Call to Action on Making Physical Activity Assessment and Prescription a Medical Standard of Care

The Impact of an Electronic Best Practice Advisory on Patients' Physical Activity and Cardiovascular Risk Profile

BACKGROUND

Regular physical activity (PA) is a component of cardiovascular health and is associated with a lower risk of cardiovascular disease (CVD). However, only about half of US adults achieved the current PA recommendations.

OBJECTIVE

The study purpose was to implement PA counseling using a clinical decision support tool in a preventive cardiology clinic and to assess changes in CVD risk factors in a sample of patients enrolled over 12 weeks of PA monitoring.

METHODS

This intervention, piloted for 1 year, had 3 components embedded in the electronic health record: assessment of patients' PA, an electronic prompt for providers to counsel patients reporting low PA, and patient monitoring using a Fitbit. Cardiovascular disease risk factors included PA (self-report and Fitbit), body mass index, blood pressure, lipids, and cardiorespiratory fitness assessed with the 6-minute walk test. Depression and quality of life were also assessed. Paired t tests assessed changes in CVD risk.

RESULTS

The sample who enrolled in the remote patient monitoring (n = 59) were primarily female (51%), White adults (76%) with a mean age of 61.13 ± 11.6 years. Self-reported PA significantly improved over 12 weeks ( P = .005), but not Fitbit steps ( P = .07). There was a significant improvement in cardiorespiratory fitness (469 ± 108 vs 494 ± 132 m, P = .0034), and 23 participants (42%) improved at least 25 m, signifying a clinically meaningful improvement. Only 4 participants were lost to follow-up over 12 weeks of monitoring.

CONCLUSIONS

Patients may need more frequent reminders to be active after an initial counseling session, perhaps getting automated messages based on their step counts syncing to their electronic health record.

Implementing Individually Tailored Prescription of Physical Activity in Routine Clinical Care: A Process Evaluation of the Physicians Implement Exercise = Medicine Project

BACKGROUND

Although the prescription of physical activity in clinical care has been advocated worldwide, in the Netherlands, "Exercise is Medicine" (E = M) is not yet routinely implemented in clinical care.

METHODS

A set of implementation strategies was pilot implemented to test its feasibility for use in routine care by clinicians in 2 departments of a university medical center. An extensive learning process evaluation was performed, using structured mixed methods methodology, in accordance with the Reach, Effect, Adoption, Implementation, and Maintenance framework.

RESULTS

From 5 implementation strategies employed (education, E = M tool embedded in the electronic medical records, lifestyle coach situated within the department, overviews of referral options, and project support), the presence of adequate project support was a strong facilitator of the implementation of E = M. Also, the presence of the lifestyle coach within the department seemed essential for referral rate. Although clinicians appreciated the E = M tool, barriers hampered its use in practice.

CONCLUSIONS

Specific implementation strategies, tailored to the setting, are effective in facilitating the implementation of E = M with specific regard to education for clinicians on E = M, deployment of a lifestyle coach within a department, and project coordination. Care providers do see a future for lifestyle coaches who are structurally embedded in the hospital, to whom they can easily refer.

Cardiovascular Health in Black and Latino Adults With Type 2 Diabetes

BACKGROUND

The incidence of type 2 diabetes (T2DM) among U.S. adults has been rising annually, with a higher incidence rate in Black and Hispanic adults than in Whites. The American Heart Association (AHA) has defined cardiovascular health according to the achievement of seven health behaviors (smoking, body mass index [BMI], physical activity, diet) and health factors (total cholesterol, blood pressure, fasting glucose). Optimal cardiovascular health has been associated with a lower risk of cardiovascular disease, and awareness of this risk may influence healthy behaviors.

OBJECTIVES

This study aimed to assess cardiovascular health in a sample of Black and Hispanic adults (age: 18-40 years) with T2DM and explore the barriers and facilitators to diabetes self-management and cardiovascular health.

METHODS

This was an explanatory sequential mixed-method design. The study staff recruited adults with T2DM for the quantitative data followed by qualitative interviews with a subsample of participants using maximum variation sampling. The seven indices of cardiovascular health as defined by the AHA's "Life's Simple 7" were assessed: health behaviors (smoking, BMI, physical activity, diet) and health factors (total cholesterol, blood pressure, A1C). Qualitative interviews were conducted to explore their results as well as the effects of the pandemic on diabetes self-management. Qualitative and quantitative data were integrated into the final analysis phase.

RESULTS

The majority of the sample was female, with 63% identifying as Black and 47% as Hispanic. The factor with the lowest achievement of ideal levels was BMI, followed by a healthy diet. Less than half achieved ideal levels of blood pressure or physical activity. Themes that emerged from the qualitative data included the impact of social support, the effects of the pandemic on their lives, and educating themselves about T2DM.

DISCUSSION

Achievement of ideal cardiovascular health factors varied, but the achievement of several health factors may be interrelated. Intervening on even one factor while providing social support may improve other areas of cardiovascular health in this population.

Implementing a Clinical Decision Support Tool to Improve Physical Activity

BACKGROUND

Currently, only about half of U.S. adults achieve current physical activity guidelines. Routine physical activity is not regularly assessed, nor are patients routinely counseled by their healthcare provider on achieving recommended levels. The three-question physical activity vital sign (PAVS) was developed to assess physical activity duration and intensity and identify adults not meeting physical activity guidelines. Clinical decision support provided via a best practice advisory in an electronic health record (EHR) system can be triggered as a prompt, reminding healthcare providers to implement the best practice intervention when appropriate. Remote patient monitoring of physical activity can provide objective data in the EHR.

OBJECTIVES

This study aimed to evaluate the feasibility and clinical utility of embedding the PAVS and a triggered best practice advisor into the EHR in an ambulatory preventive cardiology practice setting to alert providers to patients reporting low physical activity and prompt healthcare providers to counsel these patients as needed.

METHODS

Three components based in the EHR were integrated for the purpose of this study: Patients completed the PAVS through their electronic patient portal prior to an office visit, a best practice advisory was created to prompt providers to counsel patients who reported low levels of physical activity, and remote patient monitoring via Fitbit synced to the EHR provided objective physical activity data. The intervention was pilot-tested in the Epic EHR for 1 year (July 1, 2021 to June 30, 2022). Qualitative feedback on the intervention from both providers and patients was obtained at the completion of the study.

RESULTS

Monthly assessments of the use of the PAVS and best practice advisory and remote patient monitoring were completed. Patients' completion of the PAVS varied from 35% to 48% per month. The best practice advisory was signed by providers between 2% and 65% and was acknowledged by 2%-22% per month. The majority (58%) of patients were able to sync a Fitbit device to their EHR for remote monitoring.

DISCUSSION

Although uptake of each component needs improvement, this pilot demonstrated the feasibility of incorporating a physical activity promotion intervention into the EHR. Qualitative feedback provided guidance for future implementation.

Implementation of Exercise Management Services Among Sports Medicine Physicians in the United States

OBJECTIVE

Assessment of physical activity and exercise prescription has been widely supported by many organizations, yet provision of such services remains limited in the United States. We sought to uncover why such services have not been widely adopted.

DESIGN

The American Medical Society for Sports Medicine organized a task force to canvas physicians and survey the American Medical Society for Sports Medicine membership.

SETTING

Peer-to-peer and telecommunication discussions and web-based questionnaires.

PARTICIPANTS

Sports medicine physicians in the United States.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Percentage of sports medicine physicians who provide exercise management services and mechanisms of billing for exercise management, identify barriers to such services, and identify industry collaborations for promoting physical activity through physicians.

RESULTS

Three of 4 sports medicine physicians spend at least 1 min encouraging exercise with patients, using Evaluation and Management codes to bill or receive credit. Exercise counseling is often bundled within other patient care. Few health plans leverage the patient's relationship with a primary care physician to promote exercise. Most employed sports medicine physicians do not receive incentives to incorporate exercise counseling into practice, and only 1 in 6 have decision-making authority to hire an exercise professional. Major obstacles are the lack of a business model and knowledge about exercise prescription.

CONCLUSION

The existing E&M codes adequately characterize the work, but physicians desire greater payment or credit for providing exercise management services. Physicians desire to do more exercise prescription, but health system bureaucracy, inadequate support, and economic disincentives are barriers to the provision of exercise management services.

