The Call for a Physical Activity Vital Sign in Clinical Practice

Abstract

According to the Bureau of Labor Statistics, the most common shared occupational health risk is sedentary behavior. Physical inactivity increases the relative risk of coronary artery disease, stroke, hypertension, and osteoporosis by 45%, 60%, 30%, and 59%, respectively.1Booth F.W. Lees S.J. Fundamental questions about genes, inactivity, and chronic disease.Physiol Genomics. 2007; 28: 146-157Crossref PubMed Scopus (125) Google Scholar Epidemiologic data suggest that physical inactivity is associated with an increased risk of 25 chronic diseases.2Booth F.W. Gordon S.E. Carlson C.J. Hamilton M.T. Waging war on modern chronic diseases: primary prevention through exercise biology.J Appl Physiol (1985). 2000; 88: 774-787PubMed Google Scholar Because approximately 90% of American adults do not meet current physical activity guidelines,3Tucker J.M. Welk G.J. Beyler N.K. Physical activity in U.S. adults: compliance with the Physical Activity Guidelines for Americans.Am J Prev Med. 2011; 40: 454-461Abstract Full Text Full Text PDF PubMed Scopus (716) Google Scholar deaths attributable to physical inactivity may soon exceed those attributed to cigarette smoking.4Lee I.M. Shiroma E.J. Lobelo F. et al.Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.Lancet. 2012; 380: 219-229Abstract Full Text Full Text PDF PubMed Scopus (5014) Google Scholar, 5Mokdad A.H. Marks J.S. Stroup D.F. Gerberding J.L. Actual causes of death in the United States, 2000.JAMA. 2004; 291: 1238-1245Crossref PubMed Scopus (4362) Google Scholar For these reasons, physical inactivity is increasingly recognized as a major public health problem.6Blair S.N. Physical inactivity: the biggest public health problem of the 21st century.Br J Sports Med. 2009; 43: 1-2PubMed Google Scholar Increasing physical activity is reflected in improved cardiorespiratory fitness, expressed as metabolic equivalents (METs; 1 MET = 3.5 mL O2/kg/min), which in turn correlates with a reduced risk of cardiovascular disease.7Williams P.T. Physical fitness and activity as separate heart disease risk factors: a meta-analysis.Med Sci Sports Exerc. 2001; 33: 754-761Crossref PubMed Scopus (549) Google Scholar In persons with and without heart disease, each 1-MET increase in cardiorespiratory fitness is associated with an approximately 15% reduction in mortality.8Kodama S. Saito K. Tanaka S. et al.Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis.JAMA. 2009; 301: 2024-2035Crossref PubMed Scopus (2008) Google Scholar, 9Boden W.E. Franklin B.A. Wenger N.K. Physical activity and structured exercise for patients with stable ischemic heart disease.JAMA. 2013; 309: 143-144Crossref PubMed Scopus (38) Google Scholar In addition, individuals with low cardiorespiratory fitness have higher annual healthcare costs,10Weiss J.P. Froelicher V.F. Myers J.N. Heidenreich P.A. Health-care costs and exercise capacity.Chest. 2004; 126: 608-613Crossref PubMed Scopus (31) Google Scholar, 11Mitchell T.L. Gibbons L.W. Devers S.M. Earnest C.P. Effects of cardiorespiratory fitness on healthcare utilization.Med Sci Sports Exerc. 2004; 36: 2088-2092Crossref PubMed Scopus (21) Google Scholar higher rates of surgical complications,12Kaminsky L.A. Arena R. Beckie T.M. et al.The importance of cardiorespiratory fitness in the United States: the need for a national registry: a policy statement from the American Heart Association.Circulation. 2013; 127: 652-662Crossref PubMed Scopus (250) Google Scholar and are 2 to 3 times more likely to die prematurely than their comparably fitter counterparts.13Wei M. Kampert J.B. Barlow C.E. et al.Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men.JAMA. 1999; 282: 1547-1553Crossref PubMed Scopus (869) Google Scholar, 14Myers J. Prakash M. Froelicher V. et al.Exercise capacity and mortality among men referred for exercise testing.N Engl J Med. 2002; 346: 793-801Crossref PubMed Scopus (2857) Google Scholar, 15Gulati M. Pandey D.K. Arnsdorf M.F. et al.Exercise capacity and the risk of death in women: the St James Women Take Heart Project.Circulation. 2003; 108: 1554-1559Crossref PubMed Scopus (556) Google Scholar, 16Wickramasinghe C.D. Ayers C.R. Das S. et al.Prediction of 30-year risk for cardiovascular mortality by fitness and risk factor levels: the Cooper Center Longitudinal Study.Circ Cardiovasc Qual Outcomes. 2014; 7: 597-602Crossref PubMed Scopus (36) Google Scholar Collectively, these data and other recent reports17Franklin B.A. Brinks J. Sacks R. et al.Reduced walking speed and distance as harbingers of the approaching Grim Reaper.Am J Cardiol. 