4th year medical students initiate a quality improvement project for health care providers. Be sure to visit http://wp.me/p4V1Uc-sb for the pre and post test and more information.
2. Exercise Prescription & Quality Improvement
Exercise is under utilized in medicine
There is a knowledge gap about exercise in healthcare
providers
Exercise offers potential for decreased morbidity and
mortality
Exercise offers potential for decreased health care
spending
Resources
3. Outline
Background on exercise guidelines
Data review on exercise counseling by providers
Health outcomes affected by exercise prescription
Financial outcomes for decreased health care spending
Resources
4. Background on Exercise Guidelines
American College of Sports Medicine (ACSM)
Founded in 1954 by physical educators and physicians
Original CDC/ACSM public health recommendations were
published in 1995 to reduce morbidity and mortality,
which emphasized (1):
“accumulation of ≥30 min of moderate-intensity physical activity
each day”
Cited >1000 times by 2003
Adopted by NIH, AHA (1)
IOM increased recommended time to “60 minutes” of daily activity to
prevent weight gain (1)
(1) Blair SN, LaMonte MJ, Nichaman MZ. The evolution of physical activity
recommendations: how much is enough? Am J Clin Nutr 2004;79(5):913S-20S.
5. Background on Exercise Guidelines
Updated ACSM Guidelines as of 2011
ACSM’s Guidelines for Exercise Testing and Prescription (2)
Most adults engage in:
moderate-intensity cardiorespiratory exercise training for ≥30
min·d−1 on ≥5 d·wk−1 for a total of ≥150 min·wk−1,
vigorous-intensity cardiorespiratory exercise training for ≥20
min·d−1 on ≥3 d·wk−1 (≥75 min·wk−1),
or a combination of moderate- and vigorous-intensity exercise
to achieve a total energy expenditure of ≥500-1000
MET·min·wk−1.
On 2-3 d·wk−1, adults should also perform resistance exercises
for each of the major muscle groups, and neuromotor exercise
involving balance, agility, and coordination.
American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription.
8th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. p. 366.
6. Exercise Guidelines
Who do these recommendations apply to?
“When appropriately evaluated and advised by a health
professional (e.g., physician, clinical exercise
physiologist, nurse), these recommendations may also
apply to persons with certain chronic diseases or
disabilities, with modifications required according to an
individual's habitual physical activity, physical function,
health status, exercise response, and stated goals. The
advice presented in this Position Stand is intended
principally for adults whose goal is to improve physical
fitness and health...”
American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription.
8th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. p. 366.
7. Exercise Guideline Summary
The ACSM recommends that most adults engage in the
following to meet activity minimums (3):
Moderate-intensity cardiorespiratory exercise training for
≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk; or
Vigorous-intensity cardiorespiratory exercise training for
≥20 min·d on ≥3 d·wk (≥75 min·wk) or;
A combination of moderate- and vigorous-intensity
exercise to achieve a total energy expenditure of ≥500-
1000 MET·min·wk.
On 2-3 d·wk, adults should also perform resistance
exercises for each of the major muscle groups
(3) Garber, Carol Ewing, Bryan Blissmer, Michael R. Deschenes, Barry A. Franklin, Michael J.
Lamonte, I-Min Lee, David C. Nieman, and David P. Swain. “Quantity and Quality of Exercise for
Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in
Apparently Healthy Adults.” Medicine & Science in Sports & Exercise (2011): 1334-359.
8. Exercise Guideline Summary
What defines moderate intensity? Vigorous?
Moderate-intensity= 3.0-6.0 METS (3.5-7kCal/min)
Walking at moderate or brisk pace, hiking, roller skating/in-
line skating, cycling 5-9mph, yoga, moderate effort cardio,
etc.
Vigorous-intensity= >6.0 METS (>7kCal/min)
Pushing disabled car, running, downhill skiing, competitive
sports, heavy weight training, circuit training, etc.
For full list see:
U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and
Physical Activity. Promoting physical activity: a guide for community action. Champaign, IL: Human Kinetics,
1999.
9. Exercise Guideline Summary
What is a MET?
A MET is a ‘Metabolic Equivalent”
One MET is defined as the energy expenditure for sitting
quietly, which, for the average adult, approximates 3.5 ml
of oxygen uptake per kilogram of body weight per minute
(1.2 kcal/min for a 70-kg individual). For example, a 2-
MET activity requires two times the metabolic energy
expenditure of sitting quietly.