Lifestyle medicine as a modality for prevention and management of chronic diseases

Lifestyle medicine is an approach that focuses on modifying unhealthy behaviors and promoting healthy ones to prevent and manage chronic diseases. This modality addresses multiple risk factors such as physical inactivity, unhealthy diet, tobacco use, and stress. Evidence shows that adopting a healthy lifestyle can significantly reduce the incidence and progression of chronic diseases such as cardiovascular diseases, diabetes, and cancer. The implementation of Lifestyle medicine requires a multidisciplinary approach involving healthcare providers, patients, and communities. Healthcare providers play a pivotal role in educating and motivating patients to adopt healthy behaviors, while communities can provide a supportive environment that fosters healthy lifestyles. The aim of this letter to editor is to summarize the evidence supporting the use of Lifestyle medicine in the prevention and management of chronic diseases.

Prevalence and associated factors of anemia among pregnant women and the impact of clinical pharmacist counseling on their awareness level: A cross sectional study

Anemia during pregnancy is a worldwide problem that affects females worldwide. There is not enough data on the magnitude of this health problem in Al-Madinah city in Saudi Arabia. This study aimed to assess the prevalence and associated factors related to anemia during pregnancy in Al-Madinah city. In addition, assessed the impact of counseling by clinical pharmacist on anemic pregnant females. 300 pregnant females were assessed for anemia based on their hemoglobin level in a descriptive cross-sectional study. Those females were further interviewed to identify associating factors related to presence of anemia during pregnancy. Anemic females were randomized to receive either counseling by the clinical pharmacist in addition to the standard of care (interventional group) or standard of care without counseling (control group). Our result showed that 44% of pregnant women were anemic upon recruitment. Pregnant females of low socioeconomic status, those during the first trimester, multipara females, and those who did not receive nutritional education during pregnancy showed significantly higher odds of developing anemia. Clinical pharmacist-led counseling program significantly improved adherence with iron regimen (p-value < 0.01) and significantly increased patients' hemoglobin level 30-days after the intervention (p-value < 0.001).

Sports Medicine Curricular Recommendations for Undergraduate Medical Education

ABSTRACT

Sports medicine is a unique field encompassing many specialties and aspects of medicine. While musculoskeletal medicine is a significant aspect of sports medicine, the breadth of sports medicine extends beyond the musculoskeletal system and includes the spectrum of care for the patient who is or desires to be physically active. This article provides recommendations for sports medicine education in undergraduate medical education. The framework highlighting these recommendations uses domains of competence. Entrustable professional activities, measures that are endorsed by the Association of American Medical Colleges, were matched to domains of competence to provide objective markers of achievement. In addition to recommended sports medicine educational content, there should be consideration of both methods of assessment and implementation catered to each individual institution's needs and resources. These recommendations may serve as a guide for medical educators and institutions pursing optimization of sports medicine education.

Longitudinal associations between physical activity and five risk factors of metabolic syndrome in middle-aged adults in Germany

BACKGROUND

We examined the longitudinal association between (change in) physical activity (PA) with new onset of five risk factors of metabolic syndrome among 657 middle-aged adults (mean age 44.1 (standard deviation (SD) 8.6) years) who were free of the respective outcome at baseline, in a longitudinal cohort study spanning over 29 years.

METHODS

Levels of habitual PA and sports-related PA were assessed by a self-reported questionnaire. Incident elevated waist circumference (WC), elevated triglycerides (TG), reduced high-density lipoprotein cholesterols (HDL), elevated blood pressure (BP), and elevated blood-glucose (BG) were assessed by physicians and by self-reported questionnaires. We calculated Cox proportional hazard ratio regressions and 95% confidence intervals.

RESULTS

Over time, participants developed (cases of incident risk factor; mean (SD) follow-up time) elevated WC (234 cases; 12.3 (8.2) years), elevated TG (292 cases; 11.1 (7.8) years), reduced HDL (139 cases; 12.4 (8.1) years), elevated BP (185 cases; 11.4 (7.5) years), or elevated BG (47 cases; 14.2 (8.5) years). For PA variables at baseline, risk reductions ranging between 37 and 42% for reduced HDL levels were detected. Furthermore, higher levels of PA (≥ 16.6 METh per week) were associated with a 49% elevated risk for incident elevated BP. Participants who increased PA levels over time, had risk reductions ranging between 38 and 57% for elevated WC, elevated TG and reduced HDL. Participants with stable high amounts of PA from baseline to follow-up had risk reductions ranging between 45 and 87% for incident reduced HDL and elevated BG.

CONCLUSIONS

PA at baseline, starting PA engagement, maintaining and increasing PA level over time are associated with favorable metabolic health outcomes.

Acceptability and feasibility of home-based hypertension and physical activity screening by community health workers in an under-resourced community in South Africa

Background

Low-middle-income countries (LMICs) face increasing burdens from non-communicable disease (NCDs) requiring primary care task shifting to community health workers (CHWs). This study explored community members' perceptions of NCD-focused, CHW-led home visits in a historically disadvantaged township of South Africa.

Methods

Trained CHWs visited community member homes, performing blood pressure and physical activity (PA) screenings, followed by brief counselling and a satisfaction survey. Semi-structured interviews were conducted within 3 days of the visit to learn about their experiences.

Results

CHWs visited 173 households, with 153 adult community members consenting to participate (88.4%). Participants reported that it was easy to understand CHW-delivered information (97%), their questions were answered well (100%), and they would request home service again (93%). Twenty-eight follow-up interviews revealed four main themes: 1) acceptance of CHW visits, 2) openness to counselling, 3) satisfaction with screening and a basic understanding of the results, and 4) receptiveness to the PA advice.

Conclusion

Community members viewed CHW-led home visits as an acceptable and feasible method for providing NCD-focused healthcare services in an under-resourced community. Expanding primary care reach through CHWs offers more accessible and individualized care, reducing barriers for individuals in under-resourced communities to access support for NCD risk reduction.

Tracking changes in physical activity during inpatient treatment in a psychiatric clinic in Germany by asking two simple questions

Increasing physical activity is essential to improve psychiatric patients' physical and mental health. This study aimed to characterise the physical activity levels of inpatients in a general psychiatric clinic and to determine the feasibility of using a simple tool in everyday practice to assess physical activity levels in standard patient documentation. We assessed the level of physical activity undertaken by patients treated on an inpatient basis in a psychiatric hospital over 20 months. A total of 328 patients were included in the analysis. Physical activity was measured using a slightly altered version of the Exercise as a vital sign (EVS) questionnaire. All information was extracted from letters of discharge. During inpatient treatment, moderate to vigorous activity levels increased, and more patients engaged in physical activity. Patients with mood or anxiety disorders displayed the most considerable increase in physical activity. Patients with other diagnoses, such as schizophrenia, benefitted less or not at all. Factors associated with physical activity included-among others-history of substance use, education and month of admission. Investigating the feasibility of standardised documentation of physical activity showed fluctuation in documentation rates throughout the study. The level of physical activity performed by psychiatric patients can be increased during inpatient treatment. Implementing physical activity level as part of standard patient documentation is a first step in gathering data to assess the need for interventions to achieve an optimal physical activity in psychiatric patients throughout inpatient treatment.

Longitudinal association between physical activity and the risk of incident metabolic syndrome in middle-aged adults in Germany

We examined the longitudinal association between physical activity (PA) and the risk of incident metabolic syndrome (MetS) among middle-aged, community-dwelling adults, including 591 individuals (314 females; mean (SD) age, 43.8 (8.5) years) who were free of MetS at baseline. Habitual and sports-related PA was assessed by a self-reported questionnaire. MetS was defined based on HDL-cholesterols, triglycerides, glucose or HbA1c, blood pressure, and waist circumference. We calculated Cox proportional hazard ratios (HR) and 95% confidence intervals (CI) using regression analyses. Over a mean follow-up of 12.5 years, 205 participants developed incident MetS. Four different sports-related PA measures were associated with a decreased risk of incident MetS: (1) Engaging in ≥ 75 min/week (HR 0.71, 95% CI 0.53-0.94), (2) maintaining a continuously high amount from baseline to follow-up of ≥ 75 min/week (HR 0.66, 95% CI 0.46-0.94), (3) starting from < 150 min/week at baseline to ≥ 150 min/week at follow-up (HR 0.65, 95% CI 0.45-0.94), and (4) increasing from < 16.6 MET-hours/week at baseline to ≥ 16.6 MET-hours/week at follow-up (HR 0.47, 95% CI 0.31-0.71). Thus, maintaining, starting or increasing sports-related PA is associated with a lower risk of incident MetS.

