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Physical Activity Promotion in the Health Care System

      Abstract

      Physical activity (PA) and exercise training (ET) have great potential in the prevention, management, and rehabilitation of a variety of diseases, but this potential has not been fully realized in clinical practice. The health care system (HCS) could do much more to support patients in increasing their PA and ET. However, counseling on ET is not used widely by the HCS owing partly to attitudes but mainly to practical obstacles. Extensive searches of MEDLINE, the Cochrane Library, the Database of Abstracts of Reviews of Effects, and ScienceDirect for literature published between January 1, 2000, and January 31, 2013, provided data to assess the critical characteristics of ET counseling. The evidence reveals that especially brief ET counseling is an efficient, effective, and cost-effective means to increase PA and ET and to bring considerable clinical benefits to various patient groups. Furthermore, it can be practiced as part of the routine work of the HCS. However, there is a need and feasible means to increase the use and improve the quality of ET counseling. To include PA and ET promotion as important means of comprehensive health care and disease management, a fundamental change is needed. Because exercise is medicine, it should be seen and dealt with in the same ways as pharmaceuticals and other medical interventions regarding the basic and continuing education and training of health care personnel and processes to assess its needs and to prescribe and deliver it, to reimburse the services related to it, and to fund research on its efficacy, effectiveness, feasibility, and interactions and comparability with other preventive, therapeutic, and rehabilitative modalities. This change requires credible, strong, and skillful advocacy inside the medical community and the HCS.

      Abbreviations and Acronyms:

      CVD (cardiovascular disease), DPP (death prevented or postponed), EE (energy expenditure), ET (exercise training), ETR (exercise training referral), HCS (health care system), HMEE (household management energy expenditure), PA (physical activity), PC (perfect care), PHC (primary health care), PIA (physical inactivity), QALY (quality-adjusted life year)
      Article Highlights
      • Physical activity (PA) is essential for the development, maintenance, and recovery of health and functional capacity, but it is seriously neglected by people, health professionals, and politicians.
      • The health care system (HCS) has an obligation, as well as an effective, cost-effective, and feasible means, to increase the use of PA and exercise training (ET) for the prevention, management, and rehabilitation of diseases.
      • A variety of attitudes and practical obstacles in the HCS are reported to hinder efforts to increase the use of PA/ET for health.
      • A large common factor leading to the obstacles to PA interventions is the low priority given to PA/ET in the whole HCS, from basic education to clinical services. If the priority is sufficient, then changes that are needed to increase and improve especially the most feasible measure—PA/ET advising—can be implemented, especially in small units without major organizational or financial resources.
      • Encouraging patients to be more active can be done simply by emphasizing the basic messages of current PA guidelines: “more activity is better than none” and “more is better than less, at least up to a point”; and walking is the most common and feasible PA for most individuals.
      • However, to make wide and sustainable applications in the HCS, effective distribution of knowledge and strong advocacy related to PA/ET should be undertaken by influential organizations and leaders to change the perception and understanding of PA/ET from discretionary leisure time pursuits to an evidence-based medical measure comparable with pharmaceutical agents and other established modalities.
      Physical activity (PA) is an essential biological stimulus for the development and maintenance of healthy structures and functions of the human body. Long-standing lack of sufficient PA leads to weaknesses and degeneration of structures and aberrations in metabolism that lead to and appear as functional deficiencies and diseases in a variety of organ systems.
      • Booth F.W.
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      • Hamilton M.T.
      Waging war on modern chronic diseases: primary prevention through exercise biology.
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      Fundamental questions about genes, inactivity, and chronic disease.
      Research has gradually provided data on the amount of PA, and particularly the energy expenditure (EE) caused by it, that is necessary to prevent the development of various diseases,

      Department of Health and Human Services. 2008 Physical activity guidelines for Americans. http://www.health.gov/paguidelines/pdf/paguide.pdf. Accessed November 15, 2012.

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      A systematic review of the evidence for Canada's physical activity guidelines for adults.
      including cardiovascular disease (CVD) (Figure 1).
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      Sports and exercise as contributors to the health of nations.
      Owing to the steep decline during the past decades in the need to use muscular effort in occupational (Figure 2, A)
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      Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity.
      and domestic (Figure 2, B)
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      45-year trends in women’s use of time and household management energy expenditure.
      activities and in transportation and to the only partial compensation of it by increasing leisure time PA, the amount of PA has become insufficient for health in most populations in the world.
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      Global physical activity levels: surveillance progress, pitfalls, and prospects.
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      Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.
      Figure thumbnail gr1
      Figure 1Associations of moderate to vigorous physical activity with key health events, including all-cause mortality.
      From Lancet,
      • Khan K.M.
      • Thompson A.M.
      • Blair S.N.
      • et al.
      Sports and exercise as contributors to the health of nations.
      with permission.
      Figure thumbnail gr2
      Figure 2A, Occupational daily energy expenditure (EE) in US men and women since 1960. From PLoS One,
      • Church T.S.
      • Thomas D.M.
      • Tudor-Locke C.
      • et al.
      Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity.
      with permission. B, The decade to decade change in mean household management energy expenditure (HMEE) per week for all US women (aged 19-64 years) and by employment status.
      From PLos One,
      • Archer E.
      • Shook R.P.
      • Thomas D.M.
      • et al.
      45-year trends in women’s use of time and household management energy expenditure.
      with permission.
      Currently, insufficient PA ranks high among 67 risk factors for burden of disease and injuries (sum of deaths and disability-adjusted life years) in all parts of the world: fifth in Western Europe and Australasia; sixth in high-income North America, Central Europe, and Central Latin America; seventh in Eastern Europe and Southern Latin America; and eighth in Tropical and Andean Latin America and Southeast Asia.
      • Lim S.S.
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      • Flaxman A.D.
      • et al.
      Comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
      The population-attributable fractions for some major noncommunicable diseases associated with physical inactivity (PIA) are also high (eg, in Europe, North America, and Latin America, respectively, the population-attributable fractions for coronary heart disease are 5.5%, 8.2%, and 7.1%; for type 2 diabetes mellitus are 6.8%, 7.6%, and 8.7%; for breast cancer are 9.3%, 10.8%, and 12.5%; for colon cancer are 9.9%, 11.0%, and 12.6%; and for all-cause mortality are 8.8%, 9.9%, and 11.4%). The cited estimates of the burden of PIA are conservative for methodological reasons.
      • Lee I.M.
      • Shiroma E.J.
      • Lobelo F.
      • Puska P.
      • Blair S.N.
      • Katzmarzyk P.T.
      Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.
      Physical activity is important for public health, but it is also a valuable component in the clinical management of a variety of diseases,

      Department of Health and Human Services. 2008 Physical activity guidelines for Americans. http://www.health.gov/paguidelines/pdf/paguide.pdf. Accessed November 15, 2012.

      Professional Associations for Physical Activity (Sweden). Physical activity in the prevention and treatment of disease. http://www.fyss.se/wp-content/uploads/2011/02/fyss_2010_english.pdf. Accessed March 30, 2013.

      and it is recommended for these purposes in numerous evidence-based clinical guidelines (eg, Weiler et al
      • Weiler R.
      • Feldschreiber P.
      • Stamatakis E.
      Medicolegal neglect? the case for physical activity promotion and exercise medicine.
      listed 39 British national guidelines that included promotion of PA, and in a Finnish Web-based tool for physicians, the rationale and evidence-based advice for PA and exercise training [ET] are given for 35 health-related indications

      Exercise medicine. Potilaan Lääkärilehti website. http://www.potilaanlaakarilehti.fi/palvelut/liikuntalaake. Accessed May 3, 2013.

