This individual project will focus on a case study about Kaiser Exercise Vital Sign program and the details of the case study and questions requiring written responses can be found in the file “HCD510 Kaiser…” below.
Submit your responses in a voice over PowerPoint or Prezi with one slide for your response to each question followed by a reference slide). So, there will be 8 slides in all: (title slide, question responses, and reference slide. DO NOT put all you have to say on the slide, but use it for highlights and augment the points you are making through your voice over. In other words, DON’t just read the slides. Make sure your references are cited where used in the question responses and linked to the reference page as you would in a written paper.
12-SHCD
September 1, 2013
Temperature, check. Pulse, check. Oxygen, check. Exercise?
An individual visiting a physician’s office is accustomed to having vital signs measured at every
appointment. A doctor, nurse or medical assistant will check the patient’s pulse rate,
temperature, blood pressure and respiratory rate as a way to assess how the body is
functioning. In a revolutionary move, Kaiser Permanente has adopted a fifth vital sign, one that
evaluates a patient’s level of physical activity. Measuring this vital sign is giving health care
professionals a key to unlocking one of the most powerful yet under-utilized prevention tools
available to patients – exercise.
Champions for change
When Dr. Robert Sallis, MD, assumed the role of president of the American College of Sports
Medicine (ACSM) in 2007, his agenda was singular. A board-certified family medicine physician
who completed his residency at Kaiser Permanente in southern California and still practices
with that organization today, Dr. Sallis underwent additional training in the field of sports
medicine and was acutely aware of the positive impact of physical activity on the short and
long-term health of his patients. Concurrent research also delivered clear evidence regarding
the role of exercise in reducing the occurrence of largely preventable conditions like Type 2
diabetes, heart disease, obesity and even certain cancers, as well as promoting overall physical
health and emotional well-being. The sedentary lifestyle was already a key contributor to a fullscale public health crisis, as evidenced by these findings reported by the ACSM:
•
•
•
•
According to the World Health Organization’s 2004 Global Health Risks data, after high
blood pressure, tobacco use and high blood glucose, physical inactivity constitutes the
fourth leading cause of death globally, with about 3.3 million attributable deaths per
year. More recent evidence (2009) using direct measure, rather than survey data, shows
physical inactivity to be the leading cause of death in the U.S.
More than half of adults (56 percent) do not meet the recommendations for sufficient
physical activity in the 2008 Physical Activity Guidelines.
In a study of older adolescents and adults in the US, participants spent almost eight
hours a day in sedentary behaviors, while as many as 36 percent of adults engaged in no
leisure-time physical activity at all.
A study in 2008 shows that physical inactivity costs the U.S. health care system $330 per
person each year, an annual expense of $102 billion.
Kerry Hamilton, MBA, prepared this case on behalf of the Arizona State University School for the Science of Health Care Delivery. The case is
based on field research and interviews with representatives from health care organizations. The case was developed solely for the purpose of class
discussion and is not intended as an endorsement, primary data or an illustration of effective or ineffective management. Some names and
identities have been changed to protect confidentiality.
Copyright©2013 Arizona State University. This publication may not be digitized, photocopied or otherwise reproduced without express written
consent from Arizona State University.
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•
Forty percent of U.S. primary care doctors and 36 percent of U.S. medical students do
not meet 2008 federal physical activity guidelines. Physically inactive doctors are less
likely to provide exercise counseling to patients and provide less credible role models
for the adoption of healthy behaviors. Not surprisingly, only 34 percent of U.S. adults
report having received exercise counseling at their last medical visit.
The aforementioned statistics further underscored Dr. Sallis’ goal while helming the ACSM: To
launch an initiative that would compel health care systems and physician practices to integrate
a physical activity vital sign as a pathway to prescribing exercise to patients.
Dr. Sallis’ first move was to facilitate a partnership with Dr. Ronald Davis, the president of the
American Medical Association (AMA) at the time. Dr. Davis shared Dr. Sallis’ perspectives on the
tremendous value of exercise in protecting patient health and the two organizations aligned to
issue an imperative to the medical profession, calling on all health care providers to assess and
review every patient’s physical activity program at every visit. Together, they unveiled a
national campaign called Exercise is Medicine® later that year.
The organizations established a set of shared guiding principles for Exercise is Medicine, which
were developed, according to materials published by the joint initiative, to “improve the health
and well-being of our nation through a regular physical activity prescription from doctors and
other health care providers.” Specifically, the guiding principles stated the following:
•
•
•
Exercise and physical activity are important to health and the prevention and treatment
of many chronic diseases.
More should be done to address physical activity and exercise in healthcare settings.
ACSM and AMA are making efforts to bring a greater focus on physical activity and
exercise in healthcare settings.
The campaign delivered communications and proven resources to arm healthcare providers,
health and fitness professionals, the community, media and even government organizations
with the tools they needed to integrate a physical activity vital sign on a large scale. Once the
initiative was launched, Dr. Sallis next set his sights on his own employer, Kaiser Permanente
(KP). He was determined to convert his vision to reality by earning acceptance of the exercise
vital sign by one of the nation’s largest and most recognized health maintenance organizations
(HMOs).
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Temperature, check. Pulse, check. Oxygen, check. Exercise?
Making exercise vital at KP
Implementing a physical activity vital sign at KP was no small task, but Dr. Sallis was riding the
wave of momentum from the launch of the Exercise is Medicine (EIM) campaign and was ready
for the challenge. KP was the ideal institution to integrate an exercise vital sign because, as an
HMO, the organization optimizes its financial health when its patients are healthy. In Dr. Sallis’
words, “Our motives are vastly different than those of a typical private practice. We do not
operate a fee-for-service model. An exercise vital sign makes sense in our practice setting
because exercise is such a powerful treatment form.”
Ample evidence was available to demonstrate the power of physical activity as a form of
medical treatment. The ACSM regularly called out data as part of its EIM effort to make a case
to the healthcare community, including the following:
•
•
•
•
•
•
Research shows that a low level of physical activity exposes a patient to a greater risk of
dying than does smoking, obesity, hypertension, or high cholesterol, and for older men,
regular physical activity can decrease the risk of death by 40 percent.
Active individuals in their 80s have a lower risk of death than inactive individuals in their
60s.
Regular physical activity can:
o Reduce mortality and the risk of recurrent breast cancer by approximately 50
percent.
o Lower the risk of colon cancer by over 60 percent.
o Reduce the risk of developing of Alzheimer’s disease by approximately 40
percent.
o Reduce the incidence of heart disease and high blood pressure by approximately
40 percent.
o Lower the risk of stroke by 27 percent.
o Lower the risk of developing Type 2 diabetes by 58 percent.
o Be twice as effective in treating Type 2 diabetes than the standard insulin
prescription and can save $2250 per person per year when compared to the cost
of standard drug treatment.
o Decrease depression as effectively as Prozac or behavioral therapy.
Adults with better muscle strength have a 20 percent lower risk of mortality (33 percent
lower risk of cancer-specific mortality) than adults with low muscle strength.
A low level of fitness is a bigger risk factor for mortality than mild-moderate obesity. It is
better to be fit and overweight than unfit with a lower percentage of body fat.
Regular physical activity has been shown to lead to higher SAT scores for adolescents.
