Robert E. Sallis

Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association

Mounting evidence has firmly established that low levels of cardiorespiratory fitness (CRF) are associated with a high risk of cardiovascular disease, all-cause mortality, and mortality rates attributable to various cancers. A growing body of epidemiological and clinical evidence demonstrates not only that CRF is a potentially stronger predictor of mortality than established risk factors such as smoking, hypertension, high cholesterol, and type 2 diabetes mellitus, but that the addition of CRF to traditional risk factors significantly improves the reclassification of risk for adverse outcomes. The purpose of this statement is to review current knowledge related to the association between CRF and health outcomes, increase awareness of the added value of CRF to improve risk prediction, and suggest future directions in research. Although the statement is not intended to be a comprehensive review, critical references that address important advances in the field are highlighted. The underlying premise of this statement is that the addition of CRF for risk classification presents health professionals with unique opportunities to improve patient management and to encourage lifestyle-based strategies designed to reduce cardiovascular risk. These opportunities must be realized to optimize the prevention and treatment of cardiovascular disease and hence meet the American Heart Association’s 2020 goals.

Exercise is medicine and physicians need to prescribe it

The three major factors that influence our health and longevity are genetics, the environment and behaviour. Because we have very little control over genetic factors, it is critical that we focus on the environmental and behavioural factors we can control to improve health. Whereas great strides have been made in reducing the environmental factors influencing disease, such as through vaccinations, hygiene and safety regulations, little has been done to target behavioural factors such as physical inactivity. It is tragic that so little has been done to address the one major factor affecting our health and longevity that is almost entirely under our control. At this point in time, I believe physical inactivity has become the greatest public health problem of our time and finding a way to get patients more active is absolutely critical to improving health and longevity in the 21st century. The beneficial relationship between exercise and health has been well known dating back to the 5th century BC, when Hippocrates said that “Eating alone will not keep a man well; he must also take exercise. For food and exercise… work together to produce health”.1 This relationship has been further defined by years of scientific research that shows a clear correlation between physical activity and health status. That is, those individuals who maintain an active and fit way of life live longer and healthier lives than those who do not. This association between physical activity and health persists in virtually every subgroup of the population, regardless of age, sex, race or environmental condition.2 There is clear scientific evidence proving the benefit of regular physical activity on both the primary and secondary prevention of diabetes, hypertension, cancer (particularly breast and colon cancer), depression, osteoporosis and dementia. Furthermore, regular physical activity has been shown to be essential in …

Initial validation of an exercise "vital sign" in electronic medical records.

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 min·wk), 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.

Strategies for Promoting Physical Activity in Clinical Practice

The time has come for healthcare systems to take an active role in the promotion of physical activity (PA). The connection between PA and health has been clearly established and exercise should be viewed as a cost effective medication that is universally prescribed as a first line treatment for virtually every chronic disease. While there are potential risks associated with exercise, these can be minimized with a proper approach and are far outweighed by the benefits. Key to promoting PA in the clinical setting is the use of a PA Vital Sign in which every patients exercise habits are assessed and recorded in their medical record. Those not meeting the recommended 150min per week of moderate intensity PA should be encouraged to increase their PA levels with a proper exercise prescription. We can improve compliance by assessing our patients barriers to being more active and employing new and evolving technology like accelerometers and smart phones applications, along with various websites and programs that have proven efficacy.

Prevention and management of non-communicable disease: the IOC consensus statement, Lausanne 2013

Morbidity and mortality from preventable, non-communicable chronic disease (NCD) threatens the health of our populations and our economies. The accumulation of vast amounts of scientific knowledge has done little to change this. New and innovative thinking is essential to foster new creative approaches that leverage and integrate evidence through the support of big data, technology, and design thinking. The purpose of this paper is to summarize the results of a consensus meeting on NCD prevention sponsored by the International Olympic Committee (IOC) in April, 2013. Within the context of advocacy for multifaceted systems change, the IOC’s focus is to create solutions that gain traction within health care systems. The group of participants attending the meeting achieved consensus on a strategy for the prevention and management of chronic disease that includes the following:1.Focus on behavioural change as the core component of all clinical programs for the prevention and management of chronic disease.2.Establish actual centres to design, implement, study, and improve preventive programs for chronic disease.3.Use human-centered design in the creation of prevention programs with an inclination to action, rapid prototyping and multiple iterations.4.Extend the knowledge and skills of Sports and Exercise Medicine (SEM) professionals to build new programs for the prevention and treatment of chronic disease focused on physical activity, diet and lifestyle.5.Mobilize resources and leverage networks to scale and distribute programs of prevention.True innovation lies in the ability to align thinking around these core strategies to ensure successful implementation of NCD prevention and management programs within health care. The IOC and SEM community are in an ideal position to lead this disruptive change. The outcome of the consensus meeting was the creation of the IOC Non-Communicable Diseases ad-hoc Working Group charged with the responsibility of moving this agenda forward.