      ).
      The following example reveals the comparative effectiveness of PA when used for disease prevention and management.
      • Kottke T.E.
      • Faith D.A.
      • Jordan C.O.
      • Pronk N.P.
      • Thomas R.J.
      • Capewell S.
      The comparative effectiveness of heart disease prevention and treatment strategies.
      The authors calculated the number of deaths caused by CVD that could be prevented or postponed (DPPs) if perfect care (PC) for the prevention and treatment of this disease were achieved in a hypothetical population resembling US adults aged 30 to 84 years. Direct comparison of CVD prevention and treatment strategies in patients receiving PC revealed that PC before the first CVD event would prevent or postpone 33% of all deaths, PC between acute events would prevent or postpone 23% of all deaths, and PC during acute events would prevent or postpone 8% of all deaths. In comparing the potential impact of the interventions found to be associated with lower risk of death or known to reduce death from CVD, the largest increase in DPPs would accrue from increasing population levels of adequate PA (44% of all DPPs in this subpopulation). Likewise, comparing the interventions of known efficacy in individuals who have CVD without symptomatic left ventricular dilation, the largest potential to prevent or delay death was associated with increasing the percentage of individuals who remain with high PA (45% of all DPPs). In interventions of known effectiveness in patients with CVD complicated by left ventricular dilation, the largest increase in DPPs would accrue from increasing the percentage of individuals who have high PA (50% of all DPPs). The total calculated number of DPPs by increasing or maintaining PA was 334 in a population of 100,000 adults. In comparison, the corresponding number of DPPs attainable by abstaining from smoking was 139. In addition to the prevented or delayed deaths caused by CVD, the practice of PA and ET would bring numerous other individual and population-wide benefits. One of the most traditional uses of ET in medicine is to include it as part of secondary prevention or rehabilitation programs for CVD (Table).
      • Swift D.L.
      • Lavie C.J.
      • Johannsen N.M.
      • et al.
      Physical activity, cardiorespiratory fitness and exercise training in primary and secondary coronary prevention.
      TableBenefits of Formal Cardiac Rehabilitation and Exercise Training Programs
      From Circ J,
      • Swift D.L.
      • Lavie C.J.
      • Johannsen N.M.
      • et al.
      Physical activity, cardiorespiratory fitness and exercise training in primary and secondary coronary prevention.
      with permission.
      Improvements in exercise capacity
       Estimated METs, +35%
       Peak VO2, +15%
       Peak anaerobic threshold, +11%
      Improvement in lipid profiles
       Total cholesterol, –5%
       Triglycerides, –15%
       HDL-C, +6% (higher in patients with low baseline)
       LDL-C, –2%
       LDL-C/HDL-C, –5% (higher in certain subgroups)
      Reduction in inflammation (hs-CRP, –40%)
      Reductions in indices of obesity
       BMI, –1.5%
       % Fat, –5%
       Metabolic syndrome, –37%
      Improvements in behavioral characteristics
       Depression
       Anxiety
       Hostility
       Somatization
       Overall psychological distress
      Improvements in quality of life and components
      Improvements in autonomic tone
       Increased heart rate recovery
       Increased heart rate variability
       Reduced resting pulse
      Improvements in blood rheology
      Reduction in hospitalization costs
      Reduction in major morbidity and mortality
      BMI = body mass index; hs-CRP = high-sensitivity C-reactive protein; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; MET = metabolic equivalent; VO2 = oxygen uptake.
      The pandemic of PIA that has arisen is increasing in depth and area. It has to be addressed by multiple approaches. Significant progress has been achieved in creating awareness of this issue at a high political level,
      World Health Organization
      Physical Inactivity: A Global Public Health Problem.
      and the development and implementation of policies by a variety of scientific and professional organizations is under way.
      • Kohl H.W.
      • Craig C.L.
      • Lambert E.V.
      • et al.
      The pandemic of physical inactivity: global action for public health.
      • Pratt M.
      • Sarmiento O.L.
      • Montes F.
      • et al.
      Lancet Physical Activity Series Working Group
      The implications of megatrends in information and communication technology and transportation for changes in global physical activity.
      Population-wide measures and environmental changes based on multiple policies and cross-sectorial collaboration are likely to be the most effective and sustainable means in counteracting PIA and increasing PA.
      • Pratt M.
      • Sarmiento O.L.
      • Montes F.
      • et al.
      Lancet Physical Activity Series Working Group
      The implications of megatrends in information and communication technology and transportation for changes in global physical activity.
      However, the health care system (HCS) and the medical profession as its leader also have an important role in PA promotion for several reasons. Physical activity belongs to the mandate and obligations of the HCS as one domain of health promotion,
      • Chakravarthy M.
      • Joyner M.J.
      • Booth F.W.
      An obligation for primary care physicians to prescribe physical activity to sedentary patients to reduce the risk of chronic health conditions.
      and PA/ET has great potential to further the preventive and clinical goals and obligations of the HCS. The leaders in health care are respected experts and authorities in matters related to health at national, regional, and local levels. The attitudes and opinions of health care personnel, especially of physicians, have considerable influence when the importance and positioning of various health-related issues are debated and discussed. In most of the population, the HCS is considered a reliable and appropriate institution for providing advice on PA.
      • Leijon M.E.
      • Stark-Ekman D.
      • Nilsen P.
      • et al.
      Is there a demand for physical activity interventions provided by the health care sector? findings from a population survey.
      • Richmond R.
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      • Heather N.
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      • Webster I.
      General practitioners' promotion of healthy life styles: what patients think.
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      The Victorian Active Script Programme: promising signs for general practitioners, population health, and the promotion of physical activity.
      • Jacobson D.M.
      • Strohecker L.
      • Compton M.T.
      • Katz D.L.
      Physical activity counseling in adult primary care setting: position statement of the American College of Preventive Medicine.
      • Märki A.
      • Bauer G.B.
      • Angst F.
      • Nigg C.R.
      • Gillmann G.
      • Gehring T.M.
      Systematic counselling by general practitioners for promoting physical activity in elderly patients: a feasibility study.
      • Robertson R.
      • Jepson R.
      • Shepherd A.
      • McInnes R.
      Recommendations by Queensland GPs to be more physically active: which patients were recommended which activities and what action they took.
      • Schofield G.
      • Croteau K.
      • McLean G.
      Trust levels of physical activity information sources: a population study.
      Advice on PA from physicians can be a strong cue to begin ET.
      • Jacobson D.M.
      • Strohecker L.
      • Compton M.T.
      • Katz D.L.
      Physical activity counseling in adult primary care setting: position statement of the American College of Preventive Medicine.
      • Whitlock E.P.
      • Orleans C.T.
      • Pender N.
      • Allan J.
      Evaluating primary care behavioral counseling interventions: an evidence-based approach.
      • Smith A.W.
      • Borowski L.A.
      • Liu B.
      • et al.
      U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients.
      • McPhail S.
      • Schippers M.
      An evolving perspective on physical activity counseling by medical professionals.
      Furthermore, primary health care (PHC) has frequent contacts with a large part of the population, especially with less healthy, less well-off, less educated, and elderly people,
      • Leijon M.E.
      • Stark-Ekman D.
      • Nilsen P.
      • et al.
      Is there a demand for physical activity interventions provided by the health care sector? findings from a population survey.
      • McPhail S.
      • Schippers M.
      An evolving perspective on physical activity counseling by medical professionals.
      • Patrick K.
      • Pratt M.
      • Sallis R.E.
      The healthcare sector's role in the US national physical activity plan.
      • Schmid M.
