AHA Strengthens Stand on Exercise for Disease Prevention

Damian McNamara

April 11, 2018

The importance of physicians promoting physical activity for patients to prevent or ameliorate the risk for stroke, Alzheimer's disease, cardiovascular disease, and many other conditions has been promulgated by medical societies and researchers for years. However, no group has specifically addressed the feasibility, validity, and effectiveness of assessing and promoting physical activity in a healthcare setting — until now.

A new scientific statement from the American Heart Association (AHA) takes a pragmatic approach: highlighting recent research, offering solutions, and recommending a "systems change" approach.

Recognizing the challenges of counseling adults about behavior change, the 12 authors suggest healthcare providers no longer go it alone. Other clinicians, community leaders, and fitness experts can help get people moving and reduce their risk for morbidity and mortality from conditions associated with physical inactivity.

Physical activity plays a significant role, the authors state, for prevention and management of more than 40 diseases beyond cardiovascular disease. Obesity, diabetes mellitus, cancer, depression, Alzheimer's disease, arthritis, and osteoporosis are prime examples.

"Up until now the approach has not been standardized," lead statement author, Felipe Lobelo, MD, PhD, chair of the AHA Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health, told Medscape Medical News. "It has been essentially up to the clinician to do it or not."

Patients could be better served by using validated tools, recording findings in an electronic medical record system or using results to guide specific counseling or referral to behavioral interventions, added Lobelo, an associate professor in the Hubert Department of Global Health at Emory University's Rollins School of Public Health in Atlanta, Georgia.

The AHA Scientific Statement was published online April 4 in Circulation.

Physical Activity a "Vital Sign"

"Although the exact mechanisms behind PA [physical activity] as an independent modifiable risk factor remain incompletely elucidated, strong evidence suggests that regular PA slows and even reverses adverse vascular remodeling associated with aging," the statement authors note.

The AHA includes a physically active lifestyle as one of seven factors in their My Life Check - Life's Simple 7 interventions to reduce risk for cardiovascular disease and to improve overall health.

The association also promotes physical activity as part of its 2020 Impact Goals to improve cardiovascular health and reduce deaths caused by stroke and cardiovascular disease.

The current 33-page statement complements and builds on previous AHA guidance on the assessment of physical activity for clinical and research applications (Circulation. 2013;128:2259-2279).

"The role of physical activity in the primary, secondary and tertiary prevention of stroke, Alzheimer's, Parkinson's and other neurologic conditions is well established," Lobelo said (Stroke. 2014;45:2532-2553; JAMA Neurol2013;70:156-157).

"Routine documentation of patient's physical activity levels — as a vital sign — in the medical record will enable healthcare providers to routinely discuss how physical activity habits fit in the patient's management plans," he added.

Lobelo and colleagues compared physical activity questionnaires examined in systematic reviews in the literature up until 2016. A total 14 questionnaires met their initial criteria (up to 12 items; less than 5 minutes to complete).

When they ranked them, the Rapid Assessment of Physical Activity emerged with the highest score, followed in order by the single question by Milton et al (Br J Sports Med. 2011;45:203-208), the Physical Activity Vital Sign, and the Exercise Vital Sign (each consisting of two questions).

Highlighting a number of valid and feasible questionnaires gives providers an option to choose the best assessment method for their individual practice, the authors write.

Given the competing priorities of healthcare providers, the statement recommends integrating physical activity assessment into the clinical workflow; this can be accomplished at patient check-ins, when taking vital signs, or as part of the rooming process.

Wearables

The statement authors also examined and ranked wearable activity monitoring (WAM) devices. The authors evaluated WAMs for validity, ability to assess adherence to physical activity guidelines, patient feasibility, feasibility for healthcare system integration, and incorporation of evidence-based methods of behavior change.

Of the 23 devices that met their criteria for validity and feasibility, they ranked two products the highest: the Fitbit Zip and Fitbit One.