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Temperature, check. Pulse, check. Oxygen, check. Exercise?
•
In an elementary school setting, regular physical activity can decrease discipline
incidents involving violence by 59 percent and decrease out of school suspensions by 67
percent.
Armed with this evidence, the influence of the EIM initiative, and his personal drive to
transform public health through exercise, Dr. Sallis set forth to make his own case to KP.
Convincing the skeptics
Founded in 1945, Oakland, Calif.-based Kaiser Permanente cares for nearly 10 million patients
across the nation. The largest contingent of those patients – approximately 7 million – reside in
California. The organization has three arms: Kaiser Health Plan, a nonprofit organization which
enrolls members in the HMO insurance plan; Permanente Medical Group, the for-profit
physician group contracted by Kaiser Health Plan to provide care for members; and the
nonprofit Kaiser Foundation Hospitals, where members receive acute and emergency care.
Under the staff model HMO, Kaiser members pay a monthly premium for care rendered by KP
physicians and allied health professionals at KP facilities. KP has a history of investing heavily in
prevention and wellness programming to improve the health of their members and avoid the
costs associated with advanced-stage disease. As such, encouraging members to engage in
regular physical activity remains a high priority in KP’s mission to promote total health.
Because of his affiliation with the Permanente Medical Group and its direct and regular access
to KP members in outpatient settings, Dr. Sallis focused his attention there to gain acceptance
for a physical activity vital sign. KP was an early adopter of an innovative electronic medical
record (EMR) system called HealthConnect, so incorporating the vital sign prompt into the
system could be accomplished without an overwhelming amount of time or money. Still, initial
cost estimates indicated adding this fifth vital sign would require an investment of hundreds of
thousands of dollars simply to reprogram the technology, not including any training,
communications or data collection.
An organization the size of KP means layers of decision makers, all of whom have different
priorities and objectives, so Dr. Sallis was singlehandedly charged with convincing leadership in
the information technology, financial and clinical divisions of the worthiness of this endeavor.
He started by meeting one-on-one with decision makers in each of these areas, to secure their
endorsement and demonstrate cross-department support. Along the way, Dr. Sallis was able to
connect with KP’s chief medical officer in southern California, a proponent of exercise who
believed the proposed pilot program was warranted, and identified another highly placed
leader in northern California who concurred.
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Temperature, check. Pulse, check. Oxygen, check. Exercise?
After months of meetings, negotiations and discussions, Dr. Sallis received approval to
implement the fifth vital sign in the southern California locations of the Permanente Medical
Group. He drew up an implementation plan for what KP would term the Exercise Vital Sign
(EVS) that involved him making personal visits to every Permanente Medical Group in southern
California. Dr. Sallis made presentations to the staff to explain the purpose of the EVS, provided
training on its use, explained the health and fitness referral resources available when providers
issued an exercise prescription, and secured champions in each facility to assist in the roll-out.
The EVS initiative was assigned to the Patient Education department, and Dr. Sallis obtained
assistance from experts in that department and in regional locations to support the
introduction and integration of the EVS. Implementation commenced in October 2009.
Careful thought was given to the most effective methods to encourage adoption of the EVS by
Permanente Medical Group providers. Already, physicians and staff complained about extra
responsibilities and documentation requirements, so mandating the EVS was not considered
optimal. As a practicing physician, Dr. Sallis empathized with the frustration of his colleagues,
and in order to gain acceptance for the EVS, he recognized a heavy-handed approach could sink
the initiative from the start. Rather, he focused his messaging on the positive outcomes that
could be generated for patients using the EVS and the overall value of the fifth vital sign in
advancing total health, a goal for all Permanente Medical Group staff. Also, Dr. Sallis knew that
his pilot program could only grow if enough data on individual patients’ physical activity was
captured, so he was necessarily reliant on his colleagues to engage in the initiative in order to
fulfill his own vision.
The standard forms of communication when rolling out a clinical effort of this magnitude were
utilized for the EVS implementation. Internal handouts, memos, posters, mock prescription
pads highlighting the EVS and similar reminders or flags complemented Dr. Sallis’ team training
meetings with medical assistants (MAs), the individuals responsible for taking vital signs.
Also, physicians regularly receive reports of their compliance with EMR standards, and
physician names are listed with statistics on their use and fulfillment of EMR categories for
patient charts. While the EVS was not mandated, these reports showed publicly which
physicians were completing charts to their fullest. Since MAs are graded on their usage of EMRs
by their supervising physicians, this report was a trigger for physicians to address any missing
information with support staff. The competitive nature of issuing public reports also functioned
as a catalyst to gain compliance.
While extremely time-consuming and exhausting, Dr. Sallis’ more personalized approach to
implementation, with in-person meetings and no hard mandates, proved to be the right
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Temperature, check. Pulse, check. Oxygen, check. Exercise?
combination. In year one, 81 percent of adult KP members who had an office visit had an EVS
recorded in their chart.
The EVS in action
A valid measurement of physical activity has been historically difficult to capture. Unlike other
vital signs, which are taken using instruments like a thermometer for temperature or a
sphygmomanometer for blood pressure, no proven clinical assessment tool exists for exercise.
Thus, KP approached its design of the EVS with accuracy, timeliness and documentation
requirements in mind, recognizing that exercise behavior is still largely self-reported.
The goal was to provide a numerical value for the minutes per week or at least moderate
exercise, as reported by the patient, and to record that value at each visit. The EVS was also
linked the first strategy of the National Physical Activity Plan (NPAP) for the health care sector,
specifically, “Strategy 1: Make physical activity a ‘vital sign’ that all health care providers assess
and discuss with their patients.” KP borrowed from many of NPAP’s recommended tactics for
implementation to keep the process simplified and useful for all parties involved. As such, two
short questions were integrated into the EMR:
1. On average, how many days each week do you engage in moderate or greater physical
activity (like a brisk walk)?
2. On those days, on average, how many minutes do you engage in this physical activity?
The EMR software multiplies the two answers to generate the patient’s minutes per week of
exercise, which is displayed in the vital sign header. The patient’s body mass index and tobacco
use history are also captured in the software. Using the number, the system promptly evaluates
the patient’s activity level relative to the suggested federal guideline of at least 150 minutes per
week for adults and 420 minutes for children, and signals the provider to counsel the patient on
the value of exercise to health and the resources available if he or she is not meeting the
guideline.
Once the patient is flagged, the physician can refer the patient to KP’s Healthy Living Help Line.
Information about the help line is included in the patient’s discharge instructions. Help line staff
is trained in behavior change theory and provide exercise, nutrition and tobacco cessation
consultation. The Healthy Living Help Line remains the primary intervention offered by KP,
though pedometers are also freely distributed by physicians to encourage exercise and other
programs and resources are in development.
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Temperature, check. Pulse, check. Oxygen, check. Exercise?
Going national
Once the EVS pilot program was completed, a review of the program was conducted to
determine if national implementation was viable. KP was impressed with the level of
compliance in using the EVS and the fact that adding the vital sign had caused minimal
disruption to patient flow. One study on the program concluded that the methods used for
capturing the EVS yielded valid information, and that the EVS had potential for providing
insights not previously available at the population level regarding the relationship between
exercise and health care in terms of usage, costs and chronic disease.