Implementing Exercise = Medicine in routine clinical care; needs for an online tool and key decisions for implementation of Exercise = Medicine within two Dutch academic hospitals

Background

There is much evidence to implement physical activity interventions for medical reasons in healthcare settings. However, the prescription of physical activity as a treatment, referring to as ‘Exercise is Medicine’ (E = M) is currently mostly absent in routine hospital care in The Netherlands. To support E = M prescription by clinicians in hospitals, this study aimed: (1) to develop an E = M-tool for physical activity advice and referrals to facilitate the E = M prescription in hospital settings; and (2) to provide an E = M decision guide on key decisions for implementation to prepare for E = M prescription in hospital care.

Methods

A mixed method design was used employing a questionnaire and face-to-face interviews with clinicians, lifestyle coaches and hospital managers, a patient panel and stakeholders to assess the needs regarding an E = M-tool and key decisions for implementation of E = M. Based on the needs assessment, a digital E = M-tool was developed. The key decisions informed the development of an E = M decision guide.

Results

An online supportive tool for E = M was developed for two academic hospitals. Based on the needs assessment, linked to the different patients’ electronic medical records and tailored to the two local settings (University Medical Center Groningen, Amsterdam University Medical Centers). The E = M-tool existed of a tool algorithm, including patient characteristics assessed with a digital questionnaire (age, gender, PA, BMI, medical diagnosis, motivation to change physical activity and preference to discuss physical activity with their doctor) set against norm values. The digital E = M-tool provided an individual E = M-prescription for patients and referral options to local PA interventions in- and outside the hospital. An E = M decision guide was developed to support the implementation of E = M prescription in hospital care.

Conclusions

This study provided insight into E = M-tool development and the E = M decision-making to support E = M prescription and facilitate tailoring towards local E = M treatment options, using strong stakeholder participation. Outcomes may serve as an example for other decision support guides and interventions aimed at E = M implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01993-5.

Predictors of physical activity promotion in clinical practice: a cross-sectional study among medical doctors

BACKGROUND

Physical activity is a major determinant of physical and mental health. International recommendations identify health professionals as pivotal agents to tackle physical inactivity. This study sought to characterize medical doctors' clinical practices concerning the promotion of patients' physical activity, while also exploring potential predictors of the frequency and content of these practices, including doctors' physical activity level and sedentary behaviours.

METHODS

A cross-sectional study assessed physical activity promotion in clinical practice with a self-report questionnaire delivered through the national medical prescription software (naturalistic survey). Physical activity and sedentary behaviours were estimated using the International Physical Activity Questionnaire (short form). Indicators of medical doctors' attitudes, knowledge, confidence, barriers, and previous training concerning physical activity promotion targeting their patients were also assessed. Multiple regression analysis was performed to identify predictors of physical activity promotion frequency by medical doctors, including sociodemographic, attitudes and knowledge-related variables, and physical activity behaviours as independent variables.

RESULTS

A total of 961 medical doctors working in the Portuguese National Health System participated (59% women, mean age 44 ± 13 years) in the study. The majority of the participants (84.6%) reported to frequently promote patients' physical activity. Five predictors of physical activity promotion frequency emerged from the multiple regression analysis, explaining 17.4% of the dependent variable (p < 0.001): working in primary healthcare settings (p = 0.037), having a medical specialty (p = 0.030), attributing a high degree of relevance to patients' physical activity promotion in healthcare settings (p < 0.001), being approached by patients to address physical activity (p < 0.001), and having higher levels of physical activity (p = 0.001).

CONCLUSIONS

The sample of medical doctors approached reported a high level of engagement with physical activity promotion. Physical activity promotion frequency seems to be influenced by the clinical practice setting, medical career position and specialty, attitudes towards physical activity, and perception of patients´ interest on the topic, as well as medical doctors' own physical activity levels.

Inclusion of physical activity in nurse practitioner programs: A national perspective

BACKGROUND

Physical activity (PA) provides a multitude of health benefits, creating an avenue for disease prevention and management. Health care providers play a crucial role in helping patients become more active, yet little is known about the preparation of primary care nurse practitioners (NPs) to aid in this effort.

PURPOSE

To examine the amount and type of PA training offered in primary care NP programs in the United States.

METHODOLOGY

A cross-sectional study design was used. Eligible programs' websites were reviewed, and an online survey of program leaders assessed details regarding the inclusion of PA training, barriers, and future plans.

RESULTS

Data extracted from 1,067 NP program websites revealed that 81.7% of websites (n = 264) with course descriptions contained one or more general health promotion keywords, whereas only 0.6% (n = 2) included a PA-specific keyword. Two-hundred institutions (53.2%) completed the program leader survey, of which 45.0% reported no inclusion of PA training. Among institutions providing PA training, 82.2% (n = 88) and 55.1% (n = 59) reported the inclusion of aerobic activity and strength training recommendations, respectively. Forty-one institutions (46.1%) felt that their institution prepared students to effectively counsel patients on starting a PA program.

CONCLUSIONS

Although some NP programs include PA content, most provide no or less-than-adequate PA training.

IMPLICATIONS FOR PRACTICE

The current state of PA training in NP programs may hinder health promotion and disease prevention efforts. Programs should dedicate sufficient time and attention to preparing future NPs to promote PA behaviors. A multifaceted, multistakeholder approach is needed to facilitate widespread adoption of PA inclusion.

Determining the Impact of an Educational Intervention on Family Medicine Residents' Social Cognitions and Behavior for Discussing Physical Activity

Problem: Primary care providers are recognized as important advocates for physical activity (PA); yet, clinical PA discussions remain infrequent. Educational approaches promoting the uptake of strategies that are proven to increase patient PA levels are effective for improving primary care providers' social cognitions and behavior for discussing PA with patients. However, research on the effectiveness of such educational interventions among family medicine residents is limited. Intervention: Using the Theory of Planned Behavior (TPB), an interactive, educational intervention was developed to increase PA discussion between first year family medicine residents and their patients. This study aimed to determine the impact of the intervention on residents' social cognitions and behavior for discussing PA with all adult (18-64 years) patients. Context: The intervention condition was comprised of 15 first year residents (2017/2018) who: (1) received the full intervention, and (2) completed both the pre- and post-intervention TPB questionnaires assessing changes in PA discussion social cognitions, and (3) had their medical charts reviewed for PA discussion behavior. The nonintervention condition was comprised of 15 first-year residents (2016/2017) who were randomly selected to have their medical charts reviewed for PA discussion behavior. Impact: Although no significant differences in social cognitions were observed pre- vs. post-intervention, intervention condition residents' perceptions of feeling adequately trained to discuss PA increased post-intervention (p = 0.005). A difference in residents' PA discussion behavior was observed between conditions at post (p = 0.01), where PA was discussed at more patient visits among intervention condition residents. Lessons Learned: Findings suggest that the observed effect of resident PA discussion behavior being greater in the intervention condition at post may be attributed to the intervention condition residents having received the theory-based, educational workshops. This study highlights the importance of educating and training residents on strategies for PA discussion; however, future interventions should address both the reflective and automatic processing aspects of behavior and strive to influence organizational factors that impact resident behavior for discussing PA.Supplemental data for this article is available online at at 10.1080/10401334.2021.1891542.

Physical Literacy in Elementary Physical Education: A Survey of Fundamental Movement Skill Practice Patterns

PURPOSE

To describe fundamental movement skill (FMS) practice patterns in the elementary physical education (PE) curriculum.

METHODS

A cross-sectional survey was sent to PE teachers of grades 1 through 6. Sixty-eight responses were included for analysis.

RESULTS

Only 38.2% of teachers taught all 12 FMS components. Compared with PE teachers for grades 4 to 6, a significantly higher proportion of PE teachers for grades 1 to 3 taught all 12 FMS and used direct instruction methods. For children falling behind, only 8.8% reported referring to an exercise program and no PE teacher sought a health care referral. A video abstract can be found in Supplemental Digital Content 1 (available at: http://links.lww.com/PPT/A342).