2015; 116: 313-317Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar suggest that the primary beneficiaries of regular exercise seem to be those constituting the bottom 20% of the cardiorespiratory fitness/physical activity continuum, and that even simple walking metrics can provide independent and additive prognostic information. Although the American Heart Association recently emphasized that physical inactivity represents a leading cause of death worldwide,18Kraus W.E. Bittner V. Appel L. et al.The National Physical Activity Plan: a call to action from the American Heart Association: a science advisory from the American Heart Association.Circulation. 2015; 131: 1932-1940Crossref PubMed Scopus (114) Google Scholar the beneficial effects of regular exercise are generally underestimated by many clinicians.19Wen C.P. Wu X. Stressing harms of physical inactivity to promote exercise.Lancet. 2012; 380: 192-193Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Consequently, the burden of physical inactivity continues to grow as physical activity is suboptimally addressed in most clinical encounters. These represent missed opportunities to counsel patients and use proven behavioral interventions,20Berra K. Rippe J. Manson J.E. Making physical activity counseling a priority in clinical practice: the time for action is now.JAMA. 2015; 314: 2617-2618Crossref PubMed Scopus (99) Google Scholar, 21Writing Group for the Activity Counseling Trial Research Group Effects of physical activity counseling in primary care: the Activity Counseling Trial: a randomized controlled trial.JAMA. 2001; 286: 677-687Crossref PubMed Scopus (315) Google Scholar, 22Lin J.S. O'Connor E. Evans C.V. et al.Behavioral counseling to promote a healthy lifestyle in persons with cardiovascular risk factors: a systematic review for the U.S. Preventive Services Task Force.Ann Intern Med. 2014; 161: 568-578Crossref PubMed Scopus (134) Google Scholar including pedometers, accelerometers, smart-phone apps,23Sallis R. Franklin B. Joy L. et al.Strategies for promoting physical activity in clinical practice.Prog Cardiovasc Dis. 2015; 57: 375-386Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar and heart rate monitors.24Wicks J.R. Oldridge N.B. Nielsen L.K. Vickers C.E. HR index–a simple method for the prediction of oxygen uptake.Med Sci Sports Exerc. 2011; 43: 2005-2012Google Scholar, 25Fowler G.A. Stop counting 10,000 steps; check your personal activity intelligence.Wall Street Journal. January 20, 2016; Google Scholar Accordingly, habitual physical activity, the key determinant of cardiorespiratory fitness, should be considered a “vital sign.” Vital signs (eg, blood pressure, heart rate, tobacco use) are metrics that reflect key parameters underlying health and disease. Their ubiquity in clinical practice is driven by several factors. First, vital signs inform clinicians about the likelihood of future disease and the presence and severity of acute and chronic illness. Second, they provide temporal trends that may signify occult, subclinical disease or the favorable impact of lifestyle and/or pharmacologic intervention. Finally, they represent discrete quantitative measurements that can be used to educate and engage patients in the therapeutic process. In this role, vital signs are most effective when they can be linked to health outcomes that have direct meaning to both patient and provider. Smoking status, a metric that fulfills the criteria delineated above, provides an example of a successful vital sign implementation. After the development of a broad literature base dating back to the 1950s that firmly established tobacco use as a potent risk factor for numerous chronic diseases,26Doll R. Hill A.B. The mortality of doctors in relation to their smoking habits: a preliminary report.Br Med J. 1954; 1: 1451-1455Crossref PubMed Scopus (506) Google Scholar it became standard of care to inquire about and document smoking status during routine clinical encounters. This initiative was driven by recognition that assessment of smoking status could more precisely delineate the risk of future disease as well as disease progression, thereby facilitating the implementation of targeted efforts to promote tobacco cessation. Widespread adoption of a smoking status vital sign played a key role in the successful reduction of smoking prevalence from >40% to approximately 19% among American adults.27Centers for Disease Control and Prevention. Trends in current cigarette smoking among high school students and adults, United States, 1965–2014. Available at: www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/. Accessed March 30, 2016.Google Scholar Because of the prevalence of physical inactivity, a metric with comparable or perhaps even greater clinical ramifications, timely assessment and