      • Egli K.
      • Martin B.W.
      • Bauer G.F.
      Health promotion in primary care: evaluation of a systematic procedure and stage specific information for physical activity counseling.
      • Williams N.H.
      Promoting physical activity in primary care.
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      • Hinrichs T.
      • Moschny A.
      • Klaassen-Mielke R.
      • Trampisch U.
      • Thiem U.
      • Platen P.
      General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI).
      who are in greatest need of health-related advice.
      The most feasible means of PA promotion in the HCS and other clinical settings is brief counseling or advising of individual patients on PA or ET during 1 or more visits, or referring them to third-party services (ET referral [ETR]). In a questionnaire survey of a nationally representative sample of US PHC physicians, 30% of them reported “always” and 56% “often” providing specific guidance on PA for patients without chronic disease. The corresponding figures for patients with chronic disease were 49% and 45%.
      • Smith A.W.
      • Borowski L.A.
      • Liu B.
      • et al.
      U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients.
      In Canada, 70% of PHC physicians reported using verbal counseling to promote PA, and 16% reported using written prescriptions.
      • Petrella R.J.
      • Lattanzio C.N.
      • Overend T.J.
      Physical activity counseling and prescription among Canadian primary care physicians.
      Among Catalan primary care physicians, 84% reported promoting PA at least infrequently.
      • Puig-Ribera A.
      • McKenna J.
      • Riddoch C.
      Attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary health-care system.
      In Scotland, 62% of general practitioners reported that they were very likely or likely to recommend that all apparently healthy adult patients undertake moderate ET.
      • Douglas F.
      • Torrance N.
      • van Teijlingen E.
      • Meloni S.
      • Kerr A.
      Primary care staff's views and experiences related to routinely advising patients about physical activity.
      In Denmark, PA/ET advising is systematically implemented in PHC, and in 2 such areas more than 95% of general practitioners reported providing this service at least weekly.
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      In most countries, PA/ET advising is not used systematically but rather is largely based on individual preferences.
      • Podl T.R.
      • Goodwin M.A.
      • Kikano G.E.
      • Stange K.C.
      Direct observation of exercise counseling in community family practice.
      • Livaudais J.E.
      • Kaplan C.P.
      • Haas J.S.
      • Pérez-Stable E.J.
      • Stewart S.
      • Jarlais G.D.
      Lifestyle behavior counseling for women patients among a sample of California physicians.
      • Croteau K.
      • Schofield G.
      • McLean G.
      Physical activity advice in the primary care settings: results of a population study in New Zealand.
      • Sinclair J.
      • Lawson B.
      • Burge F.
      Which patients receive advice on diet and exercise? do certain characteristics affect whether they receive such advice?.
      • VanWormer J.J.
      • Pronk N.P.
      • Kroeninger G.J.
      Clinical counseling for physical activity: translation of a systematic review into care recommendations.
      • Bock C.
      • Diehm C.
      • Schneider S.
      Physical activity promotion in primary health care: results from a German physician survey.
      The proportion of patients receiving advice on PA varies widely. Nationally representative data from the United States show that currently approximately 1 in 3 adults who have seen a physician or other health professionals in the past year (approximately 8 in 10 adults) have been advised to begin or continue ET or PA.
      • Barnes P.M.
      • Schoenborn C.A.
      Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional.
      The prevalence of advising has increased from 23% in 2000 to 32% in 2010, and this trend is seen universally across population subgroups. Advising was highest and had increased especially for overweight and obese patients (Figure 3, A) and for those with health conditions, in whom research has found that PA and ET are associated with substantial health benefits (Figure 3, B).
      Figure thumbnail gr3
      Figure 3Percentage of adults 18 years and older whose physician or another health professional recommended exercise training or physical activity by body mass index category and year (A) and by chronic condition and year (B): United States, 2000, 2005, and 2010.
      From NCHS Data Brief ,
      • Barnes P.M.
      • Schoenborn C.A.
      Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional.
      with permission.
      Corresponding findings have been reported in the studies of PA advising by PHC physicians. In Nova Scotia, Canada, 42% of patients of PHC receive frequent advice on ET
      • Sinclair J.
      • Lawson B.
      • Burge F.
      Which patients receive advice on diet and exercise? do certain characteristics affect whether they receive such advice?.
      ; in Germany, one-third of older patients managed in PHC had received advice on PA from their general practitioner during the preceding 12 months.
      • Hinrichs T.
      • Moschny A.
      • Klaassen-Mielke R.
      • Trampisch U.
      • Thiem U.
      • Platen P.
      General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI).
      In Queensland, Australia, the corresponding proportion was 18%,
      • Robertson R.
      • Jepson R.
      • Shepherd A.
      • McInnes R.
      Recommendations by Queensland GPs to be more physically active: which patients were recommended which activities and what action they took.
      and in New Zealand 13%.
      • Croteau K.
      • Schofield G.
      • McLean G.
      Physical activity advice in the primary care settings: results of a population study in New Zealand.
      Especially high figures for ET counseling are seen in settings where it is in systematic use, eg, in some parts of Denmark.
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      Taken together, the cited data indicate that there is a substantial mismatch between the need to advise patients in PHC on PA and ET and the prevalence of this practice. This discrepancy has lately led to strong statements and demands for change.
      • Weiler R.
      • Feldschreiber P.
      • Stamatakis E.
      Medicolegal neglect? the case for physical activity promotion and exercise medicine.
      • Khan K.M.
      • Weiler R.
      • Blair S.N.
      Prescribing exercise in primary care.
      • Matheson G.O.
      • Klugl M.
      • DvorakJ
      • et al.
      Responsibility of sport and exercise medicine in preventing and managing chronic disease: applying our knowledge and skill is overdue.
      • Hallal P.C.
      • Bauman A.E.
      • Heath G.W.
      • Kohl III, H.W.
      • Lee I.M.
      • Pratt M.
      Physical activity: more of the same is not enough.
      • Wen C.P.
      • Wu X.
      Stressing harms of physical inactivity to promote exercise.
      • Joy E.
      • Blair S.N.
      • McBride P.
      • Sallis R.
      Physical activity counselling in sports medicine: a call to action.
      To achieve substantial and sustainable increases in the provision of advising on PA and ET in the HCS, the reasons for the current situation have to be known. The attitudes and perceptions of the health care personnel; the efficacy, effectiveness, and cost-effectiveness of PA/ET advising; and the feasibility of its application are key issues for practitioners and for administrators in the HCS in making decisions on its acceptability for routine use.
      The aim of this review was to present the evidence for the previously mentioned characteristics of PA/ET advising and to suggest means to increase its use and improve its quality. The presented evidence is based on critical evaluation of recent systematic and other reviews, meta-analyses, and major primary studies. An extensive search was conducted of the MEDLINE, Cochrane Library, Database of Abstracts of Reviews of Effects, and ScienceDirect electronic databases for literature published between January 1, 2000, and January 31, 2013, and the references of relevant publications were searched by hand. The search strategy included terms for physical activity, exercise, exercise training, health care, health care system, primary health care, promotion, intervention, counseling, behavior change, effectiveness, efficacy, cost-effectiveness, and feasibility. The searches were limited to studies of adults and to publications in the English, German, and Swedish languages. Publications that included data of outcomes related to the effectiveness, efficacy, cost-effectiveness, and feasibility of various interventions to increase PA in patients in the HCS were included, but the final selection included only publications in which 1 or more of these issues could be related solely to PA/ET advising or referral.