Physical activity promotion in community pharmacies: pharmacists' attitudes and behaviours

Background

Health systems and their professionals play a key role in the promotion and maintenance of behaviours contributing to increased physical activity levels. Pharmacists are well placed within communities, making them an accessible source to provide brief advice to people on how to be more physically active.

Objective

This study aimed to characterize physical activity promotion actions taking place in the Portuguese community pharmacies, as well as the major facilitators and barriers faced by pharmacists in their daily practice.

Methods

A cross-sectional study based on an online questionnaire targeting community pharmacists was developed based on COM-B model and the Theoretical Domains Framework (TDF) and distributed by email to 94% of the Portuguese pharmacies.

Results

In total, 396 complete responses from community pharmacists were obtained. Three out of four participants reported to promote physical activity in their daily routine, of which 87.7% reported doing it in only a few attendances. The majority (92.3%) mentioned to provide information orally, with walking being the activity most promoted (99.4%). More active and younger pharmacists were more likely to promote physical activity. Nearly all pharmacists (98.7%) believed it was important or very important to practice regular physical activity for the health, but only 41.4% of the respondents were able to correctly identify the WHO general recommendations for physical activity. The lack of coordination with other healthcare professionals (M=3.35; SD=1.11), lack of interest by customers (M=3.25; SD=1.09) and lack of time (M=3.06; SD=1.10) were the main barriers to physical activity promotion, all scoring above the scale mid-point (i.e., 3).

Conclusions

Physical activity promotion in the Portuguese community pharmacies is still not present as daily activity. Younger pharmacists seem to be a generation that better understand this need and could easily integrate this practice in their daily routine. Possibilities for including pharmacies and pharmacists as promoters of physical activity in the primary health care sector in the future are discussed in the light of these findings.

Medical Education Transformation: Lifestyle Medicine in Undergraduate and Graduate Medical Education, Fellowship, and Continuing Medical Education

A gaping void of adequate lifestyle medicine (LM) training exists across the medical education continuum. The American College of Lifestyle Medicine's (ACLM's) undergraduate medical education (UME) Task Force champions the need for widespread integration of LM curriculum in UME by sharing ideas for catalyzing success, lessons learned, and publishing standards and competencies to facilitate curriculum reform. When it comes to graduate medical education and fellowship, the ACLM and American Board of Lifestyle Medicine have made great strides in filling the void, developing both Educational and Experiential Pathways through which physicians may become certified LM Physicians or LM Specialists (LMSs). The Lifestyle Medicine Residency Curriculum meets the Educational Pathway requirements and prepares resident graduates for the LM Physician board certification. LMS is the second tier of LM certification that demonstrates expertise in disease reversal. The LMS Fellowship is an Educational Pathway intent on American Board of Medical Specialties recognition of LM as a new subspecialty in the near future. Finally, continuing medical education and maintenance of certification equip physicians with LM training to support knowledge, application, and certification in LM.

Integrating "Exercise Is Medicine" into primary care workflow: a study protocol

As a major contributor to the burden of most chronic diseases, insufficient physical activity (PA) creates a significant financial burden on the health care system. Numerous interventions effectively increase PA, but few are integrated into primary care clinic workflows. Exercise Is Medicine (EIM) is a global health initiative committed to the belief that PA is integral to the prevention and treatment of diseases and should be routinely assessed as a vital sign and treated in the health care setting. This paper describes an in-progress embedded quality improvement (QI) project that integrates EIM into routine clinical practice. A combination of implementation science (IS) and QI models are used to adapt, implement, and evaluate the integration of EIM into six primary care clinics. The Practical, Robust Implementation and Sustainability Model (PRISM) guided preimplementation evaluation and adaptation of EIM protocol, materials, and delivery strategies. The learning evaluation QI model is used to design, test, refine, and implement EIM using rapid, 3 month Plan-Do-Study-Act microcycles. Learning meetings are used to obtain feedback and optimize workflow. The Stirman Framework is used to document adaptations to the program throughout implementation. Reach, adoption, implementation, effectiveness, and maintenance outcomes embedded within PRISM will guide the program evaluation to determine sustainability and scalability. Using an innovative approach of combining IS and QI methods to improve the identification of primary care patients with insufficient PA to increase their activity levels has great population health potential. Our work will inform the best approaches for EIM integration in primary care.

Healthcare Professionals Promotion of Physical Activity with Older Adults: A Survey of Knowledge and Routine Practice

Healthcare professionals have a key role in promoting physical activity, particularly among populations at greatest risk of poor health due to physical inactivity. This research aimed to develop our understanding of healthcare professionals knowledge, decision making and routine practice of physical activity promotion with older adults. A cross-sectional survey was conducted with practicing healthcare professionals in general practice, physiotherapy, occupational therapy and nursing in Ireland and Northern Ireland. We received 347 eligible responses, with 70.3% of all respondents agreeing that discussing physical activity is their job and 30.0% agreeing that they have received suitable training to initiate conversations with patients about physical activity. Awareness of the content and objectives of national guidelines for physical activity varied considerably across the health professions surveyed. Less than a third of respondents had a clear plan on how to initiate discussions about physical activity in routine practice with older adults. Assessment of physical activity was not routine, neither was signposting to physical activity supports. Considering the COVID-19 pandemic and its implications, 81.6% of all respondents agreed that healthcare professionals can play an increased role in promoting physical activity to older adults as part of routine practice. Appropriate education, training and access to resources are essential for supporting healthcare professionals promotion of physical activity in routine practice. Effective physical activity promotion in healthcare settings has the potential for health benefits at a population level, particularly in older adult populations.

ABC of prescribing exercise as medicine: a narrative review of the experiences of general practitioners and patients

BACKGROUND

Exercise prescribing can help patients to overcome physical inactivity, but its use in general practice is limited. The purpose of this narrative review was to investigate contemporaneous experiences of general practitioners and patients with exercise prescribing.

METHOD

PubMed, Scopus, Science Direct and Cochrane reviews were reviewed using the terms 'exercise prescription', 'exercise prescribing', 'family practice', 'general practice', 'adults' and 'physical activity prescribing'.

RESULTS

After screening by title, abstract and full paper, 23 studies were selected for inclusion. Qualitative, quantitative and mixed-methods studies revealed key experiences of general practitioners and patients. Barriers identified included: physician characteristics, patients' physical and psychosocial factors, systems and cultural failures, as well as ambiguity around exercise prescribing. We present a synthesis of the key strategies to overcome these using an ABC approach: A: assessment of physical activity: involves asking about physical activity, barriers and risks to undertaking an exercise prescription; B: brief intervention: advice, written prescription detailing frequency, intensity, timing and type of exercise; and C: continued support: providing ongoing monitoring, accountability and progression of the prescription. Multiple supports were identified: user-friendly resources, workshops for doctors, guidelines for specific illnesses and multimorbidity, electronic devices, health system support and collaboration with other healthcare and exercise professionals.

DISCUSSION

This review has identified levers for facilitating exercise prescribing and adherence to it. The findings have been presented in an ABC format as a guide and support for general practitioners to prescribe exercise.

Validity of the Exercise Vital Sign Tool to Assess Physical Activity

INTRODUCTION

Assessment and counseling by healthcare providers can successfully increase physical activity; however, a valid instrument to effectively measure physical activity is needed. This study examines the validity of the Exercise Vital Sign tool by comparing Exercise Vital Sign data collected at Kaiser Permanente Northwest with accelerometry data.

METHODS

Participants (n=521) completed accelerometer monitoring and had ≥1 Exercise Vital Sign measurement in their electronic medical record. Using accelerometry as the gold standard, the association between moderate-to-vigorous physical activity minutes per week estimated through Exercise Vital Sign and that estimated through accelerometry was examined using the Spearman correlation coefficient. Comparability of moderate-to-vigorous physical activity categories (inactive, lowly active, moderately active, sufficiently active) was assessed using simple and weighted κ statistics. Sensitivity, specificity, and positive and negative predictive values were calculated. The study was conducted in 2012-2015, with analysis in 2019-2020.