10. Exercise Guideline Summary
What is a MET?
A MET is a ‘Metabolic Equivalent”
One MET is defined as the energy expenditure for sitting
quietly, which, for the average adult, approximates 3.5 ml
of oxygen uptake per kilogram of body weight per minute
(1.2 kcal/min for a 70-kg individual). For example, a 2-
MET activity requires two times the metabolic energy
expenditure of sitting quietly.
But there might be a better way to prescribe the correct
intensity….
11. MET meets RPE
What is RPE?
Rate of Perceived
Exertion = RPE
RPE designed by Gunnar
Borg in the 1970’s
Linear scale 6-20, where
each number x 10
coincides with person’s
heart rate
e.g. RPE of 12= 120bpm
Well validated (5,6)
(5) Utter, Alan C.. “ACSM Current Comment Perceived Exertion.” American College of Sports Medicine . ASCM, n.d.
Web. 2 Feb. 2015. <http://www.acsm.org/docs/current-comments/perceivedexertion.pdf?sfvrsn=4>.
(6) Borg, G. “Perceived exertion as an indicator of somatic stress”. Scandinavian journal of rehabilitation medicine 2
(2). 1970 92–98
Moderate= 12-16, Vigorous=17-20
12. Data review on exercise counseling by providers
<10% of US adults meet physical activity guidelines (6)
Walsh et al found that <12% physicians surveyed are
familiar with these guidelines (7)
Also found 14% of physicians counsel over half their patients
on exercise
Schultzer et al. found that older patients are more likely to
change behaviors as suggested by their doctor because
they have both increased respect for their physician’s
advice and they have regular contact with their family
doctor (8)
(6) Moderate to Vigorous – What is your level of intensity? American Heart Association -Fitness Basics. American Heart Association, 20 Mar. 2014. Web. 2
Feb. 2015.
(7) Walsh, J., DM Swangard, T. Davis, and SJ McPhee. “Exercise Counseling by Primary Care Physicians in the Era of Managed Care.” American Journal of
Preventive Medicine4 (1999): 307-13.
(8) Schultzer, K., and B. Sue Graves. “Barriers And Motivations To Exercise In Older Adults.” Preventive Medicine5 (2004)
13. Health Outcomes Affected by Exercise Prescription
It’s a BIG problem
“According to the NHANES 2005–2006, fewer than 10% of U.S. adults met
the PAGA according to accelerometry….The proportion of adults meeting
the PAGA according to M2VPA was 62.0% for self-report and 9.6% for
accelerometry.”
http://www.ajpmonline.org/article/S0749-3797%2811%2900012-2/abstract
Physical inactivity causes significant morbidity and premature
mortality
“Worldwide, we estimate that physical inactivity causes 6% of the burden
of disease from coronary heart disease, 7% of type 2 diabetes, 10% of
breast cancer, and 10% of colon cancer. Inactivity causes 9% of premature
mortality, or more than 5.3 million of the 57 million deaths that occurred
worldwide in 2008.”
http://www.thelancet.com/journals/lancet/article/PIIS0140-
6736%2812%2961031-9/abstract
14. Financial Outcomes w/ Exercise Counseling
Inactivity is expensive
“The estimated direct, indirect, and total health care costs of physical
inactivity in Canada in 2009 were $2.4 billion, $4.3 billion, and $6.8 billion,
respectively. These values represented 3.8%, 3.6%, and 3.7% of the
overall health care costs.”
https://www.researchgate.net/publication/225271749_Health_care_costs_of
_physical_inactivity_in_Canadian_adults
Physical activity is likely to save $$$
“After adjustment for age, gender, comorbidity, smoking status, and body
mass index, all physical activity states had declining health care charges,
relative to those who were consistently inactive. Subjects who increased
their physical activity from 0-1 to 3+ days/week had significant declines in
their mean annualized total charges (-2,202 dollars, P < 0.01) relative to
those who remained inactive.”
http://www.ncbi.nlm.nih.gov/pubmed/14507488
15. Resources
ACSM Exercise is Medicine Homepage
http://www.exerciseismedicine.org/
Barbell Medicine
http://barbellmedicine.com/
Exercise Recommendations in Primary Care
http://www.barbellmedicine.com/news/exercise-
recommendations-in-primary-care-a-quality-improvement-
initiative/
GainzZz™ in Clinical Practice Series
http://www.barbellmedicine.com/news/gainzzz-in-clinical-
practice-part-i/