Given those outcomes, Dr. Sallis was given the go-ahead to lead the integration of the EVS in all
outpatient settings in the KP system. The Care Management Institute at KP became involved in
the integration and provides helpful training modules and other resources in a dedicated online
forum. Monthly conference calls are conducted with regional representatives to identify more
champions on the ground, improve compliance and share best practices.
The KP Innovation Consultancy, which first became aware of the EVS during the southern
California pilot phase, has been working to capture best practices that promote patient
engagement and physician compliance to complement the EVS. That same group is leading the
charge to fully activate the EVS and motivate patient behavioral change by convening a think
tank of 10 experts who are taking a scientific approach to creating a leading-edge EVS resource
tool kit for providers and patients.
By spring 2013, implementation of the EVS in KP outpatient and ambulatory care settings had
been completed.
Model behavior
While the EVS was being implemented across KP regions, the organization ran a campaign in
parallel to encourage its own physicians and staff to engage in physical activity as a way to
improve employee health and serve as role models to patients. The organization’s “Thrive”
campaign featured the tag line, “At Kaiser Permanente, we want you to live well, be well and
thrive.” Supporting internal programs called “Thrive Across America” and “KP Walk” offered
tools to employees to increase their activity levels.
In 2011, KP CEO George Halvorson introduced a non-branded national effort called “Every Body
Walk!”, which targeted KP members and the general public and for which Dr. Sallis was invited
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Temperature, check. Pulse, check. Oxygen, check. Exercise?
to serve as physician spokesperson. The U.S. Surgeon General found the program so
compelling, she asked if she could adopt it as her office’s campaign and KP agreed.
These efforts strengthened the value of the EVS by encouraging physicians, staff and employees
to demonstrate their own commitments to physical activity, and showing the general public
that KP was on the forefront of advancing public health through exercise.
The future of the EVS
Today, the EVS is used throughout KP with strong compliance – currently 91 percent in
southern California, for example – and its validity has been confirmed by research. However,
little evidence is available to suggest that healthcare providers can actually change the exercise
behaviors of their patients. Until KP and a handful of other health systems adopted a
comprehensive EVS, information about physical activity could not be captured on a broad scale,
nor has funding been available for such research. These factors are presumed to contribute to
the lack of research on the role of physicians and healthcare providers in catalyzing behavioral
change in exercise habits.
Further, the link between the healthcare and fitness industries has not been historically strong,
leaving healthcare providers reliant on either their employer to provide referral resources if
they are part of a system, or their own knowledge about available exercise options for their
patients.
While Dr. Sallis believes the EVS is the starting point for initiating changes in exercise behavior
in patients, he also recognizes that KP is “still trying to figure out how we can use it to the
greatest benefit. We need to get to a point where exercise is prescribed as a first line of
defense, before we recommend actual pills. If the exercise “prescription” doesn’t address the
high blood pressure or diabetes, for example, then we move to traditional medication.
Unfortunately, we’re not there yet. Right now, we just want to make people aware of exercise.”
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Temperature, check. Pulse, check. Oxygen, check. Exercise?
Assignment Questions
1. What features of the Kaiser model make the organization more likely to engage in proactive/
preventive care of the patient population they serve?
2. What are ways to encourage providers to incorporate physical activity recommendations into
their practice/treatment plans?
3. What resources should be available to physicians who recommend exercise to their patients?
4. What kind of education do patients need about physical activity so they will know what to do?
5. Now that physicians have access to exercise behavior via EVS data, what should they do with it
ideally?
6. How would you describe Dr. Sallis leadership approach and what leadership traits did he
demonstrate in implementing this project?
Note: Include at least four additional references (not found in any of your learning
materials)
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Appendix
Exercise is Medicine Fact Sheet
Initial Validation of an Exercise “Vital Sign” in an Electronic Medical Record
KAREN JACQUELINE COLEMAN1, EUNIS NGOR1, KRISTI REYNOLDS1, VIRGINIA P. QUINN1, CORINNA
KOEBNICK1, DEBORAH ROHM YOUNG1, BARBARA STERNFELD2, and ROBERT E. SALLIS3
1
Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; 2Division of Research,
Kaiser Permanente Northern California, Oakland, CA; and 3Department of Family Medicine Fontana Medical Center,
Kaiser Permanente Southern California, Fontana, CA
ABSTRACT
COLEMAN, K. J., E. NGOR, K. REYNOLDS, V. P. QUINN, C. KOEBNICK, D. R. YOUNG, B. STERNFELD, and R. E. SALLIS.
Initial Validation of an Exercise ‘‘Vital Sign’’ in Electronic Medical Records. Med. Sci. Sports Exerc., Vol. 44, No. 11, pp. 2071–2076,
2012. Purpose: The objective of this study is to describe the face and discriminant validity of an exercise vital sign (EVS) for use in an
outpatient electronic medical record. Methods: Eligible patients were 1,793,385 adults 18 yr and older who were members of a large
health care system in Southern California. To determine face validity, median total self-reported minutes per week of exercise as
measured by the EVS were compared with findings from national population-based surveys. To determine discriminant validity, multivariate Poisson regression models with robust variance estimation were used to examine the ability of the EVS to discriminate between
groups of patients with differing physical activity (PA) levels on the basis of demographics and health status. Results: After 1.5 yr of
implementation, 86% (1,537,798) of all eligible patients had an EVS in their electronic medical record. Overall, 36.3% of patients were
completely inactive (0 min of exercise per week), 33.3% were insufficiently active (more than 0 but less than 150 minIwkj1), and 30.4%
were sufficiently active (150 min or more per week). As compared with national population-based surveys, patient reports of PA were
lower but followed similar patterns. As hypothesized, patients who were older, obese, of a racial/ethnic minority, and had higher disease
burdens were more likely to be inactive, suggesting that the EVS has discriminant validity. Conclusions: We found that the EVS has
good face and discriminant validity and may provide more conservative estimates of PA behavior when compared with national surveys.
The EVS has the potential to provide information about the relationship between exercise and health care use, cost, and chronic disease
that has not been previously available at the population level. Key Words: PHYSICAL ACTIVITY COUNSELING, PRIMARY CARE,
PHYSICIAN, POPULATION
A
One of the focus areas in the National Physical Activity
Plan is the health care sector. Health care providers have
contact with the majority of Americans and have a unique
opportunity to encourage PA among their patients through
PA assessment and brief counseling. Recommendations
for assessment include a PA ‘‘vital sign’’ that is incorporated
into patients’ routine health screening and is kept as a health
indicator in their medical record (8). This indicator can be
monitored over time as are blood pressure and weight to
provide continued opportunities for counseling and support
for adopting a healthy lifestyle. In response to these recommendations, the American Medical Association in partnership
with the American College of Sports Medicine developed the
Exercise is Medicinei initiative (9). Specific details about the
initiative can be found at the program Web site (4). Briefly,
the vision for the initiative is as follows:
‘‘For physical activity to be considered by all health care
providers as a vital sign in every patient visit, the patients are
effectively counseled and referred as to their physical activity
and health needs, thus leading to overall improvement in the
public’s health and long-term reduction in health care cost.’’