RESULTS

Average accelerometry-based moderate-to-vigorous physical activity was 212 minutes per week, and 57% of the participants were considered sufficiently active. Exercise Vital Sign‒based moderate-to-vigorous physical activity averaged 170 minutes per week, and 53% of the participants were active. There was a positive correlation between the moderate-to-vigorous physical activity minutes per week reported through Exercise Vital Sign and that reported through accelerometry (r =0.38, p<0.0001). A fair agreement was observed between Exercise Vital Sign‒ and accelerometry-based moderate-to-vigorous physical activity categories (weighted κ=0.29), with the highest agreement occurring for those with physical activity level ≥150 minutes per week. The positive correlation increased when moderate-to-vigorous physical activity was examined dichotomously (<150 or ≥150 minutes per week, κ=0.34). The sensitivity, specificity, positive predictive value, and negative predictive value for Exercise Vital Sign (when compared with those of accelerometry) were 67%, 68%, 61%, and 73%, respectively.

CONCLUSIONS

The Exercise Vital Sign is a useful physical activity assessment tool that correctly identifies the majority of adults who do and do not meet physical activity guidelines.

Prehabilitation Coming of Age: IMPLICATIONS FOR CARDIAC AND PULMONARY REHABILITATION

While cardiac and pulmonary rehabilitation programs traditionally involve exercise therapy and risk management following an event (eg, myocardial infarction and stroke), or an intervention (eg, coronary artery bypass surgery and percutaneous coronary intervention), prehabilitation involves enhancing functional capacity and optimizing risk profile prior to a scheduled intervention. The concept of prehabilitation is based on the principle that patients with higher functional capabilities will better tolerate an intervention, and will have better pre- and post-surgical outcomes. In addition to improving fitness, prehabilitation has been extended to include multifactorial risk intervention prior to surgery, including psychosocial counseling, smoking cessation, diabetes control, nutrition counseling, and alcohol abstinence. A growing number of studies have shown that patients enrolled in prehabilitation programs have reduced post-operative complications and demonstrate better functional, psychosocial, and surgery-related outcomes. These studies have included interventions such as hepatic transplantation, lung cancer resection, and abdominal aortic aneurysm (repair, upper gastrointestinal surgery, bariatric surgery, and coronary artery bypass grafting). Studies have also suggested that incorporation of prehabilitation before an intervention in addition to traditional rehabilitation following an intervention further enhances physical function, lowers risk for adverse events, and better prepares a patient to resume normal activities, including return to work. In this overview, we discuss prehabilitation coming of age, including key elements related to optimizing pre-surgical fitness, factors to consider in developing a prehabilitation program, and exercise training strategies to improve pre-surgical fitness.

Feasibility of implementing a preventive physical exercise programme recommended by general practitioners in cardiovascular risk patients: A pre-post comparison study

Background

Physical inactivity implies a significant individual and society health burden.

Objectives

To assess the feasibility of implementing a preventive physical exercise (PE) programme for the general population and to analyse changes in fitness-related variables and quality of life.

Methods

Pre-post comparison study in which general practitioners and nurses recommended PE to participants with sedentary behaviour and hypertension or dyslipidaemia attending in primary care for primary prevention of ischaemic cardiovascular disease. Eligible participants were referred to a PE programme (10 weeks, three days a week, a total of 30 sessions of one-hour duration). Data was collected for five years (2013–2017). Outcome measures were body weight, body mass index (BMI), physical condition (aerobic fitness, muscle strength, flexibility, balance), and quality of life (SF-36).

Results

The PE programme was offered to 6,140 eligible subjects; 5,077 (82.7%) accepted to participate and received a recommendation; 3,656 (69.6% women) started the programme and 2,962 subjects (80.9% women) finished the programme. After 10 weeks, there were significant improvements (mean difference, 95% CI) in aerobic fitness (2.55 ml/min/kg, 2.32–2.79), muscle strength (0.62 m, 0.57 to 0.67), flexibility (2.34 cm, 2.06 to 2.63) and balance (−0.46 falls, −0.60 to −0.33) as well as significant decreases in body weight (−0.41 kg, −0.64 to −0.17) and BMI (−0.27 kg/m², −0.34 to −0.20).

Conclusion

Implementation of a government-supported PE programme for the general population recruited in the primary care setting and recommended by healthcare professionals is feasible, and was associated with health benefits, mainly improvements in physical fitness.

Disease prevalence and number of health care visits among members of a nationwide sports organization compared to matched controls

Background

Physical activity has positive effects on several diseases and may reduce the risk of morbidity and the mortality rate. Whether the prevalence of disease and health care consumption differ between the members of sports organizations and the general population has not been established. Hence, this pilot study aimed to compare the prevalence of diseases known to be associated with physical inactivity and health care consumption in members of a large non-profit sports organization and an age-, sex- and geographically matched random sample from the general population.

Methods

Subjects in two Swedish cities who exercised at least once a week and had been members for at least two years in the non-profit sports organization Friskis&Svettis were invited. A randomized age-, sex- and geographically matched sample was drawn from the general population. Data on disease prevalence (by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes) and health care consumption were retrieved using the members’ personal identification numbers through a regional health care database. Between-group differences in the prevalence of disease were compared using chi²-tests and logistic regression between members and controls. Health care consumption was defined as the number of visits, stratified by primary and hospital care, and was compared using chi²-tests and Mann-Whitney U-tests.

Results

In total, 3015 subjects were included in each group (response rate 11%). Controls had higher prevalence rates of musculoskeletal diseases (13.3% vs. 11.6%, p = 0.047), metabolic disease (10.4% vs. 5.4%, p < 0.001), hypertension (16.6% vs. 11.7%, p < 0.001), psychiatric diseases (8.9% vs. 7.1%, p = 0.012) and lung cancer (0.4% vs. 0%, p = 0.001) than the members. The total number of health care contacts was 22% higher in the controls than in the members, whereas the proportion of subjects with at least one health care visit was larger in the members (89% vs. 79%, p < 0.001).

Conclusions

The prevalence rates of lifestyle diseases related to musculoskeletal, metabolic and psychiatric diseases, hypertension and lung cancer, and the overall health care consumption, were lower among members of a sports organization than among controls. However, longitudinal studies are needed to establish a cause-effect relationship between membership and disease development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10466-9.

Global Public Health Guidelines on Physical Activity and Sedentary Behavior for People Living With Chronic Conditions: A Call to Action

Background: In 2020, the World Health Organization (WHO) released global guidelines on physical activity (PA) and sedentary behavior, for the first time providing population-based recommendations for people living with selected chronic conditions. This article briefly presents the guidelines, related processes and evidence, and, importantly, considers how they may be used to support research, practice, and policy. Methods: A brief overview of the scope, agreed methods, selected chronic conditions (adults living with cancer, hypertension, type 2 diabetes, and human immunodeficiency virus), and appraisal of systematic review evidence on PA/sedentary behavior is provided. Methods were consistent with World Health Organization protocols for developing guidelines. Results: Moderate to high certainty evidence (varying by chronic condition and outcome examined) supported that PA can reduce the risk of disease progression or premature mortality and improve physical function and quality of life in adults living with chronic conditions. Direct evidence on sedentary behavior was lacking; however, evidence extrapolated from adult populations was considered applicable, safe, and likely beneficial (low certainty due to indirectness). Conclusions: Clinical and public health professionals and policy makers should promote the World Health Organization 2020 global guidelines and develop and implement services and programs to increase PA and limit sedentary behavior in adults living with chronic conditions.

Training health professionals to provide physical activity counselling

There is strong evidence that physical activity (PA) counselling from a health professional (HPs) leads to increased PA of their patients. Despite this, there remains a large evidence-practice gap between HP knowledge of the contribution of physical inactivity to chronic disease prevention and management, and routine effective assessment and prescription of PA. This article will present evidence on the effectiveness of HP- PA counselling and suggested behaviour change frameworks that can be used by HP. Four case studies are provided as examples of programs integrated into current HP student and post-graduate training programs.

Efficacy of an Online Physical Activity Intervention Coordinated With Routine Clinical Care: Protocol for a Pilot Randomized Controlled Trial

Background

Most adults are not achieving recommended levels of physical activity (150 minutes/week, moderate-to-vigorous intensity). Inadequate activity levels are associated with numerous poor health outcomes, and clinical recommendations endorse physical activity in the front-line treatment of obesity, diabetes, dyslipidemia, and hypertension. A framework for physical activity prescription and referral has been developed, but has not been widely implemented. This may be due, in part, to the lack of feasible and effective physical activity intervention programs designed to coordinate with clinical care delivery.