However, there were several caveats. Few devices collect and report data in a manner that enables assessment of adherence to the physical activity guidelines.

In addition, there is no widespread integration of patient-generated data from wearable devices into electronic medical record systems, and studies in the literature tend to address versions that are no longer available by the time of publication.

"The other major practical challenge to routine PA assessment and prescription is how to review PA data within the clinical workflow," the authors write.

"Consumer devices provide near-continuous daily measures of PA, which would be overwhelming for the provider to review on a regular basis or in the context of a clinic visit."

The statement authors address some challenges associated with patient counseling.

"The PA guidelines may be perceived by some inactive individuals as too difficult to achieve," they write. They suggest providers explain recommendations for at least 60 to 100 minutes of physical activity per week, ideally in 10-minute increments of at least moderate-intensity physical activity.

A further recommendation is engaging in muscle strengthening, resistance, and flexibility exercises for major muscle groups at least twice a week.

To increase the utility of counseling, the authors recommend identifying each individual's readiness for changing their behavior. If a patient is in a precontemplative phase, for example, provide education on the benefits of physical activity.

In contrast, if a person is motivated to make changes, suggest specific goals and/or refer to resources in the community.

The AHA statement proposes a role for physical therapists, nurses, nurse practitioners, and fitness professionals.

"Single-setting interventions typically result in only low to modest improvements in PA…[so] no single intervention will solve the problem of insufficient PA in the United States," according to the statement.

Rather, a coordinated, multilevel strategy or "systems change" approach is necessary to spark the vital institutional and personal impetus for healthcare systems and providers, respectively, to break the barriers that impede integration of clinical community links for physical activity promotion.

"We need to move away from episodic care that occurs once every 6 months in 15-minute visits to models that include community care extensors that can address these aspects more effectively and efficiently than clinicians in the confines of the hospital/health care system," Lobelo said. "Other countries have had successful experiences doing this, so it is possible."

Physicians Need to "Walk the Talk"

Commenting on the statement for Medscape Medical News, Evan Pasha, PhD, a postdoctoral research fellow at the UT Southwestern Medical Center Institute of Exercise and Environmental Medicine in the Cerebrovascular Laboratory in Dallas, Texas, said he completely agrees that a "system change" approach is needed to shift healthcare to a prevention-oriented model.

"Such a change could have profound effect on the prevalence of modifiable cardiovascular [risk factors] and related diseases, such as sarcopenia and even dementia," he said.

He added that physicians need to be more adept at exercise prescription and actively work with physical therapists toward the goal of regular physical activity.

"This coordination between physicians and exercise professionals is extremely important because behavior change is so difficult, and would give the patient the best expertise and chance of success in improving physical activity behavior," he said.

He noted that there are many barriers inherent in accurately assessing physical levels because it's "well-known that physical activity questionnaires are highly subject to recall biases."

"This is why the rise of wearable technologies that objectively characterize physical activity is so interesting. However, with varying validation across devices and difficulties accurately characterizing intensity, even these objective measures have their shortcomings.

"Despite these barriers, quantifying physical activity can begin the important conversation of necessary lifestyle changes to increase physical activity between a physician and patient to prevent or delay the onset of avoidable cardiovascular diseases," he added.

When it comes to behavior change counseling, "like any intervention, there will be adopters and nonadopters," Lobelo said. The number needed to treat for one sedentary adult to meet physical activity recommendations at 1 year was 12.

"This is comparable to other preventive counseling interventions in primary care," he added, including 9.1 needed to treat for alcohol counseling and 14 needed to treat with smoking cessation counseling.

"Sometimes patients ask me what is the best app, Sudoku or game for brain health. I typically say any — just make sure to go for a 30-minute walk first and then get on that app," Lobelo said. "Also walking the talk is a big component… the biggest predictor of a clinician providing [effective] physical activity counseling is if that clinician is physically active."

Lobelo and Pasha have disclosed no relevant financial relationships.

Circulation. Published online April 4, 2018. Abstract

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