      Factors that Favor and Hinder Advising on PA/ET in the HCS

      Practitioners, especially in PHC, have mainly positive attitudes toward PA, and they consider advising on PA and ET important and believe that they have a role in its provision,
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      although contrary views have also been expressed.
      • MacAuley D.
      Physical activity may be good for you but we are not the key players.
      The attitudes and perceptions of clinicians related to PA and ET advising seem to have become more positive with time.
      • van der Ploeg H.P.
      • Smith B.J.
      • Stubbs T.
      • Vita P.
      • Holford R.
      • Bauman A.E.
      Physical activity promotion: are GPs getting the message?.
      • Buffart L.M.
      • van der Ploeg H.P.
      • Smith B.J.
      • Kurko J.
      • King L.
      • Bauman A.E.
      General practitioners' perceptions and practices of physical activity counselling: changes over the past 10 years.
      However, a large proportion of clinicians are uncertain about the effectiveness of their counseling and feel uncomfortable in providing detailed advice. The attitudes and perceptions of nurses and physiotherapists are more positive.
      • Douglas F.
      • Torrance N.
      • van Teijlingen E.
      • Meloni S.
      • Kerr A.
      Primary care staff's views and experiences related to routinely advising patients about physical activity.
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      Some evidence suggests that the advising provided by allied health care professionals alone or in conjunction with physicians produces better long-term effects than that provided by physicians alone.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.
      Several barriers to PA/ET advising are frequently reported: lack of time, knowledge, training, materials for learning, education and information, protocols for delivery of the service, system support, resources, and incentives and reimbursement; the perception of PA/ET advising as a secondary task; and the fact that patients often ignore the advice.
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      • Bock C.
      • Diehm C.
      • Schneider S.
      Physical activity promotion in primary health care: results from a German physician survey.
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      • Laitakari J.
      • Miilunpalo S.
      • Vuori I.
      The process and methods of health counseling by primary health care personnel in Finland: a national survey.
      • McKenna J.
      • Naylor P.J.
      • McDowell N.
      Barriers to physical activity promotion by general practitioners and practice nurses.
      • Abramson S.
      • Stein J.
      • Schaufele M.
      • Frates E.
      • Rogan S.
      Personal exercise habits and counseling practices of primary care physicians: a national survey.
      • Cornuz J.
      • Ghali W.A.
      • Di Carlantonio D.
      • Pecoud A.
      • Paccaud F.
      Physicians' attitudes towards prevention: importance of intervention-specific barriers and physicians' health habits.
      • Josyula K.
      • Lyle R.M.
      Barriers in the implementation of a physical activity intervention in primary care settings: lessons learned.
      Factors favoring or predicting PA and ET advising include the provider's own living habits, particularly personal PA and ET
      • Livaudais J.E.
      • Kaplan C.P.
      • Haas J.S.
      • Pérez-Stable E.J.
      • Stewart S.
      • Jarlais G.D.
      Lifestyle behavior counseling for women patients among a sample of California physicians.
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      • Abramson S.
      • Stein J.
      • Schaufele M.
      • Frates E.
      • Rogan S.
      Personal exercise habits and counseling practices of primary care physicians: a national survey.
      • Lobelo F.
      • Duperly J.
      • Frank E.
      Physical activity habits of doctors and medical students influence their counselling practices.
      ; having training on PA/ET counseling and support by colleagues; knowing patients well; and patients having risk factors or symptoms of CVD.
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      • Hinrichs T.
      • Moschny A.
      • Klaassen-Mielke R.
      • Trampisch U.
      • Thiem U.
      • Platen P.
      General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI).
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      • Abramson S.
      • Stein J.
      • Schaufele M.
      • Frates E.
      • Rogan S.
      Personal exercise habits and counseling practices of primary care physicians: a national survey.
      • Cornuz J.
      • Ghali W.A.
      • Di Carlantonio D.
      • Pecoud A.
      • Paccaud F.
      Physicians' attitudes towards prevention: importance of intervention-specific barriers and physicians' health habits.
      A recent article reported that physicians in the United States are more likely than the general public to be meeting PA guidelines, so it should be feasible for physicians who are active to encourage their patients to meet the same standards.
      • Stanford F.C.
      • Durkin M.W.
      • Blair S.N.
      • Keller Powell C.
      • Poston M.B.
      • Stallworth J.R.
      Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA.