Objective

This manuscript describes the protocol for a pilot randomized controlled trial (RCT) that tests the efficacy of a 13-week online intervention for increasing physical activity in adult primary care patients (aged 21-70 years) reporting inadequate activity levels. The feasibility of implementing specific components of a physical activity clinical referral program, including screening for low activity levels and reporting patient program success to referring physicians, will also be examined. Analyses will include participant perspectives on maintaining physical activity.

Methods

This pilot study includes a 3-month wait-listed control RCT (1:1 ratio within age strata 21-54 and 55-70 years). After the RCT primary end point at 3 months, wait-listed participants are offered the full intervention and all participants are followed to 6 months after starting the intervention program. Primary RCT outcomes include differences across randomized groups in average step count, moderate-to-vigorous physical activity, and sedentary behavior (minutes/day) derived from accelerometers. Maintenance of physical activity changes will be examined for all participants at 6 months after the intervention start.

Results

Recruitment took place between October 2018 and May 2019 (79 participants were randomized). Data collection was completed in February 2020. Primary data analyses are ongoing.

Conclusions

The results of this study will inform the development of a clinical referral program for physical activity improvement that combines an online intervention with clinical screening for low activity levels, support for postintervention behavior maintenance, and feedback to the referring physician.

Trial Registration

ClinicalTrials.gov NCT03695016; https://clinicaltrials.gov/ct2/show/NCT03695016.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18891

Implementing Individually Tailored Prescription of Physical Activity in Routine Clinical Care: Protocol of the Physicians Implement Exercise = Medicine (PIE=M) Development and Implementation Project

Background

The prescription of physical activity (PA) in clinical care has been advocated worldwide. This “exercise is medicine” (E=M) concept can be used to prevent, manage, and cure various lifestyle-related chronic diseases. Due to several challenges, E=M is not yet routinely implemented in clinical care.

Objective

This paper describes the rationale and design of the Physicians Implement Exercise = Medicine (PIE=M) study, which aims to facilitate the implementation of E=M in hospital care.

Methods

PIE=M consists of 3 interrelated work packages. First, levels and determinants of PA in different patient and healthy populations will be investigated using existing cohort data. The current implementation status, facilitators, and barriers of E=M will also be investigated using a mixed-methods approach among clinicians of participating departments from 2 diverse university medical centers (both located in a city, but one serving an urban population and one serving a more rural population). Implementation strategies will be connected to these barriers and facilitators using a systematic implementation mapping approach. Second, a generic E=M tool will be developed that will provide tailored PA prescription and referral. Requirements for this tool will be investigated among clinicians and department managers. The tool will be developed using an iterative design process in which all stakeholders reflect on the design of the E=M tool. Third, we will pilot-implement the set of implementation strategies, including the E=M tool, to test its feasibility in routine care of clinicians in these 2 university medical centers. An extensive learning process evaluation will be performed among clinicians, department managers, lifestyle coaches, and patients using a mixed-methods design based on the RE-AIM framework.

Results

This project was approved and funded by the Dutch grant provider ZonMW in April 2018. The project started in September 2018 and continues until December 2020 (depending on the course of the COVID-19 crisis). All data from the first work package have been collected and analyzed and are expected to be published in 2021. Results of the second work package are described. The manuscript is expected to be published in 2021. The third work package is currently being conducted in clinical practice in 4 departments of 2 university medical hospitals among clinicians, lifestyle coaches, hospital managers, and patients. Results are expected to be published in 2021.

Conclusions

The PIE=M project addresses the potential of providing patients with PA advice to prevent and manage chronic disease, improve recovery, and enable healthy ageing by developing E=M implementation strategies, including an E=M tool, in routine clinical care. The PIE=M project will result in a blueprint of implementation strategies, including an E=M screening and referral tool, which aims to improve E=M referral by clinicians to improve patients’ health, while minimizing the burden on clinicians.

Physical Activity, Exercise, Whole Health, and Integrative Health Coaching

Physical activity and exercise play a significant role in the management and prevention of chronic disease. Therefore, patient-center approaches offered within medical settings are essential for the promotion of health and well-being. The Whole Health model of care incorporates all aspects of care, including prevention, treatment, conventional, and complementary approaches resulting in care for the whole person. Integrative health coaching is a tool for clinicians seeking to achieve behavior changes for improved health, particularly in the areas of physical activity and exercise. The Whole Health model of care complements the rehabilitative process, using a combination of complementary and integrative medicine for health promotion. In addition to incorporating Whole Health tools into clinical care, rehabilitative specialists may partner with integrative health coaches to achieve challenging behavior changes in the areas of physical activity, exercise, and other areas of self-care.

A Qualitative Study on the Perspectives of Latinas Enrolled in a Diabetes Prevention Program: Is the Cost of Prevention Too High?

Introduction: Latinas are among the groups most affected by diabetes health disparities, yet they often benefit less from diabetes interventions even when these are culturally adapted. The purpose of this qualitative study was to explore readiness of Latinas enrolled in a diabetes prevention program to adopt recommended preventive behaviors, and to identify factors associated with the adoption and maintenance of these recommended lifestyle changes. Insights gained will be used to inform future efforts at reducing diabetes disparities and the burden of chronic diseases among Latinas. Methods: Nine focus group discussions (FGDs) and 3 key informant interviews (KIIs) were conducted after the completion of a culturally adapted diabetes prevention program led by Latino community health workers. A grounded theory approach by Charmaz informed by the transtheoretical model guided the questions. Discussions and interviews were audio-taped with participants’ permission, transcribed, coded, and themed. Results: Forty low-income Latinas contributed to FGDs and KIIs. Baseline readiness to engage in new behaviors varied. Negative personal and family health events and physician referral impacted most readiness to enroll and to adopt preventive behaviors. Built environment, financial constraints, and threat of social alienation constituted major barriers to behavior adoption and maintenance, while physician involvement, awareness of diabetes complications, and social support partially mitigated these impediments. Conclusions: Our results suggest that timing of enrollment, physician-patient dynamics, and the emotional personal/family cost of behavior modification should all be considered when planning diabetes prevention programs for low-income Latinas. Besides appropriately timing referrals to accessible culturally informed prevention programs, health educators and health care providers should be aware of the potentially negative impact of behavior modification on family dynamics and be prepared to address resulting repercussions. Future research on Latinas should also include and report data on physician involvement, family context, and social determinants of health for more consistent program comparisons.

Are primary care physicians ill equipped to evaluate and treat childhood physical inactivity?

Objective: To investigate primary care physician clinical practice patterns, barriers, and education surrounding pediatric physical activity (PA), and to compare practice patterns by discipline.Study design: Cross-sectional studyMethods: 4500 randomly selected pediatricians, family practice, and sports medicine physicians in the United States were surveyed (11% response rate). Main outcome measures were questionnaire answers on clinical effort, attitudes, and barriers surrounding PA, medical education in exercise science, and awareness of ICD-9 diagnostic codes pertaining to physical inactivity.Results: Approximately 15% of patient interaction time was spent on the evaluation and treatment of physical inactivity for a normal weight child. For an overweight or obese child, clinical time spent on PA almost doubles. Regardless of weight, sports medicine physicians spent significantly more time on the evaluation of physical activity compared to family/internal medicine physicians and pediatricians. Mean percentage of time family/internal medicine physicians spent on PA evaluation and treatment was consistently less than sports medicine physicians, and consistently more than pediatricians. Most physicians strongly agreed that PA assessment and treatment are important for disease prevention; only 28% had ever made the diagnosis of childhood physical inactivity. Limited clinical time was identified as a primary barrier to diagnosing childhood physical inactivity. Eighty-five percent of respondents were unaware of ICD-9 codes for reimbursement of PA evaluation. Eighty-one percent reported a paucity of exercise science education in medical school.Conclusion: While physicians report that PA evaluation is important in practice, behavior patterns surrounding time evaluating PA and treating childhood physical inactivity are discrepant. Pediatricians showed less favorable attitudes and effort surrounding PA compared to other primary care disciplines. The majority of physicians are unaware of physical inactivity diagnostic codes, have never made the diagnosis of childhood physical inactivity, and may not be receiving basic pediatric exercise science training required for evaluating and treating childhood physical inactivity.

