Exercise in Primary Care

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Exercise Recommendations in Primary Care By Movicque King, Brandon Schabacker, and Jordan Feigenbaum

Transcript of Exercise in Primary Care

Exercise Recommendations in

Primary CareBy

Movicque King, Brandon Schabacker, and Jordan Feigenbaum

Exercise Prescription & Quality ImprovementExercise is under utilized in medicineThere is a knowledge gap about exercise in

healthcare providersExercise offers potential for decreased morbidity

and mortalityExercise offers potential for decreased health

care spendingResources

OutlineBackground on exercise guidelines Data review on exercise counseling by providersHealth outcomes affected by exercise

prescriptionFinancial outcomes for decreased health care

spendingResources

Background on Exercise GuidelinesAmerican 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 activityrecommendations: how much is enough? Am J Clin Nutr 2004;79(5):913S-20S.

Background on Exercise GuidelinesUpdated 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 GuidelinesWho 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 SummaryThe 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 SummaryWhat 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 SummaryWhat 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 SummaryWhat 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 RPEWhat 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 ratee.g. RPE of 12=

120bpmWell 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 exerciseSchultzer 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%296

1031-9/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