      Efficacy of PA/ET Advising

      A systematic review of 15 randomized controlled trials of 8745 sedentary adults supports the efficacy of PA/ET advising in the PHC setting.
      • Orrow G.
      • Kinmonth A.L.
      • Sanderson S.
      • Sutton S.
      Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials.
      In 11 studies, the intervention was delivered in PHC, and most interventions included written materials and 2 or more sessions of advice or counseling that was delivered face-to-face by a combination of 2 professionals from different disciplines. Eleven studies reported positive intervention effects on self-reported PA at 12 months. The effects were significant in 6 studies and approached significance in the remaining studies. Pooled analysis of 13 studies found small to medium effects for dichotomous data (odds ratio, 1.42; 95% CI, 1.17-1.73) (Figure 4, A) and continuous data (standardized mean difference, 0.25; 95% CI, 0.11-0.38) (Figure 4, B).
      Figure thumbnail gr4
      Figure 4Individual study and pooled effects of physical activity promotion on self-reported physical activity at 12 months: dichotomous data (A) and continuous data (B). The random effects model was used. IV = inverse variance.
      From BMJ,
      • Orrow G.
      • Kinmonth A.L.
      • Sanderson S.
      • Sutton S.
      Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials.
      with permission.
      Twelve (95% CI, 7-33) sedentary adults had to be treated with a PA promotion intervention, compared with any control, for 1 additional person to report meeting recommended levels of PA at 12 months. In comparison, for smoking cessation advice, the estimated number needed to treat to get 1 person to stop smoking varies between 50 and 120. Findings from additional analyses suggested that brief counseling interventions might be as effective as more intensive interventions.
      Another systematic review and meta-analysis of 21 randomized controlled trials assessed the long-term (≥12 months) effect on PA of healthy or “at risk” individuals aged 55 to 70 years (n=10,519).
      • Hobbs N.
      • Godfrey A.
      • Lara J.
      • et al.
      Are behavioral interventions effective in increasing physical activity at 12 to 36 months in adults aged 55 to 70 years? a systematic review and meta-analysis.
      Sixteen interventions were delivered by health professionals (in 15 interventions, 1 format of delivery was face-to-face), and 10 interventions were delivered on health care premises. All the interventions were tailored to some degree. Thus, the results reflect quite well the efficacy of PA/ET advising in the HCS. The interventions increased self-reported PA duration at 12 months (standardized mean difference, 0.19; 95% CI, 0.10-0.28) but not beyond 12 months, although 10 of 11 trials reported significant positive intervention effects. Also, objectively measured step count increased significantly in the intervention group compared with the control group (standardized mean difference, 1.08; 95% CI, 0.16-1.99). In agreement with previous research, there was no evidence that the mode of delivery of the intervention is necessarily important for effectiveness
      • Greaves C.J.
      • Sheppard K.E.
      • Abraham C.
      • et al.
      Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions.
      or that more contacts lead to more favorable intervention effects.
      • Hobbs N.
      • Godfrey A.
      • Lara J.
      • et al.
      Are behavioral interventions effective in increasing physical activity at 12 to 36 months in adults aged 55 to 70 years? a systematic review and meta-analysis.
      • Greaves C.J.
      • Sheppard K.E.
      • Abraham C.
      • et al.
      Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions.
      However, in line with other studies, tailoring the intervention to participants with, eg, personalized step-count goals or information about local opportunities for PA in the environment,
      • McPhail S.
      • Schippers M.
      An evolving perspective on physical activity counseling by medical professionals.
      • King W.C.
      • Belle S.H.
      • Brach J.S.
      • Simkin-Silverman L.R.
      • Soska T.
      • Kriska A.M.
      Objective measures of neighborhood environment and physical activity in older women [published correction appears in Am J Prev Med. 2005;29(3):245-246].
      • Gebel K.
      • Bauman A.
      • Owen N.
      Correlates of non-concordance between perceived and objective measures of walkability.
      • Heath G.W.
      • Parra D.C.
      • Sarmiento O.L.
      • et al.
      Evidence-based intervention in physical activity: lessons from around the world.
      • Bauman A.E.
      • Reis R.S.
      • Sallis J.F.
      • Wells J.C.
      • Loos R.J.
      • Martin B.W.
      Correlates of physical activity: why are some people physically active and others not?.
      may be important.
      Advising on PA/ET provided by the PHC system has been shown to increase PA/ET in a small to moderate degree in various population subgroups, including women,
      • Lawton B.A.
      • Rose S.B.
      • Elley C.R.
      • et al.
      Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial.
      older people,
      • Hirvensalo M.
      • Heikkinen E.
      • Lintunen T.
      • Rantanen T.
      The effect of advice by health care professionals on increasing physical activity of older people.
      • Armit C.M.
      • Brown W.J.
      • Marshall A.L.
      • et al.
      Randomized trial of three strategies to promote physical activity in general practice.
      • Mänty M.
      • Heinonen A.
      • Leinonen R.
      • et al.
      Long-term effect of physical activity counseling on mobility limitation among older people: a randomized controlled study.
      • Neidrick T.J.
      • Fick O.M.
      • Loeb S.J.
      Physical activity promotion in primary care targeting the older adult.
      and chronically ill adults.
      • Conn V.S.
      • Hafdahl A.R.
      • Brown S.A.
      • Brown L.M.
      Meta-analysis of patient education interventions to increase physical activity among chronically ill adults.
      Counseling on PA/ET has led to other positive although mainly modest effects, such as improved physical functioning and mental health in middle-aged and older women,
      • Lawton B.A.
      • Rose S.B.
      • Elley C.R.
      • et al.
      Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial.
      increased aerobic fitness
      • Petrella R.J.
      • Lattanzio C.N.
      • Shapiro S.
      • Overend T.
      Improving aerobic fitness in older adults: effects of a physician-based exercise counseling and prescription program.
      and mobility
      • Mänty M.
      • Heinonen A.
      • Leinonen R.
      • et al.
      Long-term effect of physical activity counseling on mobility limitation among older people: a randomized controlled study.
      in older adults, and improved CVD and metabolic risk factors in persons with high baseline levels.
      • Fleming P.
      • Godwin M.
      Lifestyle interventions in primary care: systematic review of randomized controlled trials.
      • Lin J.S.
      • O'Connor E.
      • Whitlock E.P.
      • Beil T.L.
      Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force.
      • Baruth M.
      • Lee D.C.
      • Sui X.
      • et al.
      Emotional outlook on life predicts increases in physical activity among initially inactive men.
      • Kujala U.M.
      • Jokelainen J.
      • Oksa H.
      • et al.
      Increase in physical activity and cardiometabolic risk profile change during lifestyle intervention in primary care: a 1-year follow-up study among individuals at high risk for type 2 diabetes.
      The interventions in the referred studies have most commonly included 1 or more face-to-face sessions delivered by various health professionals and tailored prescriptions for ET. Owing to the only modest effects on CVD risk factors, the US Preventive Services Task Force recommends that behavioral counseling on PA for CVD prevention also should be used selectively for patients with other risk factors and factors favoring positive results of ET counseling.
      • Moyer V.A.
      U.S. Preventive Services Task Force
      Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement.

