Physicians Impacting Public Health: Current Approach to Physical Activity

By Michael R. Kushnick, PhD, Mike J. Knutson, BS and Jay H. Shubrook, DO, FACOFP

Abstract: The sedentary lifestyle more than half of all Americans choose to lead is contributing to increased obesity and obesity-related chronic diseases. Physical activity can be a useful tool to prevent and treat these diseases but, for various reasons, many family physicians do not provide exercise counseling to their patients. The family physician serves as both a role model and a trusted source of information, acting as a catalyst to help patients become more physically active and improve their health. Though several barriers to providing exercise counseling may exist, current data indicates that these barriers can be overcome and physicians can play a significant role in providing patients with simple suggestions and guidelines aimed at helping them lead healthier, more physically active lifestyles.

Statement of the Problem
According to the Behavioral Risk Factor Surveillance System, less than one half of U.S. adults are engaged in the recommended levels of physical activity.1 Specifically, 49.7 percent of adult men and 46.7 percent of adult women participate in moderate intensity physical activity for at least 30 minutes per day, five days per week or vigorous intensity for at least 20 minutes per day, three days per week.

Moreover, 65 percent of U.S. adults are overweight or obese2 and there is clear evidence that low levels of physical activity are somewhat to blame.3,4 The current pattern of adult obesity also reflects a doubling of the incidence since 1980.2 Further escalation is anticipated as childhood obesity blossoms into worsening adult obesity as this pattern of sedentary lifestyle increases throughout the lifespan.1 Since obesity and many other chronic diseases can be attenuated through primary interventions such as increased physical activity, a better understanding of the family physician’s role in this process is warranted.

The American Osteopathic Association’s “Fit for Life Campaign” is an important step toward increasing the awareness of the role physical activity and exercise can play as therapeutic and preventive tools to achieve good health.5 However, despite the important role assumed by a primary care physician in maintaining a patient’s well-being, the current literature demonstrates that most physicians provide limited counseling on physical activity.6,7 A recent survey7 illustrated that less education and counseling is provided for physical activity than for nutrition or diet (approximately 14 percent of all office visits, as compared to 20 percent for nutrition or diet) and this was lower than previously reported (approximately 34 percent).8

Counseling on physical activity presents a unique opportunity for physicians to reinforce and complement traditional medical approaches that focus on improving health and providing optimal advice (and information) from a credible source. Currently, over 73 percent of the United States adult population have access to the internet9 where health and medical Information websites are easily accessible to the public. However, the family physician remains one of the most trusted sources of health information for patients.10,11,12

In fact, patients often report seeking advice about the safety and benefits of routine physical activity and, if not received from their physician, will seek other sources for this information including medical universities and federal government websites.12 This information may be overwhelming and not geared to patients’ needs or educational level. As a result, they may turn to less credible and trustworthy sources, including non-reputable or commercial websites. This presents a major concern for the health care provider and the public alike.12,13

Who is most likely to get counseled on physical activity?
Numerous studies have reported that people with underlying health issues get more routine counseling on physical activity8,14,15,16 than healthier individuals. Unfortunately, this may indicate that many physicians fail to recognize the importance of physical activity as a preventive tool. It is well recognized that regular physical activity decreases the incidence of cardiovascular diseases, diabetes and some cancers,3,17 and can reduce mortality rates from these common chronic diseases.

It was reported in 2004 through the National Ambulatory Medical Care Survey that only 57.0 percent of patients with obesity during office visits (n=11,605,132), 24.0 percent with dyslipidemias (n=40,115,352), 19.5 percent with hypertension (n=91,669,689), and 17.9 percent with type 2 diabetes mellitus (n=41,277,834) received any counseling on physical activity or exercise.18

Other published information indicates that there are trends as to who is most likely to receive counseling on physical activity. For example, middle-aged individuals,15,16 men,16,19 those with a college degree or higher,15,16 and/or those with better health insurance16,19 are more likely to receive counseling from their physicians on physical activity. While this is likely inadvertent, it is also likely that counseling and education on physical activity provided by the trusted family physician will benefit, at least to some extent, all patients.

