Promoting Physical Activity in Routine Health Care: Time to Walk the Talk

Physical inactivity is a prevalent, modifiable risk factor for common cardiovascular diseases such as myocardial infarction, heart failure, and atrial fibrillation.^1-3 Recent studies have attributed up to 9% of overall global premature mortality to physical inactivity, making it at par with smoking-related deaths.⁴ Physical inactivity has also had a significant adverse economic impact on health care, contributing to 11% of overall health care expenditure in the United States.⁵

The current guidelines recommend up to 30 minutes of moderate to vigorous physical activity on most days of the week for US adults.⁶ These recommendations are based on prior studies demonstrating favorable associations between physical activity levels at or above these doses and improvements in cardiac, metabolic risk factors, structural and functional effects on the heart and blood vessels, as well as long-term risk of adverse cardiovascular events.⁶ Furthermore, recent studies have demonstrated that physical activity levels in excess of the guideline recommended doses might be even better to reduce risk of certain cardiovascular conditions such as heart failure, particularly heart failure with preserved ejection fraction, a common phenotype of heart failure.^2,7 Despite all this evidence highlighting the importance of physical activity in cardiovascular disease prevention, 4 out of 5 US adults fail to meet the guideline recommended levels of physical activity.⁸ This sobering statistic underscores the existing implementation gap in the translation of these policies and recommendations into effective strategies for promotion of physical activity.

The present scientific statement by the American Heart Association on the feasibility and effectiveness of physical activity promotion in health care settings is an important step towards bridging this gap. As highlighted in this scientific statement, an important first step towards in physical activity promotion is routine assessment of physical activity levels in routine healthcare settings. The widespread use of electronic health records (EHR) has made it feasible to capture health behaviors such as physical activity longitudinally allowing health care providers to routinely discuss physical activity habits with their patients. Such physical activity assessments can be performed using well-validated, self-reported questionaries’ that can be efficiently integrated into the clinical workflow during routine clinic encounters. The current scientific statement provides an excellent overview of overall reliability, validity, and ease of administration of the available self-reported physical activity assessment tools that may help healthcare providers identify the best-fit model for physical activity assessment in their setting.

One such physical activity assessment tool, the exercise vital sign, has been successfully implemented by the Kaiser Permanente health system in California into the EHR work-flow for routine clinical encounters and has been shown to have high use rates and favorably modify physical activity related practices and associated outcomes.^9-11 This successful experience with implementation of EHR based physical activity assessment in a large health system like Kaiser Permanente highlights the feasibility of such an approach towards physical activity promotion. Furthermore, the recent m-health boom with increasing use of wearable activity monitors (WAM) in the general population has created new opportunities for integration of more objective and efficient assessment of physical activity patterns into clinical workflow. However, there are several challenges to successful use of WAM data for physical activity assessment in clinical settings, some of which are addressed by the authors in this scientific statement. These include, translating data obtained from WAM into clinically meaningful information, harmonization of data obtained from different WAM platforms, and validation of available WAM against gold-standard assessment of physical activity levels and caloric expenditure. Taken together, the available data suggests that WAM are not yet ready for prime time use for routine assessments of physical activity in health care settings while we await the m-Health and EHR technology stakeholders to work on addressing these challenges.

The scientific statement also identifies and addresses several other provider and system level barriers to physical activity assessment and promotion in health care settings. These include, but are not limited to, lack of physician reimbursements for physical activity specific care practices, lack of infrastructure in health systems to implement evidence based physical activity promotion programs, and inadequate training among providers regarding physical activity promotion and counseling. Incentivizing assessment and promote physical activity levels among patients as goals of clinical excellence for providers, better education of providers about strategies to maximize reimbursements for physical activity related care practices, and greater engagement of community-level physical activity programs for exercise interventions may help overcome some of these challenges.

Finally, an important aspect of physical activity promotion is using a personalized approach to exercise prescription. The guideline recommended targets for physical activity might not be feasible or might require creative approaches to achieve for many inactive individuals with co-existing co-morbidities. Similarly, individuals may not have the same degree of physical activity/fitness improvement in response to a particular form of exercise recommendations. Accordingly, it is important to monitor physical activity behavior in individuals longitudinally, modify exercise goals over time, and tailor the exercise therapy based on the specific individual requirement and response to initial prescription. As highlighted in this scientific statement, a multi-disciplinary approach to physical activity promotion that involves partnership among physicians, physical therapists, and community-based fitness professionals may be useful in providing personalized exercise prescriptions for individuals.

While significant progress has been made in understanding the importance of physical activity for prevention of cardiovascular diseases and promotion of overall healthy aging, pragmatic implementation of this knowledge to improve overall physical activity levels in the general population is still lacking. The current AHA scientific statement is an important step in this direction as it provides a roadmap to the health care systems and providers for implementation of effective strategies of physical activity assessment and promotion.