Answering the AHA Call to Action: Are you a Physical Activity Ambassador?

In this issue of Circulation, Kraus et al¹ highlight the well-established deleterious impact of a sedentary lifestyle and the current ominous trends related to physical inactivity on a population level. Numerous initiatives have been undertaken to increase the amount of physical activity Americans participate in on a daily basis; this includes the National Physical Activity Plan (NPAP), which the American Heart Association (AHA) participated in developing. The current Scientific Advisory encourages individual AHA members to be a part of this important physical activity campaign.

Physical Activity is an Ancient Medicine

Historical figures speaking of the value of physical activity dates back thousands of years²; hence, the health benefits derived from being physically active and the detriments of the converse, a sedentary lifestyle, are no secret.³ However, while we recognize the importance of physical activity to one’s health, there is a global crisis with respect to current and future physical inactivity projections.^{4, 5} The question becomes, now that we have officially, and rightfully, labeled exercise as medicine,^{6, 7} how do we increase physical activity patterns on a population level?

The Current State of Affairs: Where Are We, Where Do We Need to Go?

The body of literature demonstrating the benefits from physical activity is immense. A PubMed search with the phrase “physical activity” produces hundreds of thousands of peer-reviewed publications. Moreover, there are numerous reports, scientific statements, and clinical practice guidelines that unequivocally state that increasing physical activity is a population-level imperative; this includes the NPAP^{8, 9} cited by Kraus et al.¹ Simply stated, we know that increasing physical activity in all individuals is what is best; there is no contesting this fact. What is now needed is implementation, in real life, on a population level.

The Key Message in the AHA Call to Action

The AHA Scientific Advisory by Kraus et al1 eloquently reviews the body of literature related to the population-level crisis associated with sedentary lifestyle patterns, efforts to increase physical activity, the NPAP, the role of the health care sector in promoting physical activity (from educational, clinical practice, and research perspectives), and current AHA physical activity goals and initiatives. These themes have been addressed before in a collection of other publications. However, they are all important aspects related to this issue and the current AHA Scientific Advisory brings them together in a unique and valuable fashion. The true novelty of this AHA Scientific Advisory, the aspect that is vitally important to increasing physical activity on a population level, comes in the final two sections: 1) A Call to Action to the AHA Community and 2) The AHA Commitment. In these sections, Kraus et al¹ stress the importance of the individual “to seek out opportunities to further the goals of and objectives outlined” in the NPAP. This is the key component to this Scientific Advisory, no number of policies and initiatives will meaningfully increase physical activity patterns without a population of individuals committed to the cause, creatively seeking out opportunities to increase physical activity for themselves and all others their work impacts. The individual call has been missing from this conversation, and I applaud Kraus et al1 for beginning this conversation and asking for such an individual commitment. I am very confident that AHA leadership will receive this message and advance the importance of member commitment to physical activity promotion even further. Such a commitment can be achieved through numerous creative paths. For example, AHA members can complete a physical activity pledge, acknowledging that they will, as eloquently stated by Kraus et al,¹ “seek out opportunities to further the goals of and objectives outlined” in the NPAP.

Expanding the AHA Call to Action

The NPAP includes a number of sectors outlined in Table 3 of the AHA Scientific Advisory,¹ including education, business/industry, parks, recreation, fitness and sports, land use and community design, health care, public health, and mass media. There is evidence that increasing physical activity on a population level is possible through a multi-sector collaborative approach.¹⁰ Leaders from all relevant sectors should read this AHA Scientific Advisory with enthusiasm and consider their own individual-level call to action, focused on seeking “out opportunities to further the goals of and objectives outlined” in the NPAP. Such an approach aligns perfectly with the physical activity movement. Personal commitment by all individuals in each sector that positively influences physical activity patterns, from one person to the population, captures the key message in the current AHA Scientific Advisory on a much broader scale with a potential for significantly greater impact.