In response to the Exercise is Medicinei initiative, Kaiser
Permanente Southern California (KPSC), a large health
care system, has incorporated questions about PA into the
lthough the benefits of regular physical activity (PA)
have been well documented, including those for prevention and treatment of cardiovascular disease,
cancer, and depression (7), the high prevalence of physical
inactivity remains a major public health concern. The national 2008 Physical Activity Guidelines for Americans (7),
recommend that Americans engage in at least 150 minIwkj1
of moderate-to-vigorous intensity PA to receive maximal
health benefits. Recent estimates using objective PA assessment found that only 8% of the US adult population
achieved the recommended levels of PA (11), although selfreport measures found the prevalence to be considerably
higher than this (60%) (11).
Address for correspondence: Karen Jacqueline Coleman, Ph.D., Department of
Research and Evaluation, Southern California Permanente Medical Group, 100
S. Los Robles, 2nd Floor, Pasadena, CA; E-mail: Karen.J.Coleman@kp.org.
Submitted for publication March 2012.
Accepted for publication June 2012.
0195-9131/12/4411-2071/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2012 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e3182630ec1
2071
Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
CLINICAL SCIENCES
Initial Validation of an Exercise ‘‘Vital Sign’’
in Electronic Medical Records
CLINICAL SCIENCES
measurement of traditional vital signs (blood pressure, pulse,
temperature, and respirations), which are currently assessed
for every patient during an outpatient visit. This exercise
vital sign (EVS) was designed to identify patients who are
not meeting PA recommendations and to assist health care
providers in promoting PA among patients.
This article describes the initial results from efforts to
validate the KPSC EVS. Face validity for the KPSC EVS
was established by comparing exercise levels found with
this measure to those found in US population surveys. We
also examined the ability of the KPSC EVS to discriminate
between groups of patients with differing activity levels on
the basis of demographics and health status. We hypothesized
that women would be less active than men, older patients
would be less active than younger patients, ethnic minority patients would be less active than non-Hispanic white
patients, obese patients would be less active than patients
having a healthy weight, and those patients with a higher
disease burden would be less active than those without
chronic health conditions.
METHODS
Participants and Setting
KPSC provides comprehensive health care services for
approximately 3.4 million residents of Southern California.
Members enroll through the Kaiser Foundation Health Plan
for prepaid health care insurance. KPSC provides care at 14
hospitals and nearly 200 medical offices through a partnership of more than 4000 physicians who comprise the entire
range of medical specialists. Data were examined for the
period of April 2010 to March 2011. This time frame was
chosen to reflect 1 yr of full implementation of the EVS after
a 6-month implementation phase (18 months total). During
this time, there were 2,149,800 adult patients who were
KPSC members. Of these patients, 1,793,385 (83%) had at
least one outpatient medical visit and were eligible for the
study. Study procedures were approved by the KPSC Institutional Review Board for Human Subjects. The KPSC Institutional Review Board approved a waiver of informed
consent for this study.
EVS. Use of the EVS began in October of 2009, with
every patient being asked two questions during their intake procedures as part of an outpatient visit: 1) ‘‘On average, how many days per week do you engage in moderate to
strenuous exercise (like a brisk walk)?’’ and 2) ‘‘On average,
how many minutes do you engage in exercise at this level?’’
These questions are typically asked by medical assistants
and licensed vocational nurses who enter patients’ responses
into the electronic medical record. Response choices for
days are categorical (0–7). Minutes are recorded in blocks
of 10: 0, 10, 20, 30, 40, 50, 60, 90, 120, and 150 or greater.
The electronic medical record system software then multiplies the two self-reported responses to display minutes per
week of moderate or strenuous exercise for the health care
2072
Official Journal of the American College of Sports Medicine
provider to review. There is a comment section to note any
issues with the assessment. The EVS is embedded in the
‘‘vital sign’’ section of the electronic medical record, which
also contains height, weight, body mass index (BMI), blood
pressure, pulse, respirations, and body temperature.
The EVS was developed with assistance from leading
experts in the PA promotion and assessment community as
part of the national Exercise is Medicinei initiative and is a
modified version of the Behavioral Risk Factor Surveillance
System (BRFSS) PA questions (1,12). When modifying these
questions for clinical use, key considerations were made for
implementation so that the EVS would be easy to use and
acceptable to medical staff. This meant combining intensity categories into one question (moderate to strenuous) and
categorizing minute responses to minimize errors in data
entry. On average, the EVS takes less than 1 min to administer. A set of training materials also accompany the EVS
to assist health care professionals in asking these questions
consistently, as well as probing patients about their answers
if the patient seems uncertain or provides an answer that is
unreasonable (e.g., ‘‘I exercise five hours every day’’). These
training materials are available upon request.
A median total minutes per week of moderate to strenuous
exercise was used for each patient across the study period of
April 2010 to March 2011. The median was used instead of
the mean to control for extreme differences in self-reported
exercise across multiple visits.
Demographic and Health Variables
Demographics. Date of birth (for calculation of age),
race/ethnicity, and gender were obtained from electronic
membership files. These data are collected when patients
enroll in the KPSC health plan. Self-reported race/ethnicity
is also collected when patients have a health care visit. All
demographic variables were obtained at the beginning of the
study period (April 2010).
BMI. BMI was assessed using measured height and
weight and calculated as weight in kilograms divided by
height in meters squared. Height and weight are measured
and entered into the electronic medical record by health care
professionals each time a patient has a health care visit. We
directly accessed electronic records to obtain all BMI values
during the study period (April 2010 to March 2011) and then
calculated a median value for analyses.
Disease burden. Disease burden was assessed by calculating a modified Charlson Comorbidity Index for each
patient in the study population. The modified Charlson
Comorbidity Index was created using diagnosis codes assessed in the 3 yr before enrollment in the study to provide
a summary score assessing a patient’s risk for 10 yr of mortality based upon 22 different health conditions (3).
Analyses. Data on patient demographics and health
are presented as descriptive frequencies. To establish the
face validity of the KPSC EVS, we further consolidated
data into categories to compare with the estimates reported by the 2005–2006 Nutrition Health and Examination
http://www.acsm-msse.org
Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
RESULTS
Patient characteristics. From the 1,793,385 KPSC
adult patients with an outpatient medical visit during April
2010 to March 2011, we identified 1,537,798 (86%) with
an EVS measure. Table 1 presents patient characteristics for
those patients who did and did not have an EVS measure. In
general, patients with an EVS were older, were female, had
TABLE 1. Characteristics of KPSC adult patients 18 yr and older with a medical outpatient visit during the study period of April 2010 to March 2011 are shown with and
without an EVS.