      Feasibility and Effectiveness of Advising on PA/ET

      The feasibility and effectiveness of advising on PA/ET can be evaluated on the basis of studies conducted in “real-life” conditions. Several studies support the notion that PA/ET advising can be successfully implemented in the routine practice of PHC.
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      • Leijon M.E.
      • Bendtsen P.
      • Nilsen P.
      • Ekberg K.
      • Ståhle A.
      Physical activity referrals in Swedish primary health care prescriber and patient characteristics, reasons for prescriptions, and prescribed activities.
      • Eakin E.G.
      • Brown W.J.
      • Marshall A.L.
      • Mummery K.
      • Larsen E.
      Physical activity promotion in primary care: bridging the gap between research and practice.
      • Aittasalo M.
      • Miilunpalo S.
      • Kukkonen-Harjula K.
      • Pasanen M.
      A randomized intervention of physical activity promotion in primary care.
      • Kallings L.V.
      • Leijon M.
      • Hellenius M.L.
      • Ståhle A.
      Physical activity on prescription in primary health care: a follow-up of physical activity level and quality of life.
      • Persson G.
      • Ovhed I.
      • Hansson E.E.
      Simplified routines in prescribing physical activity can increase the amount of prescriptions by doctors, more than economic incentives only: an observational intervention study.
      • Sargent G.M.
      • Forrest L.E.
      • Parker R.M.
      Nurse delivered lifestyle interventions in primary health care to treat chronic disease risk factors associated with obesity: a systematic review.
      • Grandes G.
      • Sanchez A.
      • Sanchetz-Pinilla R.O.
      • et al.
      Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial.
      Also, the effectiveness of PA/ET advising delivered in routine PHC is supported by research evidence. In a large pragmatic randomized trial, patients counseled on PA/ET by family physicians increased their PA by 18 min/wk (95% CI, 6-31 min/wk) more than control patients at 6-month follow-up. Patients achieving the recommended level of PA was 3.9% (95% CI, 1.2%-6.9%; number needed to treat = 26) higher in the intervention group.
      • Grandes G.
      • Sanchez A.
      • Sanchetz-Pinilla R.O.
      • et al.
      Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial.
      During follow-up at 12 and 24 months, however, the intervention effect observed at 6 months had declined, suggesting that maintenance intervention is needed. Accordingly, in the subgroup of intervention patients who received repeated PA prescriptions, there were 10.2% more than in the control group who achieved the minimum recommended level of PA at 24 months.
      • Grandes G.
      • Sanchez A.
      • Montoya I.
      • et al.
      Two-year longitudinal analysis of a cluster randomized trial of physical activity promotion by general practitioners.
      Several factors, most of which can be incorporated into PA/ET advising in routine clinical work, have been found to be related to improved effectiveness:
      • Advising persons with an increased risk of chronic diseases.
        • Schmid M.
        • Egli K.
        • Martin B.W.
        • Bauer G.F.
        Health promotion in primary care: evaluation of a systematic procedure and stage specific information for physical activity counseling.
        • Orrow G.
        • Kinmonth A.L.
        • Sanderson S.
        • Sutton S.
        Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials.
        • Moyer V.A.
        U.S. Preventive Services Task Force
        Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement.
        • Grandes G.
        • Sanchez A.
        • Cortada J.M.
        • et al.
        Is integration of healthy lifestyle promotion in primary care feasible? discussion and consensus sessions between clinicians and researchers.
      • Individual assessment of the needs, motivation, current habits, preferences, and barriers of the patient and individual ET advice based on that information.
        • Leijon M.E.
        • Bendtsen P.
        • Ståhle A.
        • Ekberg K.
        • Festin K.
        • Nilsen P.
        Factors associated with patients self-reported adherence to prescribed physical activity in routine primary health care.
        • Grandes G.
        • Sanchez A.
        • Torcal J.
        • Sanchez-Pinilla R.O.
        • Lizarraga K.
        • Serra J.
        Targeting physical activity promotion in general practice: characteristics of inactive patients and willingness to change.
        • Muller-Riemenschneider F.
        • Reinhold T.
        • Nocon M.
        • Willich S.N.
        Long-term effectiveness of interventions promoting physical activity: a systematic review.
        • Leijon M.
        • Faskunger J.
        • Bendtsen P.
        • Festin K.
        • Nilsen P.
        Who is not adhering to physical activity referrals, and why?.
        Experience from diet counseling and recommendations indicate that the message should be simple, clear, specific, and realistic
        • Boylan S.
        • Louie K.Y.
        • Gill T.P.
        Consumer response to healthy eating, physical activity and weight-related recommendations: a systematic review.
        ; use valid behavior change methods,
        • Greaves C.J.
        • Sheppard K.E.
        • Abraham C.
        • et al.
        Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions.
        including emphasizing behavioral and cognitive approaches,
        • Conn V.S.
        • Hafdahl A.R.
        • Brown S.A.
        • Brown L.M.
        Meta-analysis of patient education interventions to increase physical activity among chronically ill adults.
        • Conn V.S.
        • Hafdahl A.R.
        • Mehr D.R.
        Interventions to increase physical activity among healthy adults: meta-analysis of outcomes.
        setting clear and proximal instead of distal goals, emphasizing internal instead of external motivating factors, and improving self-efficacy; and use self-monitoring, social support, and follow-up prompts.
        • Armit C.M.
        • Brown W.J.
        • Marshall A.L.
        • et al.
        Randomized trial of three strategies to promote physical activity in general practice.
        • Muller-Riemenschneider F.
        • Reinhold T.
        • Nocon M.
        • Willich S.N.
        Long-term effectiveness of interventions promoting physical activity: a systematic review.
        • Michie S.
        • Abraham C.
        • Whittington C.
        • McAteer J.
        Effective techniques in healthy eating and physical activity interventions: a meta-regression.
        • Ashford S.
        • Edmunds J.
        • French D.P.
        What is the best way to change self-efficacy to promote lifestyle and recreational physical activity? a systematic review with meta-analysis.
        • Rhodes R.E.
        • Pfaeffli L.A.
        Mediators of physical activity behaviour change among adult non-clinical populations: a review update.
        • Fjeldsoe B.
        • Neuhaus M.
        • Winkler E.
        • Eakin F.
        Systematic review of maintenance of behavior change following physical activity and dietary interventions.
        • van Achterberg T.
        • Huisman-de Waal G.G.
        • Ketelaar N.A.
        • Oostendorp R.A.
        • Jacobs J.E.
        • Wollersheim H.C.
        How to promote healthy behaviours in patients? an overview of evidence for behaviour change techniques.
        • Williams S.L.
        • French D.P.
        What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behavior - and are they the same?.
        • Petersen C.B.
        • Severin M.
        • Hansen A.W.
        • Curtis T.
        • Grönbaek M.
        • Tolstrup J.S.
        A population-based randomized controlled trial of the effect of combining a pedometer with an intervention toolkit on physical activity among individuals with low levels of physical activity or fitness.
        • Teixeira P.J.
        • Carraca E.V.
        • Markland D.
        • Silva M.N.
        • Ryan R.M.
        Exercise, physical activity, and self-determination theory: a systematic review.
      • Until now, face-to-face delivery has been most effective,
        • Conn V.S.
        • Hafdahl A.R.
        • Mehr D.R.
        Interventions to increase physical activity among healthy adults: meta-analysis of outcomes.
        • Fjeldsoe B.
        • Neuhaus M.
        • Winkler E.
        • Eakin F.
        Systematic review of maintenance of behavior change following physical activity and dietary interventions.
        although various mediated modes show promising results.
        • Conn V.S.
        • Hafdahl A.R.
        • Mehr D.R.
        Interventions to increase physical activity among healthy adults: meta-analysis of outcomes.
        • Fjeldsoe B.
        • Neuhaus M.
        • Winkler E.
        • Eakin F.
        Systematic review of maintenance of behavior change following physical activity and dietary interventions.
        • Goode A.D.
        • Reeves M.M.
        • Eakin E.G.
        Telephone-delivered interventions for physical activity and dietary behavior change: an updated systematic review.
        • Stephens J.
        • Allen J.
        Mobile phone interventions to increase physical activity and reduce weight: a systematic review.
        • Short C.E.
        • James E.L.
        • Plotnikoff R.C.
        • Girgis A.
        Efficacy of tailored-print interventions to promote physical activity: a systematic review of randomized trials.
        • Broekhuizen K.
        • Kroeze W.
        • van Poppel M.N.
        • Oenema A.
        • Brug J.
        A systematic review of randomized controlled trials on the effectiveness of computer-tailored physical activity and dietary behavior promotion programs: an update.
        • Davies C.A.
        • Spence J.C.
        • Vandelanotte C.
        • Caperchione C.M.
        • Mummery W.K.
        Meta-analysis of internet-delivered interventions to increase physical activity levels.