treatment using a similar approach is warranted. The goal of a physical activity vital sign is to ensure that the physical activity habits of every patient are assessed at each visit, and that patients are briefly counseled as to whether they are meeting the US Physical Activity Guidelines recommendation of at least 150 minutes per week of moderate-intensity activity (eg, brisk walking). We submit that universal implementation of a physical activity vital sign is the logical first step toward ensuring all patients understand the proven connection between regular physical activity and optimal health. Currently a physical activity vital sign is successfully being used in several large healthcare systems, including Kaiser Permanente, Intermountain Healthcare (Utah), and the Greenville Health System (South Carolina). It consists of 2 brief questions that are generally asked by a medical assistant when they are recording traditional vital signs: 1) “On average, how many days per week do you engage in moderate-to-vigorous physical activity (like a brisk walk)?” and 2) “On average, how many minutes do you engage in physical activity at this level?” These responses are multiplied to give minutes per week of reported moderate or greater physical activity. The result is then recorded into the chart for that visit alongside traditional vital signs. Implementation of this physical activity vital sign on 2.1 million adult patients at Kaiser Permanente in Southern California demonstrated an 85% capture rate during the first year.28Coleman K.J. Ngor E. Reynolds K. et al.Initial validation of an exercise “vital sign” in electronic medical records.Med Sci Sports Exerc. 2012; 44: 2071-2076Crossref PubMed Scopus (212) Google Scholar The experience at Kaiser and other large healthcare systems proves that a physical activity vital sign can be implemented efficiently in even large healthcare systems, with minimal disruptions in work flow and time management. It is recommended that healthcare providers review the physical activity vital sign and offer 1 of 2 recommendations. The first is to congratulate the patient who is currently meeting physical activity guidelines and to encourage them to continue this activity level. The second is to inform patients doing lesser amounts of weekly exercise that they are not meeting the physical activity guideline, while highlighting the proven health benefits that this amount of physical activity confers. Emphasizing the beneficial effect of physical activity on any disease process that the patient currently has (or is at risk for) helps to personalize this message and to make him/her more likely to comply with an exercise prescription. Important calls to action to make physical activity a priority in clinical settings have recently been made, including one from the 19th Surgeon General of the United States, Vivek Murthy.29US Department of Health and Human Services Step It Up! The Surgeon General's Call to Action to Promote Walking and Walkable Communities. US Dept. of Health and Human Services, Office of the Surgeon General, Washington, DC2015Google Scholar This directive is different in that it is specifically aimed at you the clinician. Prioritization of physical activity in the clinical setting is easily and effectively operationalized by implementation of a physical activity vital sign. The purpose of this editorial is 3-fold. First, we aim to emphasize the critical importance of addressing physical activity with each of your patients. Second, we propose the use of a physical activity vital sign as means to accomplish this important goal. Third, we strive to provide you with the tools, references, and resources (see exerciseismedicine.org) to begin this process that we believe will enhance patient outcomes in your clinic or healthcare system. It has been suggested that “a prescription to walk 30 minutes per day could be one of the most important prescriptions a patient could receive.”20Berra K. Rippe J. Manson J.E. Making physical activity counseling a priority in clinical practice: the time for action is now.JAMA. 2015; 314: 2617-2618Crossref PubMed Scopus (99) Google Scholar Clinicians play a trusted and influential role in providing needed care and counsel to patients and can offer a powerful nudge to getting patients more active. Perhaps Joseph Alpert summed it up best.30Alpert J.S. You only have to exercise on the days that you eat.Am J Med. 2011; 124: 1Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar When asked by friends or family, “How often should I exercise?”, he replied, “Only on the days you eat.” The time is now—today—to address physical activity through the use of a physical activity vital sign with all your patients.