Age (yr)
18–29
30–39
40–49
50–64
65+
Gender
Female
Male
Race/ethnicity
Non-Hispanic white
Hispanic
Non-Hispanic black
Asian/Pacific Islander
Native American/Alaskan
Others
Multiple
Unknown
BMI (kgImj2)
18–24.99
25–29.99
30–34.99
35–39.99
40+
Unknown
Charlson index
0
1
2
Q3
Outpatient visits
0
1
2–4
Q5
Patients with an EVS
(n = 1,537,798)
Patients without an EVS
(n = 255,587)
228,802 (14.9%)
243,531 (15.8%)
293,639 (19.1%)
456,833 (29.7%)
314,993 (20.5%)
51,705 (20.2%)
46,340 (18.1%)
52,423 (20.5%)
71,536 (28.0%)
33,583 (13.1%)
891,420 (58.0%)
646,364 (42.0%)
125,623 (49.2%)
129,960 (50.8%)
504,365 (32.8%)
437,813 (28.5%)
136,869 (8.9%)
120,505 (7.8%)
2269 (0.1%)
27,171 (1.8%)
3392 (0.2%)
305,414 (19.9%)
75,527 (29.6%)
57,930 (22.7%)
16,099 (6.3%)
18,382 (7.2%)
284 (0.1%)
4401 (1.7%)
510 (0.2%)
82,454 (32.3%)
418,413 (27.4%)
536,458 (35.1%)
322,868 (21.1%)
140,344 (9.2%)
90,504 (5.9%)
19,023 (1.2%)
56,125 (22.1%)
64,693 (25.5%)
36,819 (14.5%)
14,481(5.7%)
9019 (3.6%)
72,833 (28.7%)
1,392,988 (90.6%)
57,303 (3.7%)
33,205 (2.2%)
54,302 (3.5%)
245,423 (96.0%)
4635 (1.8%)
2411 (0.9%)
3118 (1.2%)
—
158,831 (10.3%)
494,331 (32.1%)
884,636 (57.5%)
—
103,667 (40.6%)
103,720 (40.6%)
48,200 (18.9%)
All characteristics are significantly different between patients with and without an EVS
(P G 0.001).
PHYSICAL ACTIVITY ASSESSMENT IN PRIMARY CARE
less missing information for race/ethnicity and BMI, and had
more comorbid conditions and more outpatient visits when
compared with those patients who did not have an EVS.
Face validity. Exercise participation is shown for different participant characteristics in Table 2. Comparison data
for face validity are provided from the 2005–2006 US
NHANES and 2007 California BRFSS. In general, KPSC
patient self-reported levels of sufficient exercise (median,
150 min or more of exercise per week) were lower than
those self-reported in either NHANES or BRFSS surveys
(31% vs. 60% and 50%, respectively). The patterns of PA
among different KPSC patient populations were similar to
the population measures.
Discriminant validity. Table 3 describes Poisson regression results of patient-reported PA from the KPSC EVS
measure. Models are fully adjusted for all variables. Patients
who were 65 yr and older were 1.25 (95% CI, 1.24–1.26)
times more likely to be inactive when compared with
patients 18–29 yr old. The likelihood of physical inactivity
was significantly greater with each age category because
they were compared with 18–29 yr old patients. Women
were 1.12 (95% CI, 1.11–1.12) times more likely than men
to be inactive, and both Hispanics (PR = 1.16; 95% CI,
1.15–1.16) and non-Hispanic blacks (PR = 1.05; 95% CI,
1.05–1.06) were more likely to be inactive than non-Hispanic
whites. In addition, a greater disease burden increased the
likelihood of inactivity. Those patients with a modified
Charlson Comorbidity Index of 3 or more (highest disease
burden) were 1.54 (95% CI, 1.53–1.55) times more likely to
be inactive as compared with patients with an index of 0.
Finally, higher BMI levels also increased the likelihood of
inactivity. Extremely obese patients (BMI, Q40 kgImj2) were
1.61 (95% CI, 1.60–1.62) times more likely to be inactive
as compared with patients having a healthy weight (BMI,
18–24.99 kgImj2). Similar associations were found with inadequate activity (more than 0 but less than 149 min or less
per week), although the effects were somewhat attenuated.
DISCUSSION
We found that self-reported exercise assessment can be
successfully incorporated as a vital sign into the electronic
medical record of a large health care system serving a diverse population. Within 18 months of implementation, 86%
of all adult members who had at least one outpatient medical
visit had an EVS measure. As hypothesized, the KPSC EVS
discriminated between different patient populations such that
increasing age, female gender, being of a racial/ethnic minority group, and increasing BMI were all associated with
lower PA. Higher disease burden was also significantly related to inactivity.
Although the general patterns of PA were similar between
the KPSC EVS and other population-based self-report measures, the KPSC EVS exercise levels were less than those
found for both self-reported BRFSS and NHANES data. For
example, only 30.4% of KPSC patients self-reported that they
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2073
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Survey (NHANES) for the United States (11) and the 2007
California BRFSS (1). These categories were completely
inactive (median, 0 minIwkj1), insufficiently active (median
value, 90 but G149 minIwkj1), and sufficiently active (median, Q150 minIwkj1).
To determine the discriminant validity of the KPSC EVS,
we used multivariate Poisson regression models with robust
variance estimation. Prevalence ratios (PR) and their corresponding 95% confidence intervals (CIs) were calculated to
determine how levels of inactivity and insufficient activity
were associated with patient age, gender, race/ethnicity,
Charlson Comorbidity Index (disease burden), and BMI. All
analyses were done with SAS Enterprise Guide 4.3 (SAS
Institute Inc., Cary, NC).
TABLE 2. Self-reported exercise levels as measured with the EVS for KPSC adult patients 18 yr and older.
CLINICAL SCIENCES
KPSC EVS
Overall (n = 1,537,798)
NHANES age (yr)
20–29
30–39
40–49
50–59
60–69
70+
BRFSS age (yr)
18–24
25–34
35–44
45–64
65+
Gender
Female
Male
Race/ethnicity
Non-Hispanic white
Hispanic
Non-Hispanic black
BMI (kgImj2)
18–24.99
25–29.99
30–34.99
35+
NHANES
BRFSS
Inactive
(%)
Insufficient
(%)
Sufficient
(%)
Inactive
(%)
Insufficient
(%)
Sufficient
(%)
Inactive
(%)
Insufficient
(%)
Sufficient
(%)
36.3
33.3
30.4
12.5
27.9
59.6
12.5
37.6
50.0
31.9
35.9
36.4
35.5
35.0
44.9
31.8
34.4
34.3
34.7
33.4
31.1
36.3
29.7
29.3
29.8
31.6
24.0
10.5
10.0
10.5
9.3
13.8
25.9
25.6
30.9
25.1
31.9
26.6
27.2
63.9
59.0
64.4
58.8
59.7
46.9
30.4
34.2
36.6
35.5
41.6
28.9
33.9
34.5
34.4
31.6
40.7
31.9
28.9
30.1
26.8
37.9
34.2
35.0
30.9
27.1
34.9
14.1
10.7
30.2
25.5
35.5
40.2
39.3
31.7
34.3
34.6
32.8
25.5
26.1
9.6
27.0
18.3
30.5
33.6
40.2
47.5
32.4
33.7
33.9
33.5
37.1
32.7
25.9
19.0
11.6
11.6
11.7
17.7
Not available
Not available
—
10.4
10.7
13.4
20.5
29.8
37.5
40.6
39.5
36.0
64.4
52.1
48.7
47.1
43.5
55.8
63.9
12.5
12.5
38.6
36.4
48.9
51.1
27.5
32.3
34.0
63.0
40.7
47.7
6.3
18.1
—
36.6
36.4
36.2
57.1
45.5
49.6
25.3
29.8
29.2
27.8
63.1
58.6
59.1
54.5
Not available
Levels are compared with the 2005–2006 NHANES (11) and the 2007 California BRFSS (1). Levels are presented as inactive (0 median minutes of moderate to strenuous exercise per
week), insufficient (more than 0 but less than 149 median minutes of exercise per week), and sufficient (150 median minutes or more of exercise per week). BRFSS and NHANES use
different age categorizations, so both age categorizations are shown here in comparison with the KPSC EVS.