      Efficacy and Effectiveness of ETR

      In ETR, a PHC professional refers a person having usually 1 or more chronic disease risk factors to a third-party service provider, such as a facility to improve cardiorespiratory fitness and musculoskeletal fitness using individualized ET programs.
      A systematic review and meta-analysis of 8 randomized controlled trials (5190 participants, 6-12 months of follow-up) found weak evidence supporting the efficacy of ETR programs to increase PA. The authors concluded that considerable uncertainty remains as to the effectiveness of ETRs and whether they are an efficient use of resources when offered for sedentary people with or without medical diagnoses.
      • Pavey T.G.
      • Taylor A.H.
      • Fox K.R.
      • et al.
      Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis.
      In another systematic review and meta-analysis of 7 randomized controlled trials, the same authors found no consistent evidence of increased PA or favorable changes in, eg, cardiorespiratory fitness, serum lipid levels, or quality of life as a result of ETR.
      • Pavey T.G.
      • Anokye N.
      • Taylor A.H.
      • et al.
      The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation.
      The results of the Wales version of the ETR were slightly more positive, revealing an increase in PA at 12 months in the referred patients (odds ratio, 1.19; 95% CI, 0.99-1.43) and in those referred for CVD risk (odds ratio, 1.29; 95% CI, 1.04-1.60) compared with usual care patients.
      • Murphy S.M.
      • Edwards R.T.
      • Williams N.
      • et al.
      An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative.
      The Swedish version of ETR, somewhat less intensive and more flexible than the English one, has been shown to be efficacious in substantially increasing the PA level and improving body composition and cardiometabolic risk factors in overweight/obese elderly individuals.
      • Kallings L.V.
      • Sierra Johnson J.
      • Fisher R.M.
      • et al.
      Beneficial effects of individualized physical activity on prescription on body composition and cardiometabolic risk factors: results from a randomized controlled trial.
      The feasibility of ETRs can be estimated on the basis of the extent of their use by PHC personnel and by the uptake and adherence to them by patients. Findings from a systematic review suggest at least reasonable feasibility.
      • Conn V.S.
      • Hafdahl A.R.
      • Mehr D.R.
      Interventions to increase physical activity among healthy adults: meta-analysis of outcomes.
      The wide implementation and positive experiences of the use of ETR in the Swedish
      • Leijon M.E.
      • Bendtsen P.
      • Nilsen P.
      • Ekberg K.
      • Ståhle A.
      Physical activity referrals in Swedish primary health care prescriber and patient characteristics, reasons for prescriptions, and prescribed activities.
      • Kallings L.V.
      • Leijon M.
      • Hellenius M.L.
      • Ståhle A.
      Physical activity on prescription in primary health care: a follow-up of physical activity level and quality of life.
      and Danish
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      • Sorensen J.B.
      • Skovgaard T.
      • Bredahl T.
      • Puggaard L.
      Exercise on prescription: changes in physical activity and health-related quality of life in five Danish programs.
      PHC systems support the feasibility of the programs used in those countries. In a systematic review,
      • Pavey T.
      • Taylor A.
      • Hillsdon M.
      • et al.
      Levels and predictors of exercise referral scheme uptake and adherence: a systematic review.
      the pooled level of uptake of ETR in 14 observational studies was 66% (95% CI, 57%-75%), and adherence was 49% (95% CI, 40%-59%). The corresponding figures for the 6 randomized trials included in the review were higher for uptake (81%) and lower for adherence (43%).
      The effectiveness of ETR in routine PHC services has been studied, eg, in the widely implemented practice in Sweden. In one region, 6300 PA prescriptions with referral to a third-party organization were issued in 2 years. Twelve months after the ETR, 51% of the patients who were contacted reported an increase in self-assessed PA. The proportion of inactive patients decreased from 33% at baseline to 20% at 12 months, and the proportion of regularly active individuals increased from 22% at baseline to 32% at 12 months, corresponding to medication adherence in developed countries.
      • Leijon M.E.
      • Bendtsen P.
      • Nilsen P.
      • Festin K.
      • Ståhle A.
      Does a physical activity referral scheme improve the physical activity among routine primary health care patients?.
      The adherence of patients to the prescribed program was, on average, 50% at 12 months.
      • Leijon M.E.
      • Bendtsen P.
      • Ståhle A.
      • Ekberg K.
      • Festin K.
      • Nilsen P.
      Factors associated with patients self-reported adherence to prescribed physical activity in routine primary health care.
      Another Swedish study found that 65% of insufficiently PA patients adhered to the ET prescription at 6 months. This level of adherence is as good as or better than that for other treatments of chronic diseases.
      • Kallings L.V.
      • Leijon M.E.
      • Kowalski J.
      • Hellenius M.L.
      • Ståhle A.
      Self-reported adherence: a method for evaluating prescribed physical activity in primary health care patients.
      In the Danish ETR program, 1 in 3 to 1 in 6 participants with elevated risk of cardiometabolic disease increased their PA level until the 16-month follow-up assessment.
      • Sorensen J.B.
      • Skovgaard T.
      • Bredahl T.
      • Puggaard L.
      Exercise on prescription: changes in physical activity and health-related quality of life in five Danish programs.

      Cost-Effectiveness of PA Promotion in PHC

      A systematic review of 13 randomized controlled trials found that most interventions based in PHC or community settings, such as ET prescription, were cost-effective, especially if direct supervision of ET was not required. Many PA interventions had similar cost-utility estimates as funded pharmaceutical interventions. The cost to move one person to the “active” category at 12 months was estimated for 4 interventions and ranged from €331 ($448) to €3673 ($4972). The cost-utility was estimated in 9 studies and varied substantially between the studies from €348 to €86,877 ($470 to $117,597) per quality-adjusted life year (QALY).
      • Garrett S.
      • Elley C.R.
      • Rose S.B.
      • O'Dea D.
      • Lawton B.A.
      • Dowell A.C.
      Are physical activity interventions in primary care and the community cost-effective? a systematic review of the evidence.
      Another systematic review of 8 studies of healthy adults found that behavioral interventions delivered by PHC increased the PA of healthy individuals to the recommended level at reasonable costs, eg, for approximately €800 ($1083) per year.
      • Muller-Riemenschneider F.
      • Reinhold T.
      • Willich S.N.
      Cost-effectiveness of interventions promoting physical activity.
      Estimation of the cost-effectiveness of ETR using a modeling approach in individuals with a medical condition revealed that a program was cost-effective at £20,000 ($31,974) per QALY at 51% probability and that a program was cost-effective at £30,000 ($47,860) per QALY at 88% probability. In subgroup analyses, the cost per QALY for an ETR scheme in sedentary obese individuals was £14,618 ($23,370), in sedentary hypertensive patients was £12,834 ($20,517), and in sedentary persons with depression was £8414 ($13,450). These cost-effectiveness estimates are subject to significant uncertainty because ETR programs are associated with only modest increases in lifetime costs and benefits.
      • Anokye N.K.
      • Trueman P.
      • Green C.
      • Pavey T.G.
      • Hillsdon M.
      • Taylor R.S.
      The cost-effectiveness of exercise referral schemes.
      The estimation of cost-effectiveness of the Wales ETR scheme for persons with coronary heart disease risk or mild to moderate depression, anxiety, or stress found that the base-case incremental cost-effectiveness ratio was £12,114 ($19,366) per QALY. Thus, this version of ETR for patients with CVD is likely to be cost-effective with respect to prevailing payer thresholds.
      • Murphy S.M.
      • Edwards R.T.
      • Williams N.
      • et al.
      An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative.