Physical activity counselling in sports medicine: a call to action

Physical activity (PA) is a key component of healthy lifestyle and disease prevention. In contrast, physical inactivity accounts for a significant proportion of premature deaths worldwide. Physicians are in a critical position to help patients develop healthy lifestyles by actively counseling on PA. Sports medicine physicians, with their focus on sports and exercise medicine are uniquely trained to provide such expertise to patients, learners and colleagues. To succeed, physicians need clinical tools and processes that support PA assessment and counseling. Linking patients to community resources, and specifically to health and fitness professionals is a key strategy. Efforts should be made to expand provider education during medical school, residency and fellowship training, and continuing medical education. Lastly, physically active physicians are more likely to counsel patients to be active. A key message for the sports medicine community is the importance of serving as a positive PA role model.

STRESS FRACTURES IN ATHLETES : HOW TO SPOT THIS UNDERDIAGNOSED INJURY

Stress fractures are an increasingly common injury in competitive athletes, especially runners. Amenorrheic athletes are at particularly high risk. A radionuclide bone scan should be considered when the index of suspicion for stress fracture is high. Plain radiographs are of little use in establishing the diagnosis in the early stages of the injury. Early diagnosis and prompt institution of conservative therapy allow for a favorable outcome in most cases. Avoidance of or reduced participation in the inciting activity is important for pain control. Certain stress fractures, such as those involving the femoral neck, should be monitored closely and treated aggressively with internal fixation when conservative measures fail. Runners who have exercise-induced amenorrhea should be advised to decrease their training intensity to a level where menses resume. Cyclic therapy with conjugated estrogens and progesterone should also be considered, as should daily calcium supplementation.

Exercise is medicine: a call to action for physicians to assess and prescribe exercise

Abstract Engaging in regular physical activity is one of the major determinants of health. Studies have demonstrated the benefits of exercise in the treatment and prevention of most every common medical problem seen today. It is clear that patients who engage in an active and fit way of life, live longer, healthier, and better lives. For these reasons, every patient should be asked about exercise at every visit using an exercise vital sign (EVS) and, when needed, provided with an exercise prescription that encourages them to get 150 minutes or more moderate-to-vigorous physical activity. Physicians have an obligation to assess each patients exercise habits and inform them of the risks of being sedentary. Such an approach is critical to help stem the rising tide of deaths around the world due to noncommunicable diseases, which are so closely associated with a sedentary lifestyle.

Exercise and the heart--the harm of too little and too much.

Physical activity and exercise training are underutilized by much of Westernized society, and physical inactivity may be the greatest threat to health in the 21st century. Many studies have shown a linear relationship between one’s activity level and heart health, leading to the conclusion that “if some exercise is good, more must be better.” However, there is evolving evidence that high levels of exercise may produce similar or less overall cardiovascular (CV) benefits compared with those produced by lower doses of exercise. Very high doses of exercise may be associated with increased risk of atrial fibrillation, coronary artery disease, and malignant ventricular arrhythmias. These acute bouts of excessive exercise may lead to cardiac dilatation, cardiac dysfunction, and release of troponin and brain natriuretic peptide. The effects of too little and too much exercise on the heart are reviewed in this article, along with recommendations to optimize the dose of exercise to achieve heart health.

Recognizing and treating common cold-induced injury in outdoor sports.

We briefly review the physiology of cold exposure, the spectrum and prevention of common cold-induced injuries (especially in athletes participating in outdoor sports), and the potentially harmful side effects of localized cryotherapy. Severe cold affects all organ systems and especially the central nervous and cardiovascular systems; many biochemical reactions and pathways become distorted or slowed at low body core temperatures and can thus affect athletic performance. Low body shell temperature, too, can interfere with athletic ability by weakening and slowing muscle contractions, by delaying nerve conduction time, and by facilitating injury. Cold-induced injuries may be local or systemic, but they can usually be prevented by knowledge, good physical condition, appropriate nutrition and equipment, and avoidance of moisture.