were sufficiently active (Q150 minIwkj1), whereas 50%
of BRFSS and 59.6% NHANES participants self-reported
these levels. This may be due to some factors. One of the
most important differences between the population measures
and the KPSC EVS, and a limitation of its use in measuring
different exercise intensities, is that the EVS combined
moderate and vigorous PA. By selecting 150 minIwkj1 as
the threshold for being sufficiently active, we may not have
captured those patients obtaining 75 minIwkj1 of vigorous
activity, which also meets PA guidelines. However, it is unlikely that this made a large effect on the findings given that
so few Americans engage in regular vigorous PA (11), especially those populations represented in the KPSC EVS
analyses: ethnic minorities, women, and older patients with
higher disease burdens.
It may be more likely that the difference in activity levels
between the KPSC patient population and respondents on
the NHANES and BRFSS surveys was due to differences
in demographics. On the basis of published data, NHANES
and California BRFSS participants were 50% female and
47% non-Hispanic white, and 32% were at 20–39 yr old and
23%–34% were obese (2,5). KPSC had more female (58%)
and fewer non-Hispanic white (33%) members, but age distribution was similar to NHANES and BRFSS. KPSC obesity rates (36%) were similar to NHANES but higher than
BRFSS findings. It is possible that more women and ethnic/
racial minority participants, two populations known to have
lower levels of PA, could have contributed to the lower PA
levels reported by KPSC patients.
2074
Official Journal of the American College of Sports Medicine
It is also possible that overall PA reports would be higher
had they included patients who did not have an EVS measure (14% of patients having an outpatient medical visit
during April 2010 to March 2011). Those patients without
an EVS were younger, healthier, and more likely to be male
when compared with patients with an EVS. These are all
characteristics associated with higher levels of PA. Despite
this fact, it is unlikely that 14% of the population would
make a substantial effect on estimates for 86% of the KPSC
population.
There were also several other differences between the
KPSC EVS measure and the population-based measures of
PA that could have accounted for the difference seen in PA
estimates. Although the KPSC EVS most closely resembled
the BRFSS questions, the word ‘‘strenuous’’ was used instead of ‘‘vigorous.’’ A second difference is that the KPSC
EVS did not provide patients with a specific referent time
frame for assessing PA (i.e., past month or week). This may
lead patients to consider their ‘‘usual’’ pattern of activity
when answering the question. In the only other study of an
EVS, Greenwood et al. (6) found that asking about a typical
week, rather than using the time frame of the last week, was
a better predictor of obesity in an adult sample of 137
patients. However, Greenwood et al. did not report total
minutes of PA, and thus, it is difficult to directly compare
their results with the KPSC EVS.
A final difference between the KPSC EVS and populationbased questions of PA like the BRFSS is the use of the word
‘‘exercise’’ instead of PA. This may frame the question such
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TABLE 3. PRs and CIs are shown for median total minutes of moderate to strenuous
exercise per week by patient demographics and health status for KPSC adult patients
18 yr and older.
Determinant
Age (yr)
18–29
30–39
40–49
50–64
65+
Gender
Male
Female
Ethnicity
Non-Hispanic white
Hispanic
Non-Hispanic black
Asian/Pacific Islander
Native American/Alaskan native
Multiple
Other
Unknown
Charlson index
0
1
2
Q3
BMI (kgImj2)
18–24.99
25–29.99
30–34.99
35–39.99
Q40
Unknown
0–149 vs. Q150
minIwkj1
PR
95% CI
PR
95% CI
1.00
1.09
1.10
1.07
1.25
—
1.08–1.10
1.09–1.11
1.06–1.07
1.24–1.26
1.00
1.09
1.10
1.09
1.15
—
1.09–1.10
1.09–1.10
1.085–1.09
1.145–1.15
1.00
1.12
—
1.11–1.12
1.00
1.13
—
1.12–1.13
1.00
1.16
1.05
0.99
1.05
0.99
1.00
1.02
—
1.15–1.16
1.05–1.06
0.98–1.00
1.00–1.11
0.94–1.03
0.98–1.01
1.02–1.03
1.00
1.11
1.06
1.10
1.01
1.04
1.03
1.02
—
1.11–1.11
1.06–1.07
1.09–1.10
0.98–1.04
1.02–1.06
1.02–1.04
1.01–1.02
1.00
1.19
1.26
1.54
—
1.17–1.20
1.25–1.28
1.53–1.55
1.00
1.09
1.12
1.23
—
1.09–1.10
1.12–1.13
1.22–1.23
1.00
1.10
1.31
1.47
1.61
1.25
—
1.09–1.11
1.30–1.32
1.46–1.48
1.60–1.62
1.23–1.28
1.00
1.08
1.18
1.25
1.31
1.06
—
1.07–1.08
1.18–1.19
1.25–1.26
1.31–1.32
1.05–1.07
Data were analyzed using two comparisons: 1) inactive (median, 0 min exercise per week
during the study period of April 2010 to March 2011) versus active (anything greater than
0 median exercise per week reported during the study period), and 2) insufficiently active
(median, 149 min or less exercise per week during the study period) versus sufficiently
active (median, 150 min or more per week reported during the study period). Models are
fully adjusted for all determinants listed in the table.
that patients considered only traditional aerobic exercises
when answering rather than including lifestyle activities
such as gardening and housework. Evidence suggests that
aerobic fitness, increased primarily by traditional exercises
such as walking, running, and swimming, may be the key to
disease treatment and prevention rather than any kind of
lifestyle activity (10). Consequently, the KPSC EVS may be
a good indicator of moderate aerobic exercise levels and
provide an ideal opportunity to study the effect of moderate
aerobic exercise on disease prevention and treatment at the
population level.
Regardless of the differences between the KPSC EVS and
the population-based surveys of PA, embedding these questions in the electronic medical record provides an opportunity
Funding for this research was provided by the Southern California
Permanente Medical Group.
None of the authors have any conflicts of interest to declare.
The results of the present study do not constitute endorsement
by the American College of Sports Medicine.
REFERENCES
1. California Behavioral Risk Factor Surveillance System Web site
[Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [cited 2012 Feb 21]. Available from: http://apps.nccd.cdc.gov/
PASurveillance/DemoCompareResultV.asp#result.
PHYSICAL ACTIVITY ASSESSMENT IN PRIMARY CARE
2. California Behavioral Risk Factor Surveillance System Web site
[Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [cited 2012 Feb 21]. Available from: http://apps.nccd.cdc.
gov/BRFSS/page.asp?cat=DE&yr=2007&state=CA.
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2075
CLINICAL SCIENCES
0 vs. 90
minIwkj1
to counsel millions of patients during routine medical care
regarding the importance of PA for health. There are very
few tools for health promotion available to health care and
public health professionals that provide the same level of
reach as the KPSC EVS. Although we did not assess whether
the EVS increased PA counseling rates, future studies will
examine if adding a PA assessment to vital signs in primary
care actually leads to higher rates of physician counseling for PA and eventually increases in the PA levels of the
KPSC adult population.