      Possibilities to Increase and Improve PA/ET Advising in the HCS

      Basic advising on PA and ET, especially for preventive purposes and for cardiorespiratory and musculoskeletal fitness but also to support the management of several chronic conditions, is possible for every properly trained physician who follows the established steps of clinical work-up
      • Kottke T.E.
      • Blackburn H.
      • Brekke M.L.
      • Solberg L.I.
      The systematic practice of preventive cardiology.
      and uses current information readily available, eg, from recommendations and clinical guidelines. However, as mentioned earlier, there are numerous factors that hinder
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      • Wen C.P.
      • Wu X.
      Stressing harms of physical inactivity to promote exercise.
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      • Laitakari J.
      • Miilunpalo S.
      • Vuori I.
      The process and methods of health counseling by primary health care personnel in Finland: a national survey.
      • Josyula K.
      • Lyle R.M.
      Barriers in the implementation of a physical activity intervention in primary care settings: lessons learned.
      or facilitate
      • Schmid M.
      • Egli K.
      • Martin B.W.
      • Bauer G.F.
      Health promotion in primary care: evaluation of a systematic procedure and stage specific information for physical activity counseling.
      • Jorgensen T.K.
      • Nordentoft M.
      • Krogh J.
      How do general practitioners in Denmark promote physical activity?.
      • Hinrichs T.
      • Moschny A.
      • Klaassen-Mielke R.
      • Trampisch U.
      • Thiem U.
      • Platen P.
      General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI).
      • Livaudais J.E.
      • Kaplan C.P.
      • Haas J.S.
      • Pérez-Stable E.J.
      • Stewart S.
      • Jarlais G.D.
      Lifestyle behavior counseling for women patients among a sample of California physicians.
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      • Cornuz J.
      • Ghali W.A.
      • Di Carlantonio D.
      • Pecoud A.
      • Paccaud F.
      Physicians' attitudes towards prevention: importance of intervention-specific barriers and physicians' health habits.
      • Josyula K.
      • Lyle R.M.
      Barriers in the implementation of a physical activity intervention in primary care settings: lessons learned.
      skillful and effective PA/ET advising for diverse indications and its provision in a systematic way in the HCS. Many of the facilitating factors are “mirror images” of the hindering factors. Most of both kinds of factors belong in 2 groups. The first group includes factors related to the amount and quality of education and training of the practitioners on the principles and practice of counseling on living habits and their change, particularly PA and ET. Provision of opportunities for the needed education and training and requirements to use these opportunities are, in large part, on the mandate of the HCS and its functional units.
      The other group of factors hindering and facilitating PA/ET advising is related to the organization of the HCS and its units. They have to offer opportunities, materials, fiscal and organizational resources, and incentives for systematically and professionally providing services that they have decided to provide, and they must require that the staff delivers these services.
      Decisions of policy makers, administrators, and superiors of the clinical staff on delivering certain services and on providing prerequisites such as education and training for it depends on the priority they give to those services. The lack of adequate education and training of health professionals on PA/ET advising and the lack of opportunities, responsibility, resources, and incentives for providing this service are results or reflections of the low priority of PA/ET advising in the HCS and in most of its functional units. If the priority of PA/ET counseling and PA promotion in general would increase, there would develop corresponding conditions for providing these services as there are for a variety of established clinical procedures and preventive services that have higher priority.
      • Kottke T.E.
      • Brekke M.L.
      • Solberg L.I.
      Making “time” for preventive services.
      These conditions include knowledge of the benefit of the service by practitioners and patients, skills for its provision, organization allowing and supporting the delivery of the service, adequate financial return of providing it, perceived demand for the service by a substantial proportion of patients, perceived effectiveness of the service by practitioners and patients, perceived legitimacy of providing the service, confidence in its effectiveness, and a commitment to providing it following rules and guidelines.
      In examining possibilities for systematically increasing and improving PA/ET advising in the HCS, the conceptual framework developed to improve medical practice
      • Solberg L.I.
      Improving medical practice: a conceptual framework.
      is useful (Figure 5).
      Figure thumbnail gr5
      Figure 5Conceptual framework for improving clinical service.
      From Ann Fam Med,
      • Solberg L.I.
      Improving medical practice: a conceptual framework.
      with permission.
      Presently, the key part of the framework is the priority for several reasons. Because the priority of PA/ET advising is low in ranking among the functions of the HCS in general and in most of its functional units, the perceived need in the system for organizational changes and changes in the content of the advising service is weak. Second, the changes needed to deliver PA/ET advising systematically, especially in small units, and the changes in the content of this service are not great and do not require extensive organizational, fiscal, or other resources. The needed resources can often be made available and put into use when the priority of PA/ET advising is sufficiently high.
      One possibility to increase the priority of PA/ET advising and PA promotion in the HCS would be to make attempts to change the connotation of the words PA and ET away from recreation and sports and closer to medically useful terminology. Because the effects and potential use of PA and ET can be compared with those produced by pharmaceutical drugs, PA and ET should be seen and dealt with in the same ways as pharmaceutical agents and other medical interventions in the HCS. Logical consequences would be that PA and ET would be included as an essential part in the basic and continuing education and training of physicians, physician assistants, nurse practitioners, nurses, etc; there would be established rules and processes to assess the PA needs of individual patients, to prescribe it, to deliver it, to follow up, and to reimburse the services related to it; and there would be funding and opportunities to conduct clinical research on its efficacy, effectiveness, feasibility, interactions, and comparability with other means, its risks, etc, and to conduct applied behavioral research. This approach is included in the global Exercise is Medicine initiative.

      Exercise is Medicine website. http://exerciseismedicine.org/global.htm. Accessed January 10, 2013.

      Using the slogan “exercise is medicine” may also be useful in marketing PA/ET to the public to improve its status and increase the demand for PA/ET advising.
      Another approach to raise the priority of PA/ET advising and possibly other PA promotion services in the HCS would be to make them accepted as performance measures and in the United States as Healthcare Effectiveness Data and Information Set measures in appropriate connections. The consequence would be the same development as outlined previously herein.
      A third approach to increase the priority of PA and ET would be to make the potential of PA/ET and the ways and means to use this potential better known to health professionals, especially to physicians, by publishing original research and thorough reviews on various aspects of PA and ET and their use for health in respected scientific and professional journals with large medical readership. Until now, most reports of research related to the health-enhancing potential of PA/ET and its use have been published in journals that are read by only a small number of health professionals, particularly clinicians. The result is the frequently reported “lack of knowledge.” The knowledge is there, but not easily at hand. Good examples of articles generating great interest and impact in the medical community are the highly cited reports on primary prevention of type 2 diabetes mellitus in the New England Journal of Medicine
      • Knowler W.C.
      • Barrett-Connor E.
      • Fowler S.E.
      • et al.
      Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
      • Tuomilehto J.
      • Lindström J.
      • Eriksson J.G.
      • et al.
      Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.
      and the series of articles in the Lancet in connection with the London Olympic Games.

      Physical activity. The Lancet website. http://www.thelancet.com/series/physical-activity. Published July 18, 2012. Accessed May 3, 2013.

      What is said herein applies also to conference presentations.
      One essential condition for increasing the priority of PA and ET and services related to them in the HCS is that they will be accepted by the leading medical and public health experts and by the leading scientific and professional organizations as a means to further their goals and to be included in their interests and activities. Furthermore, this acceptance is a key condition to getting the change process in Figure 5 initiated and performed effectively and leading to sustainable changes. The real breakthrough of PA/ET as medicine has to take place in the medical community and medical practices, and it has to be supported and performed by their members. There is great need for credible, strong, and skillful advocacy to convince the right people and the right organizations inside the medical community to work for this change.
      In the meantime, much can be done. When willingness to increase and improve PA/ET-related services is sufficient, the change process can be accomplished, especially in small clinical units, by paying attention to the realization of the following factors: strong effective leadership, a commonly understood framework and infrastructure for managing the process, people at all levels who have change management skills, adequate time and resources allocated to the process, an appropriate clinical information system, good communication and management skills, a high degree of team work, individual accountability, and a high degree of involvement and engagement of personnel at all levels.
      • Solberg L.I.
      Improving medical practice: a conceptual framework.
      An important goal of the change process is to rationalize the work of the clinicians and, thus, improve their motivation and to increase the amount and improve the quality of the provided service. One means to this end is to decrease the time and other resources needed to deliver the advising. Although it would be desirable to provide this service by using thorough behavior change processes, the competing interests and pressure on resources in the HCS do not typically allow this practice. Considerable evidence suggests that in terms of using the resources and the effectiveness of the intervention, brief counseling sessions are the most appropriate means to promote ET in the health care units.
      • Orrow G.
      • Kinmonth A.L.
      • Sanderson S.
      • Sutton S.
      Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials.
      • Armit C.M.
      • Brown W.J.
      • Marshall A.L.
      • et al.
      Randomized trial of three strategies to promote physical activity in general practice.
      • Grandes G.
      • Sanchez A.
      • Sanchetz-Pinilla R.O.
      • et al.
      Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial.
      • Kallings L.V.
      • Sierra Johnson J.
      • Fisher R.M.
      • et al.
      Beneficial effects of individualized physical activity on prescription on body composition and cardiometabolic risk factors: results from a randomized controlled trial.
      • Leijon M.E.
      • Bendtsen P.
      • Nilsen P.
      • Festin K.
      • Ståhle A.
      Does a physical activity referral scheme improve the physical activity among routine primary health care patients?.
      • Muller-Riemenschneider F.
      • Reinhold T.
      • Willich S.N.
      Cost-effectiveness of interventions promoting physical activity.
      The tasks of physicians and other clinicians and paramedical staff could be limited mainly to this stage, and the next steps can be successfully conducted by other health and exercise professionals.
      • Jacobson D.M.
      • