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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
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
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.
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.
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.
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.
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.
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.
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….
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
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)
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
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
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/

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Exercise in Primary Care

  • 1.
  • 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/