What obstacles are faced in providing counseling on physical activity?
The most common obstacle to counseling patients on physical activity as reported by physicians is a lack of time14,20 followed by poor reimbursement for their efforts.6,20,21 Time constraints appear to represent a significant barrier. In 2005, the CDC reported that the average physician visit was only 19.7 minutes long.22 However, several opportunities for counseling may exist, as in this study it was found that on average 17 percent of adults age 18 or older had one office visit, while 26 percent had 2-3 visits, 23 percent had 4-9 visits and 14 percent had 10 or more visits over the past 12 months. Each visit is a missed opportunity to prevent or treat chronic disease with physical activity. in addition, despite the lack of remuneration, well placed, even limited communication, may prove worthwhile for the patient’s health.

Other barriers are also likely to limit the physicians in their ability to promote healthy lifestyles and increase patients’ physical activity. For example, reports suggest there is little time dedicated to the topics of physical activity or exercise prescription in medical education curriculum23. This lack of knowledge and training can decrease the confidence and skill of the physician to prescribe this therapeutic intervention.6,21,23,24 Furthermore, Douglas et al. 6 reported that physicians feel there is a lack of information regarding physical activity they can provide their patients that is in an “easily digestible” format. This also presents a barrier for physicians being able to advise patients on the optimal ways to increase physical activity.6,24

Despite these barriers, it should be recognized that physicians can have significant influence over their patients’ interest and receptiveness to participation in healthy lifestyle interventions, including weight loss, dietary practices and physical activity.25 Moreover, physicians should view themselves as role models. Interestingly, a recent report by Frank et al. 26 suggests that physicians who are more physically active are more likely to promote and counsel their patients on physical activity.

Educating the Educators
Definitions:
Physical activity is defined as “any bodily movement produced by skeletal muscles that results in energy expenditure”.27 In fact, physical activity is somewhat different than exercise, in that exercise is “planned, structured bodily movement done to improve or maintain one or more components of physical fitness.” 28

While the majority of physical activity information focuses on cardiorespiratory (aerobic-type) activity; movements that are continuous, dynamic, utilize large muscle mass, and requiring aerobic metabolism, resulting in an elevation of heart rate;28 more recent information also promotes the addition of activities that increase muscular strength and endurance.29

The consensus statements:
In 1995, a joint statement issued by the American College of Sports Medicine and the Centers for Disease Control and Prevention was published outlining the recommendations for physical activity for public health.30 Since then, there has been numerous, often misinterpreted and seemingly conflicting information published about the recommended guidelines for physical activity. For example, in 2002 the Institute of Medicine published guidelines that suggested 60 minutes of moderate intensity physical activity was necessary in healthy adults to balance energy intake and move from a largely sedentary lifestyle to a more active lifestyle.

However this recommendation, at first seemingly unattainable for most U.S. adults, was more reasonable than first recognized. Specifically the 60 minutes included all activities (e.g. work-related tasks) that were “above sleeping and breathing.” 31 Therefore, in 2007, an updated joint statement was issued by the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) for Physical Activity and Public Health that applied to healthy adults.17 The recommendations were similar to those previously presented but provided further clarification. These specific recommendations are presented in Table 1 and, of these, the most notable is the concept that the participant will derive more benefit from “exceeding the minimum recommended amount of physical activity.” 17

Guidelines for screening patients before participating in physical activity
It is important for family physicians to be knowledgeable about the medical screening process to determine who needs further evaluation before engaging in a physical activity program. While the ACSM recommends symptom-limited exercise testing before vigorous intensity exercise programs are initiated (>60 percent VO2max) in men ≥45 and women ≥ 55 years of age, or those with two or more symptoms of coronary artery disease or known cardiovascular, pulmonary or metabolic diseases,32 there is limited information substantiating this recommendation.33

Moreover, the guidelines of the AHA33 suggest that exercise testing is not necessary in asymptomatic adults who are initiating physical activity programs. Specifically, there is an established prognostic value of exercise testing and that some non-electrocardiographic measures strongly predict adverse events, such as BP response and heart rate recovery. Overall there is limited randomized trial data available on the clinical value of screening.33

The Take Home Messages
Promote physical activity:

Promotion and counseling of physical activity are vital aspects of the physician-patient relationship, and they are central components of the American Osteopathic Association’s “Fit for Life Campaign.”5 The dose response for physical activity and public health (see Figure 1.) suggests that the largest benefit ascertained from a given dose of physical activity (e.g. 20 minute continuous walk at a moderate intensity) will be gained by those who currently have the lowest levels of physical activity.30 In fact, recommendations to increase physical activity that are structured and rigid are less likely to be followed than those that are perceived as flexible and manageable34 and, often result in similar adaptations for individuals who are sedentary upon initiation.35

An important caveat is that the family physician should help the patient identify realistic goals toward physical activity that are proper for their level of fitness and health and encourage their participation. If additional information on physical activity is deemed necessary, or if the physician believes that the patient meets the current guidelines for exercise testing prior to initiation of a moderate- or vigorous-intensity physical activity program,32,33 they can guide the patient to the appropriate resources.

What can the physician and patient expect?
Case 1. While some patients will benefit from simple increases in daily activities such as parking the car further from home or their workplace, using the stairs rather than the elevator, and increasing the times they choose to walk rather than drive, it is important for their physicians to recognize that this is moving them closer to the recommended guidelines for physical activity. In fact, realistic outcomes for this level of activity may include long-term weight maintenance, improved physical working capacity, muscular strength and endurance and, overall, the patient may “feel better.” 4,17

Case 2. For those patients who lead active lifestyles (e.g. work on their feet, care for and tend to a household, etc.) and are apparently healthy, but do not routinely exercise, the goal of reducing cardiovascular disease risk factors including obesity, hypertension or hypertriglyceridemia (as well as a sedentary lifestyle) may be well within their abilities.

To reach such an end though, according to the current recommendations, patients who are age
18-65 years old, should participate in moderate-intensity physical activity five days each week by elevating their heart rate in large muscle mass activities (e.g. walking, bicycling, etc.). These bouts can be performed as a single session lasting ≥30 minutes, or as multiple sessions of ≥10 minutes each (totaling ≥30 minutes per day). In addition, it is recommended that individual’s work towards increasing their light-intensity activities performed throughout the day on each day of the week.

Moreover, at least twice a week individuals should focus on performing activities that promote muscular strength and endurance that target all major muscle groups. This can be accomplished by utilizing their own body weight in activities (e.g. sit-to-stand, wall pushups, stair stepping, etc.) or with the assistance of weights, machines, or implements (e.g. hand-held weights, stability balls, rubber bands, books, soup cans, etc.) and performing between 8-12 continuous repetitions (complete movements through the entire range of motion for that body part) with a light rest after each set of repetitions and before moving to the next activity. For additional improvements in muscular strength and endurance additional sets can be added.17

All of these activities described can be completed by having the patient carry out physical activity in an unstructured fashion (see Table 2) for tips to help patients meet the recommended guidelines and also the additional resources below), or can be attained through a more regimented and controlled exercise prescription.34 This “advanced” prescription could include factors such as identifying target heart rates for aerobic exercise, tracking the duration of each bout of exercise, and organizing a resistance training plan – well beyond the scope of this article, but not beyond its reach.

For additional information on identifying resources to help patients address these “advanced” exercise prescriptions, see below. As a result, while short-term (e.g. weeks to a few months) goals may be readily observed (e.g. less breathlessness at a given submaximal intensity, etc.), long-term maintenance of a new-found active lifestyle, meeting or exceeding the current recommendations for physical activity will result in overall improved health and disease prevention.17

Conclusion
The current lack of physical activity by the average American adult is contributing to the prevalence of obesity and other chronic diseases among this population. The family physician must not underestimate the importance of their role in counseling their patients about the benefits of physical activity as a therapeutic and preventive measure to combat these diseases.

As a role model and trusted source of information, the physician is poised to significantly impact the physical activity levels of their patients and contribute to the attenuation of the obesity epidemic this country faces. To do this, physicians must strive to find creative solutions to the existing barriers to providing exercise counseling such as lack of time and poor reimbursement. Additionally, organizations such as the American Osteopathic Association and the American College of Osteopathic Family Physicians should continue to develop and distribute “easily digestible” sources of physical activity-related information for patients and also work towards improving educational resources for medical students and physicians alike.

Additional Resources for Promoting Physical Activity
There are numerous print and website resources to assist physicians in becoming more familiar with prescribing physical activity and exercise and to use as tools in counseling patients. Table 3 provides a list and description of a brief sampling of well-established, user-friendly sites.

Michael Kushnick earned his Ph.D. from Florida State University in Exercise Physiology, is an American College of Sports Medicine certified Health Fitness Instructor and is currently an Assistant Professor at Ohio University. Mike Knutson earned his B.S. from Central Missouri State University in Exercise Science and is currently a working towards his M.S. in Exercise Physiology from Ohio University. Jay Shubrook DO FACOFP is a graduate of Ohio University College of Osteopathic Medicine and is currently an Assistant Professor of Family Medicine at OU-COM.

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