Despite its use, the KPSC EVS is still a self-report measure and thus subject to the biases inherent to this mode of
data collection. This is evident in comparison with recent
NHANES accelerometer results (11), which found that only
8.2% of adults were sufficiently active. The KPSC EVS
likely overestimates the levels of exercise in this population,
albeit less so than other population-based self-report measures of PA. However, despite this limitation, because the
EVS is asked in a medical setting by a health care professional (rather than a research assistant as with NHANES and
BRFSS), it may be that patients are less likely to exaggerate
their level of PA.
Assessment of PA levels in the clinical setting is a key
component of the Exercise is Medicinei initiative (8). Including PA as a vital sign reinforces its importance for prevention
and management of disease. Once assessed, self-reported
exercise levels can be used to initiate brief counseling sessions with patients about lifestyle change as recommended
by the Exercise is Medicinei initiative (9). Future research
should establish the reliability and validity of the KPSC
EVS over time by directly comparing its exercise estimates
to objective activity monitoring and concurrently administered self-report PA measures.
Importantly, the face and discriminant validity of the
KPSC EVS supports the use of this assessment tool in diverse patient populations in clinical practice. Results show
that with minimal effort on the part of clinic staff, the assessment of exercise can be integrated into the vital signs
taken as part of routine patient care and serve to initiate
patient counseling. Furthermore, the KPSC EVS may facilitate population-based research on the effect of PA on disease prevention and treatment outcomes.
CLINICAL SCIENCES
3. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method
of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40(5):373–83.
4. Exercise Is Medicine Web site [Internet]. Indianapolis (IN): American
Medical Association and American College of Sports Medicine; [cited
2012 Feb 21]. Available from: http://www.exerciseismedicine.org/
about.htm.
5. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends
in obesity among US adults, 1999–2008. JAMA. 2010;303(3):
235–41.
6. Greenwood J, Joy E, Stanford J. The physical activity vital sign: a
primary care tool to guide counseling for obesity. J Phys Act Health.
2010;7(5):571–6.
7. Physical Activity Guidelines for Americans Web site [Internet].
Washington (DC): Department of Health and Human Services;
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[cited 2012 Feb 21]. Available from: http://www.health.gov/
paguidelines/guidelines/default.aspx.
8. Sallis RE. Developing health care systems to support exercise:
exercise as the fifth vital sign. Br J Sports Med. 2011;45:473–4.
9. Sallis RE. Exercise is medicine and physicians need to prescribe it!
Br J Sports Med. 2009;43:3–4.
10. Swain DP, Franklin BA. Comparison of cardioprotective benefits
of vigorous versus moderate intensity aerobic exercise. Am J
Cardiol. 2006;97:141–7.
11. Tucker JM, Welk GJ, Beyler NK. Physical activity in US adults:
compliance with physical activity guidelines for Americans. Am J
Prev Med. 2011;40(4):454–61.
12. Yore MM, Ham SA, Ainsworth BE, Kruger J, Reis JP, Kohl HW,
Macera CA. Reliability and validity of the instrument used in BRFSS
to assess physical activity. Med Sci Sports Exerc. 2007;39(8):1267–74.
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Fact Sheet
CONTACT
www.exerciseismedicine.org
eim@acsm.org
317-637-9200
American College of Sports Medicine
P.O. Box 1440
Indianapolis, IN 46206-1440
THE PROBLEM
Physical inactivity is a fast-growing public health problem and contributes to a variety of chronic diseases and health
complications, including obesity, diabetes and cancer. In addition to improving a patient’s overall health, increasing
physical activity has proven effective in the treatment and prevention of chronic diseases. Even with all the benefits
of physical activity, in the United States and many other countries, levels of inactivity are alarming. We are facing
what is now referred to as an “inactivity epidemic,” with tremendous costs.
According to the World Health Organization’s most recent Global Health Risks data (2004) after high blood
pressure, tobacco use and high blood glucose, physical inactivity constitutes the 4th leading cause of death
globally, with about 3.3 million attributable deaths per year. More recent evidence (2009) using direct measure,
rather than survey data shows physical inactivity to be the leading cause of death in the US.
More than half of adults (56%) do not meet the recommendations for sufficient physical activity in the 2008
Physical Activity Guidelines.
In a study of older adolescents and adults in the US, participants spent almost eight hours a day in sedentary
behaviors, while as much as 36% of adults engaged in no leisure-time physical activity at all.
A study in 2008 shows that physical inactivity costs the US Health Care System $330 per person each year,
which equals more than $102 billion dollars annually.
40% of US primary care doctors and 36% of US medical students do not meet 2008 federal physical activity
guidelines. Physically inactive doctors are less likely to provide exercise counseling to patients and provide less
credible role models for the adoption of healthy behaviors. Not surprisingly, only 34% of US adults report having
received exercise counseling at their last medical visit.
THE BENEFITS:
Many research studies have shown the benefits of regular physical activities. The US Federal Physical Guidelines
and many studies show that 150 minutes per week of moderate intensity physical activity is required to achieve
these health benefits.
Research shows that a low level of physical activity exposes a patient to a greater risk of dying than does
smoking, obesity, hypertension, or high cholesterol, and for older men, regular physical activity can decrease the
risk of death by 40%.
Active individuals in their 80s have a lower risk of death than inactive individuals in their 60s.
Regular physical activity can:
Reduce mortality and the risk of recurrent breast cancer by approximately 50%.
Lower the risk of colon cancer by over 60%.
Reduce the risk of developing of Alzheimer’s disease by approximately 40%.
Reduce the incidence of heart disease and high blood pressure by approximately 40%.
Lower the risk of stroke by 27%.
Lower the risk of developing type II diabetes by 58%
Be twice as effective in treating type II diabetes than the standard insulin prescription and can save $2250 per
person per year when compared to the cost of standard drug treatment.
Can decrease depression as effectively as Prozac or behavioral therapy.
Adults with better muscle strength have a 20% lower risk of mortality (33% lower risk of cancer specific mortality)
than adults with low muscle strength.
A low level of fitness is a bigger risk factor for mortality than mild-moderate obesity. It is better to be fit and
overweight than unfit with a lower percentage of body fat.
Regular physical activity has been shown to lead to higher SAT scores for adolescents.
In an elementary school setting, regular physical activity can decrease discipline incidents involving violence by
59% and decrease out of school suspensions by 67%.
* For a list of references, please see the Exercise is Medicine® Reference sheet.
Fact Sheet
CONTACT
www.exerciseismedicine.org
eim@acsm.org
317-637-9200
American College of Sports Medicine
P.O. Box 1440
Indianapolis, IN 46206-1440
A SOLUTION TO THE GREATEST PUBLIC HEALTH PROBLEM OF THE 21ST CENTURY
Exercise is Medicine® is an initiative focused on encouraging primary care physicians and other health care
providers to include exercise when designing treatment plans for patients. Exercise is Medicine is committed to the
belief that exercise and physical activity are integral to the prevention and treatment of chronic disease and should
be regularly assessed as part of medical care. Along with the National Physical Activity Plan, Exercise is Medicine
strives to make physical activity a “vital sign” that is routinely assessed at every patient interaction with a health care
provider.
