Dis 2005; 2:A09.
4. Sallis RE. Exercise is medicine and physicians need to prescribe it! Brit J Sport Med 2009; 43:3-4.
5. Lavie CJ, Milani RV, Ventura HO. Obesity, heart disease, and favorable prognosis – truth or paradox? Am J Med 2007; 120:825-826.
6. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sport Exerc 2007; 39:1423-1434.
7. Foster C, Porcari JP, Anderson J, Paulson M, Smaczny D, Webber H et al. The talk test as a marker of exercise training intensity. J Cardiopulm Rehabil 2008; 28:2824-2830.
8. Sallis RE. Developing health care systems to support exercise: exercise as the fifth vital sign. Brit J Sport Med 2011; 45:473-474.
Robert Sallis, M.D., F.A.C.S.M., F.A.A.F.P.
Co-Director, Sports Medicine Fellowship
Kaiser Permanente Medical Center,
Clinical Professor of Family Medicine
UC Riverside School of Medicine
Fontana, California, USA
Contact: robert.e.sallis@kp.org
Image by Raniel Diaz