Mediterranean diet as medical prescription in menopausal women with obesity: a practical guide for nutritionists

Menopausal transition is associated with weight gain and increased visceral fat distribution, which acts as an endocrine organ secreting the pro-inflammatory adipocytokines, which leads to metabolic disorders typical of menopause, including type 2 diabetes and cardiovascular diseases. Given the increasing number of aging population, the nutritional strategies to prevent obesity and obesity-related diseases in menopausal women is becoming a growing need and it should be one of the main objective for Nutritionists. The Mediterranean diet is characterized from foods with anti-inflammatory and antioxidant actions, such as extra-virgin olive oil, vegetables, fruits, legumes, nuts, red wine, and whole-grain cereals. Several evidences showed that the Mediterranean diet acts on both weight control and menopause, in addition to the known effects of the Mediterranean diet on cardiovascular and metabolic diseases. The Mediterranean diet is comparable with pharmacological interventions in terms of reducing the risk of obesity and cardiovascular and metabolic events. Considering that there are no specific dietary guidelines to manage weight in menopause, the aim of this review is to provide a nutritional guideline for the management of weight in menopause, particularly focusing on the Mediterranean diet.

Exercise Is Medicine

There is overwhelming evidence in the scientific and medical literature that physical inactivity is a major public health problem with a wide array of harmful effects. Over 50% of health status can be attributed to unhealthy behaviors with smoking, diet, and physical inactivity as the main contributors. Exercise has been used in both the treatment and prevention of a variety of chronic conditions such as heart disease, pulmonary disease, diabetes, and obesity. While the negative effects of physical inactivity are widely known, there is a gap between what physicians tell their patients and exercise compliance. Exercise is Medicine was established in 2007 by the American College of Sports Medicine to inform and educate physicians and other health care providers about exercise as well as bridge the widening gap between health care and health fitness. Physicians have many competing demands at the point of care, which often translates into limited time spent counseling patients. The consistent message from all health care providers to their patients should be to start or to continue a regular exercise program. Exercise is Medicine is a solution that enables physicians to support their patients in implementing exercise as part of their disease prevention and treatment strategies.

Physical Activity Assessment and Counseling in Pediatric Clinical Settings

Physical activity plays an important role in children's cardiovascular health, musculoskeletal health, mental and behavioral health, and physical, social, and cognitive development. Despite the importance in children's lives, pediatricians are unfamiliar with assessment and guidance regarding physical activity in children. With the release of the 2018 Physical Activity Guidelines by the US Department of Health and Human Services, pediatricians play a critical role in encouraging physical activity in children through assessing physical activity and physical literacy; providing guidance toward meeting recommendations by children and their families; advocating for opportunities for physical activity for all children in schools, communities, and hospitals; setting an example and remaining physically active personally; advocating for the use of assessment tools and insurance coverage of physical activity and physical literacy screening; and incorporating physical activity assessment and prescription in medical school curricula.

Review of Recent Physical Activity Guidelines During Pregnancy to Facilitate Advice by Health Care Providers

Importance

Physical activity during pregnancy can offer many maternal and fetal health benefits.

Objective

The aim was to summarize American, Canadian, and international recommendations published recently on physical activity during pregnancy to aid health care providers in their delivery of advice on the topic.

Evidence Acquisition

A descriptive review of 3 national guidelines and 1 international guideline on physical activity during pregnancy was conducted. The guidelines included the 2019 Canadian recommendations, the 2018 United States' Physical Activity Guidelines for Americans (second edition), the 2015 (reaffirmed in 2017) American College of Obstetrics and Gynecology guideline, and the 2016-2018 International Olympic Committee recommendations for recreational and elite athletes.

Results

For apparently healthy women, under the guidance of their health care provider, moderate-intensity physical activity using both aerobic and muscle conditioning activities is recommended. The guidelines recommended at least 150 min/wk spread throughout the week (Canada, United States) or at least 20 to 30 min/d (American College of Obstetrics and Gynecology).

Conclusions and Relevance

This summary of 4 recent guidelines can facilitate use of updated recommendations by health care providers regarding physical activity during pregnancy. More detailed evidence-based guidelines on physical activity during postpartum are needed.

Physical Activity Promotion Tools in the Portuguese Primary Health Care: An Implementation Research

Background: This paper aims to discuss how physical activity (PA) brief assessment, brief counseling, and self-monitoring tools were designed and implemented in the Portuguese National Health Service (NHS), and to report on their current use by health professionals and citizens. Methods: Three digital tools to facilitate PA promotion in primary health care (PHC) were developed: 1) a PA brief assessment tool was incorporated in the electronic health record platform “SClínico Cuidados de Saúde Primários“; 2) a brief counseling tool was developed in the software “PEM—Prescrição Eletrónica Médica” (electronic medical prescription); and 3) a “Physical Activity Card” was incorporated in an official NHS smartphone app called “MySNS Carteira”. Results: From September 2017 to June 2019, 119,386 Portuguese patients had their PA assessed in PHC. Between December 2017 and June 2019, a total of 7957 patients received brief intervention for PA by a medical doctor. Regarding the app “MySNS Carteira”, 93,320 users activated the “Physical Activity Card”, between February 2018 and December 2018. Conclusions: These tools represent key actions to promote PA among Portuguese citizens using PHC as a priority setting. Further initiatives will follow, including proper assessment of their clinical impact and training programs for health care professionals on PA promotion.

Utilitarian walking and walking as exercise among community-dwelling older adults: what factors influence it?

Abstract Objective : to investigate the association between utilitarian walking and walking as exercise, and socio-demographic, clinical and functional covariates related to these walking types. Methods : a cross-sectional exploratory study was conducted with 148 older adults (aged 60 and over). Walking frequency and duration was assessed using the IPEQ-W (Incidental and Planned Exercise Questionnaire - Version W). Socio-demographic, clinical conditions, level of disability and mobility were also assessed. Types of walking were compared among the variables using the Mann-Whitney test and non-parametric Spearman rho correlations were used to investigate the association between the types of walking and the variables. Results : the participants performed a mean of 1.1 (±2.1) h/week of walking as exercise and 2.2 (±2.3) h/week of utilitarian walking. Older adults who had diabetes (p=0.015) did fewer h/week of walking as exercise. Participants who were older (p=0.014), reported poor self-rated health (p<0.001), poor disability levels (p<0.001), hypertension (p=0.048), strokes (p<0.001), heart disease (p=0.026), urinary incontinence (p<0.001), dizziness (p=0.008), or sleep disorders (p=0.042) spent fewer hours performing utilitarian walking. Correlations between the covariates and types of walking varied from very weak to weak. Conclusion : chronic diseases and unfavorable health conditions decreased walking time. Utilitarian walking was the most frequent type of walking performed by the older adults. Health care professionals and public policy managers should use utilitarian walking as a way of increasing levels of physical activity and to promote healthy aging.

A new aerobic fitness score based on lactate sensing during submaximal exercise

Given the known clinical utility of cardiorespiratory fitness, measurement of physiological responses to submaximal exercise may be a feasible approach well suited for diagnostic and prognostic purposes in non-athletes and the chronically ill. Lactate levels and watt output during a short submaximal exercise and a subsequent relaxation period yield an aerobic score that is consistent with cardiorespiratory fitness grades in non-athletes and that may be used as a marker in such approaches. In this study, 28 females (23 ± 3 years) were submitted to a 15 min submaximal recumbent bike session, and their capillary and saliva lactate concentrations were recorded and plotted against time. An individual aerobic score was calculated from this curve, using watt output during equal relative percentiles of maximum heart-rate benchmarks. The scores were compared with respective results in a V̇O_2max test and with a similar scoring system in 14 older (51 ± 9 years) females; they correlated with the 6 categories of the V̇O_2max test results and classified into 3 categories of V̇O_2max grades (very poor/poor; fair/good; excellent/superior) with a combined accuracy of 80.95%. More studies are required to validate the potential utility of this submaximal test as an additional risk factor for diagnostic purposes in non-athletes. Novelty points: A novel method for estimating cardiorespiratory fitness during submaximal exercise consistent with V̇O_2max performance. The method yields an aerobic score that may be used as a marker for diagnostic and prognostic purposes.