GUIDING PRINCIPLES OF EXERCISE IS MEDICINE
The guiding principles of Exercise is Medicine, a multi-organizational initiative coordinated by the American College
of Sports Medicine (ACSM), are designed to improve the health and well-being of our nation through a regular
physical activity prescription from doctors and other health care providers, or from a health and fitness professional
working with the health care provider. The guiding principles are as follows:
Exercise and physical activity are important to health and the prevention and treatment of many chronic
diseases.
More should be done to address physical activity and exercise in health care settings.
Multi-organizational efforts to bring a greater focus on physical activity and exercise in health care settings are
to be encouraged.
A CRITICAL CALL TO ACTION
Physical inactivity is a fast-growing public health problem and contributes to a variety of chronic diseases and health
complications, including obesity, heart disease, diabetes, hypertension, cancer, depression and anxiety, arthritis,
and osteoporosis. In addition to improving a patient’s overall health, increasing physical activity has proven effective
in the treatment and prevention of chronic diseases. Therefore, Exercise is Medicine® calls on each person and all
partners dedicated to the idea that exercise truly is medicine to continue to build, support and advocate for physical
activity as essential for global health and wellbeing by committing to action. Policy makers are called to change
policy to support physical activity as a vital sign for health. Health care providers and fitness professionals are called
to integrate exercise into every patient and client interaction. Communities, workplaces and schools are called to
promote physical activity as an essential part of health and wellbeing.
GET INVOLVED
Visit Exercise is Medicine online at www.exerciseismedicine.org to support the initiative, receive program updates
and download an Action and Promotion Guide. Visit www.exerciseismedicinemonth.org for tips, tools and ideas to
plan your own local event or activity during Exercise is Medicine Month in May or throughout the year, including a
PowerPoint slide deck and media advocacy tools.
CONTACT
www.exerciseismedicine.org
eim@acsm.org
317-637-9200
Inactivity Fact Sheet
American College of Sports Medicine
P.O. Box 1440
Indianapolis, IN 46206-1440
INACTIVITY EPIDEMIC REFERENCES
Low activity increases risk of death.
Physical inactivity: the biggest public health problem of the 21st century
Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009; 43:1-2.
Prevalence of inactivity in the US according to 2008 PA guidelines
Carlson SA, Fulton JE, Galuska DA, Kruger J, Lobelo F, Loustalot FV. Prevalence of self-reported physically
active adults – United States, 2007. MMWR; December 5 2008, Vol 57, No 48. – JAMA 2009;301(9):926-927
Eight hours a day in sedentary behaviors
Amount of time spent in sedentary behaviors in the United States, 2003-2004.
Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, Troiano RP.
Am J Epidemiol. 2008 Apr 1;167(7):875-81. Epub 2008 Feb 25.
$330 per person per year in health care expenditures dues to inactivity in 2008
Higher Direct Medical Costs Associated with Inactivity. A Team Physician’s Challenge
By: Michael Pratt, MD, MPH; Caroline A. Macera, PhD; Guijing Wang, PhD
Volume: 28, Issue: 10, Published: October 2000, Original Research
Physical Activity of doctors and medical students
Physical activity habits of doctors and medical students influence their counseling practices.
Lobelo F, Duperly J, Frank E. Br J Sports Med. 2009 Feb;43(2):89-92.
Physical Activity Counseling
Physician counseling about exercise.
Wee CC, McCarthy EP, Davis RB, et al. JAMA1999;282:1583–8.
US Physical Activity Guidelines.
http://www.health.gov/paguidelines/
US Department of Health and Human Services 2008 Physical Activity Guidelines for Americans.
Can reduce mortality and the risk of recurrent breast cancer by approximately 50%.
http://jama.ama-assn.org/cgi/content/abstract/293/20/2479
Physical activity and survival after breast cancer diagnosis.
Holmes MD et al. JAMA 2005; 293:2479
A Prospective Study of Cardiorespiratory Fitness and Breast Cancer Mortality
Peel JB, Sui X, Adams SA, Hébert JR, Hardin JW, Blair SN. Med Sci Sports Exerc. 2009 Apr;41(4):742-8.
Can lower the risk of colon cancer by over 60%.
Physical activity and colon cancer: confounding or interaction?
Medicine & Science in Sports & Exercise:
June 2002 – Volume 34 – Issue 6 – pp 913-919
Can reduce the risk of developing of Alzheimer’s disease by approximately 40%.
http://www.annals.org/content/144/2/73.abstract
Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older.
Larsen EB et al. Annals of Internal Medicine 2006; 144:73-81
CONTACT
www.exerciseismedicine.org
eim@acsm.org
317-637-9200
Inactivity Fact Sheet
American College of Sports Medicine
P.O. Box 1440
Indianapolis, IN 46206-1440
INACTIVITY EPIDEMIC REFERENCES (Continued)
Reduces the incidence of high blood pressure and heart disease by approximately 40%.
http://www.ncbi.nlm.nih.gov/pubmed/16293717
Cardiorespiratory fitness is an independent predictor of hypertension incidence among initially normotensive
healthy women.
Barlow CE et al. Am J Epidemiol 2006; 163:142-50
http://www.ncbi.nlm.nih.gov/pubmed/7934752?dopt=Abstract
Exercise in the prevention of coronary heart disease: today’s best buy in public health.
Med Sci Sports Exerc. 1994 Jul;26(7):807-14.
Lowers the risk of stroke by 27%.
http://www.ncbi.nlm.nih.gov/pubmed/10865274?
itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=8
Physical activity and risk of stroke in women.
JAMA. 2000 Jun 14;283(22):2961-7.
Reduces the incidence of diabetes by approximately 50%.
http://www.ncbi.nlm.nih.gov/pubmed/10068380
The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in
men.
Wei M et al. Annals of Internal Medicine. 1999
http://content.nejm.org/cgi/content/short/346/6/393
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
DPP Research Group. New England Journal of Medicine 2002; 346:393-403
The Diabetes Prevention Program Research Group: Within-trial cost-effectiveness of lifestyle intervention or
metformin for the primary prevention of type 2 diabetes.
DPP Res Group. Diab Care 2003; 26:2518
Can decrease depression as effectively as Prozac or behavioral therapy.
http://www.ncbi.nlm.nih.gov/pubmed/15626549
Exercise treatment for depression: efficacy and dose response.
Dunn A et al. American Journal of Preventive Medicine 2005
Muscle strength decreases mortality risk
Association between muscular strength and mortality in men.
Ruiz JR, Sui X, Lobelo F, Morrow JR, Jackson AW, Blair SN. BMJ 2008; 337:a439.
Better to be fit and fat than unfit with lower percentage of body fat.
Cardiorespiratory fitness and adiposity as mortality predictors in older adults.
Sui X, LaMonte MJ, Laditka JN, Hardin JW, Chase N, Hooker SP, Blair SN.
JAMA. 2007 Dec 5;298(21):2507-16.
Increased SAT scores.
California Dept. of Education Study, December 10, 2002
Fewer disciplinary incidents and fewer out of school suspensions.
PE 4 Life Woodland Elementary School, Kansas City PSD #33
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