Straight Talk | Promoting the Exercise Vital Sign in Clinical Practice
Substantial evidence indicates that physical activity (PA), regular exercise training (ET), and high levels of physical fitness, including muscular fitness and, especially, cardiorespiratory fitness (CRF) are extremely protective for general health and, particularly, for the prevention and treatment of most cardiovascular diseases (CVD). My close friend and colleague, Steven Blair, MD, who many consider one of the fathers of aerobic fitness, often says that physical inactivity is now the greatest threat to health in the 21st century. Over a decade ago, James O'Keefe, MD, and I surveyed a large number of American cardiologists on their personal health habits and published these results in the American Journal of Cardiology, showing that American cardiologists generally have much more favorable health habits than do the general population, including usually maintaining quite good levels of PA.1 However, one can seriously question how well many of us have translated these findings to our patients.
National federal PA guidelines suggest that all individuals should be performing >150 minutes per week of moderate PA or >75 minutes per week of vigorous PA. The Institute of Medicine suggests that all individuals should be performing at least 60 minutes per day of PA. At the present time, however, statistics suggested only 20% to as much as 50% of individuals are meeting these minimal PA requirements. Additionally, in a recent review in the Mayo Clinic Proceedings, we explained that PA is not often promoted within the health care system, with many clinicians not asking patients about their PA, documenting PA in the medical record, or advising patients to perform regular PA.2 As clinical cardiologists, we should ask ourselves: How often do we personally neglect or do our colleagues neglect this opportunity to promote PA in our practices?
Improving the prescription of PA
A potential way to impove the prescription of PA in our practices would be its inclusion as an exercise vital sign (EVS). Robert Sallis, MD, and his colleagues at Kaiser Permanente instituted this in 2009 in their electronic medical record (EMR) by just including two questions:
How many days per week do you participate in moderate PA, such as brisk walking?
On days that you do moderate PA, what are your average minutes of PA per day (zero minutes, 10 minutes, 20 minutes, 30 minutes, etc)?
Ancillary staff can enter these two data points, along with pulse, blood pressure (BP), height, and weight, in the EMR, and the computer can produce the weekly estimate of PA in minutes/week. In those adults with <150 minutes per week of PA (or <420 minutes per week in children), a prompt can ask the clinician if PA has been recommended. Although this is not perfect, this would at least present an opportunity to document PA and PA prescription in the EMR and in clinical practice. Going beyond this, Enrique Artero, MD, Dr. Blair, and my other colleagues recently described a very simplified method, including PA, to estimate CRF in clinical practice without the use of an exercise stress test, with overall excellent ability to predict CVD prognosis.3
Finally, many patients describe lack of time as the major obstacle for performing regular PA. People are often too busy with work and family activities to devote sufficient time to achieve the minimal PA requirements reviewed above. However, Chi Pang Wen, MD, described two years ago in Lancet and, more recently in JACC, substantial mortality benefits with even 15 minutes per day of PA in over 415,000 Taiwanese.4 In our recent running paper in JACC that received substantial attention in the media, Duck-chul Lee, MD, Dr. Blair, and my other colleagues described that low doses of running (e.g., <6 miles per week, <52 minutes per week, and running just one to two times per week) were associated with reductions in mortality and CVD mortality of 30% and 45%, respectively, similar to the benefits noted with considerably higher running doses.5 Therefore, even PA well below the national guidelines may produce substantial clinical benefits, thus indicating that some PA is always better than none!
As clinical cardiologists, as should almost all clinicians, we need to set a high example for PA, including asking our patients about PA, documenting this in the chart or EMR as the EVS, and regularly prescribing PA to our patients.
Abuissa H, Lavie CJ, Spertus J, O'Keefe J. Am J Cardiol. 2006;97:1093-6.
Vuori IM, Lavie CJ, Blair SN. Mayo Clin Proc. 2013;88:1446-61.
Artero EG, Jackson AS, Sui X, et al. J Am Coll Cardiol. 2014;63:2289-96.
Wen CP, Wai JP, Tsai MK, Chen CH. J Am Coll Cardiol. 2014;64:482-4.
Lee DC, Pate RR, Lavie CJ, et al. J Am Coll Cardiol. 2014;64:472-81
Keywords: Electronic Health Records, Walking, Physical Fitness, Body Weight, Cardiovascular Diseases, Running, Blood Pressure, Habits, National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division, Exercise Test
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