Rethinking What Constitutes a Physically Active Lifestyle, At Least at the Onset of a Change in Lifestyle

Consistent with current recommendations, Kraus et al¹ “recommends that adults 20 years and older perform ≥150 min/week of moderate intensity activity or ≥75 min/week of vigorous intensity activity, or a combination thereof.” This is a justifiable ultimate goal that all individuals should strive towards. However, levels of physical activity below these recommendations can result in substantial health benefits.^{11, 12} One of the seminal studies (London bus conductor study) demonstrating physical activity levels below the current standard recommendations produced substantial health was published in the early 1950s.^{13, 14} As such, an overarching imperative should be to move individuals from a completely sedentary lifestyle to some level of physical activity, even if it is below the level associated with current recommendations. This may be a more realistic approach to initiating a lifestyle that incorporates increased physical activity, particularly in individuals that are starting from a sedentary level. Higher levels of physical activity can be up-titrated as appropriate. This by no means implies that individuals should strive to underachieve with respect to physical activity levels. In fact, the greatest impact with respect to healthcare expenditures is achieved through physical activity levels at or above the recommended levels.¹⁵ However, it is important to note that some level of physical activity is better than no physical activity at all. Taking such an approach, starting at lower than optimal exercise volumes and up-titrating in an individually tailored fashion to recommended levels, may ultimately have a more favorable impact on increasing physical activity for the long term.

Health Assessment Prior to Increasing Physical Activity is Also an Important Role for Health Care Professionals

The current AHA Scientific Advisory appropriately highlights the importance of the health care sector in promoting a physically active lifestyle to patients receiving care. To the question posed at the beginning of this section, “should health care providers be doing more?”¹, I would unequivocally answer “yes.” The health risks associated with being sedentary far outweigh the risk of adverse events associated with participating in moderate intensity physical activity, even for the vast majority of individuals at risk for or diagnosed with cardiovascular disease.1^{1, 16, 17} Moreover, “asymptomatic men and women who plan to be physically active at the minimum levels of moderate-intensity activity do not need to consult with a physician or health care provider prior to beginning unless they have specific medical questions.”¹⁸ However, for those individuals receiving medical care, prior to prescribing a more physically active lifestyle, health care professionals carry the responsibility of gathering the following information: 1) quantifying the number traditional cardiovascular risk factors; 2) determining the presence of signs and/or symptoms indicating the potential for an active pathophysiologic process; and 3) diagnosing pre-existing medical conditions.¹⁷ This information is used to determine if any additional assessments are needed prior to initiating a more physically active lifestyle. Most individuals will not require any additional testing after the general health assessment and can immediately begin increasing their time spent engaging in moderate-intensity physical activity. This approach is viewed as best practice for health care professionals and is not a barrier to increasing physical activity.

Using Technology to Expand Physical Activity Initiatives

To impact physical activity patterns on any level, in particular on a population level, individuals committed to the cause would highly benefit from tools that can increase reach and enhance the ability for those receiving the intervention to independently monitor and be compliant with a more physically active lifestyle. The use of technology, in particular mobile and wearable devices and the internet, have great potential to increase physical activity patterns on a global scale.^{19, 20} If applied on a large scale, relatively small increases in physical activity facilitated through technology can have a potentially large impact on population health.¹⁹

Conclusion: Are you a Physical Activity Ambassador?

I would like to conclude this commentary with a self-reflection. I have a long history of service to the AHA, and, thus, it is important to determine if I have answered the call to action put forth by Kraus et al.¹ I have authored or co-authored numerous original investigations, reviews, and AHA Scientific Statements/Advisories related to the value of physical activity. I have presented on this topic around the world at scientific meetings and universities; of particular note, I co-chaired the AHA Global Physical Activity Congress in 2014.^{3, 21} In the academic courses I have taught over the years, stressing the importance of physical activity to future health care providers was a common theme. I have led or supported a number of interdisciplinary initiatives that integrate physical activity assessment and promotion into the medical model. One may read this component of my self-reflection and feel I have answered the call. My professional record is, however, not the strongest case I can make.

I am a lifelong exerciser, now with two children, Annamaria who is 9 years old and Anthony who is 8. I am very committed to being a good role model to my children, including showing them how to lead a physically active life. We live in downtown Chicago, space in the apartment is at a premium and the elliptical is placed in plain site; I exercise on it every morning. From an early age, my children would come talk to me about exercise as I was on the elliptical. About a year ago, Anthony, who was talking to me, suddenly went to his room. He came back 5 minutes later, after he changed into exercise clothes. He said “Dad, are you almost done because I need to exercise”. I got off and Anthony exercised for 20 minutes, Annamaria was right behind him. They now exercise regularly, without prompting, managing their own exercise routine appropriately. They also keep track of their steps and are determined to hit their goals of 10,000 steps daily. I never pressured them, and never told them they had to exercise, I just tried to be a good role model.

So to conclude, have I answered the AHA call to action, am I a physical activity ambassador “through both professional and personal efforts”1? I think I can confidently say yes to both. Can you?