Edmonton Obesity Staging System for Pediatrics, quality of life and fitness in adolescents with obesity

BACKGROUND

Body mass index (BMI) is often used to diagnose obesity in childhood and adolescence but has limitations as an index of obesity-related morbidity. The Edmonton Obesity Staging System for Pediatrics (EOSS-P) is a clinical staging system that uses weight-related comorbidities to determine health risk in paediatric populations. The purpose of this study was to investigate the associations of EOSS-P and BMI percentile with quality of life (QOL), cardiorespiratory fitness (CRF) and muscular strength in adolescents with obesity.

METHODS

Participants were enrolled at baseline in the Healthy Eating, Aerobic and Resistance Training in Youth trial (BMI = 34.6 ± 4.5 kg m-2, age = 15.6 ± 1.4 years, N = 299). QOL, CRF (peak oxygen uptake, VO2peak) and muscular strength were assessed by the Pediatric QOL Inventory (PedsQL), indirect calorimetry during a maximal treadmill test and eight-repetition maximum bench and leg press tests, respectively. Participants were staged from 0 to 3 (absent to severe health risk) according to EOSS-P. Associations were assessed using age-adjusted and sex-adjusted general linear models.

RESULTS

Quality of life decreased with increasing EOSS-P stages (p < 0.001). QOL was 75.7 ± 11.4 in stage 0/1, 69.1 ± 13.1 in stage 2 and 55.4 ± 13.0 in stage 3. BMI percentile was associated with VO2peak (β = -0.044 mlO2 kg-1 min-1 per unit increase in BMI percentile, p < 0.001), bench press (β = 0.832 kg per unit increase in BMI percentile, p = 0.029) and leg press (β = 3.992 kg, p = 0.003). There were no significant differences in treadmill time or VO2peak between EOSS-P stages (p > 0.05).

CONCLUSION

As EOSS-P stages increase, QOL decreases. BMI percentile was negatively associated with CRF and positively associated with muscular strength.

Implementing Follow-Along Physical Activity Videos with People Living With Chronic Conditions: A Feasibility Study

BACKGROUND

Compelling evidence supports multiple benefits of physical activity (PA) even in small bursts. Less than 50% of Americans achieve recommended PA levels, lower still for individuals living with chronic illness or disease.

PURPOSE

The purpose of this study was to develop and evaluate the feasibility and preliminary effects of 3-min follow-along video scenarios to promote brief episodes of low-moderate levels of PA among individuals with chronic diseases.

METHODS

Guided by our previous studies and self-efficacy theory, the program (WellMe in 3© for Patients) was modeled after another program developed for healthcare staff. An advisory panel and a health and fitness expert guided the creation of twelve 3-min video scenarios that included two individuals living with chronic illness and a fitness leader who guided the PA scenarios and how to adapt them based on limitations. The 12 scenarios included 3 min of aerobic activities, stretching, or balance. Preliminary pilot effects were measured among 39 patients living with chronic conditions for one month. Standardized instruments were used to measure PA levels, PA self-efficacy (SE), and quality of life (QoL); usability and satisfaction were assessed using researcher-developed tools. Descriptive and inferential statistics were used to evaluate change over time.

RESULTS

Twelve video scenarios were created tailored to persons with chronic illness. Thirty-nine participants piloted the program, reporting an average of two chronic conditions. Baseline QoL scores were lower than normative data, self-efficacy scores were low-to-moderate, and PA levels were very low. Participants averaged using one video per day. 62% of participants provided complete self-reported pre- and post-QoL and SE data and 41% provided pre- and post-PA (accelerometer) data. Significant improvements were found for general health and energy scores, and trends were found for self-efficacy scores. PA levels were highly variable with nonsignificant increases from baseline. Effect sizes were low-moderate for several measures. About 79% of participants rated program "Very good"; all recommended the program.

LINKING EVIDENCE TO ACTION

Physical activity has multiple health benefits for all people including those living with chronic conditions. Even short bouts of physical activity have health benefits. A program of 3-min follow-along PA videoclips for individuals living with chronic disease holds promise for clinicians and researchers.

Exercise Recommendations for Women with Polycystic Ovary Syndrome: Is the Evidence Enough?

In this opinion piece, we summarize, discuss implications of implementation, and critically evaluate our 2018 evidence-based guideline recommendations for exercise and physical activity in women with polycystic ovary syndrome (PCOS). We developed recommendations as part of a larger international guideline development project. The overall guideline scope and priorities were informed by extensive health professional and consumer engagement. The lifestyle guideline development group responsible for the exercise recommendations included experts in endocrinology, exercise physiology, gynecology, dietetics, and obstetrics, alongside consumers. Extensive online communications and two face-to-face meetings addressed five prioritized clinical questions related to lifestyle, including the role of exercise as therapy for women with PCOS. The guideline recommendations were formulated based on one narrative and two evidence-based reviews, before consensus voting within the guideline panel. The development process was in accordance with the Appraisal of Guidelines for Research and Evaluation (AGREE) II, and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework to assess evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation, and recommendation strength. Given the evidence for exercise as therapy in PCOS being of low quality, a consensus recommendation was made based on current exercise guidelines for the general population. Women with PCOS and clinicians are forced to adopt generic approaches when recommending exercise therapy that perpetuates clinical management with pharmacological solutions. The current status of evidence highlights the need for greater international co-operation between researchers and funding agencies to address key clinical knowledge gaps around exercise therapy in PCOS to generate evidence for appropriate, scalable, and sustainable best practice approaches.

Type 2 diabetes mellitus and osteoarthritis

OBJECTIVES

Type 2 diabetes mellitus (T2DM) and osteoarthritis (OA) are common diseases that frequently co-exist, along with overweight/obesity. While the mechanical impact of excess body weight on joints may explain lower limb OA, we sought to explore whether T2DM is linked to OA outside of excess weight and whether T2DM may play a role in OA pathophysiology. The consequence of T2DM on OA outcomes is a question of research interest.

METHODS

We conducted a critical review of the literature to explore the association between T2DM and OA, whether any association is site-specific for OA, and whether the presence of T2DM impacts on OA outcomes. We also reviewed the literature to assess the safety of anti-OA treatments in patients with T2DM.

RESULTS

T2DM has a pathogenic effect on OA through 2 major pathways involving oxidative stress and low-grade chronic inflammation resulting from chronic hyperglycemia and insulin resistance. T2DM is a risk factor for OA progression and has a negative impact on arthroplasty outcomes. Evidence is mounting for safety concerns with some of the most frequently prescribed anti-OA medications, including paracetamol, non-steroidal anti-inflammatory drugs, and corticosteroid injections, while other anti-OA medications may be safely prescribed in OA patients with T2DM, such as glucosamine and intra-articular hyaluronic acid.

CONCLUSIONS

Future research is needed to better understand whether diabetes control and prevention can modulate OA occurrence and progression. The selection of therapy to treat OA symptoms in patients with T2DM may require careful consideration of the evidence based to avoid untoward safety issues.

Physical Activity, Cardiorespiratory Fitness, and the Metabolic Syndrome

Both observational and interventional studies suggest an important role for physical activity and higher fitness in mitigating the metabolic syndrome. Each component of the metabolic syndrome is, to a certain extent, favorably influenced by interventions that include physical activity. Given that the prevalence of the metabolic syndrome and its individual components (particularly obesity and insulin resistance) has increased significantly in recent decades, guidelines from various professional organizations have called for greater efforts to reduce the incidence of this condition and its components. While physical activity interventions that lead to improved fitness cannot be expected to normalize insulin resistance, lipid disorders, or obesity, the combined effect of increasing activity on these risk markers, an improvement in fitness, or both, has been shown to have a major impact on health outcomes related to the metabolic syndrome. Exercise therapy is a cost-effective intervention to both prevent and mitigate the impact of the metabolic syndrome, but it remains underutilized. In the current article, an overview of the effects of physical activity and higher fitness on the metabolic syndrome is provided, along with a discussion of the mechanisms underlying the benefits of being more fit or more physically active in the prevention and treatment of the metabolic syndrome.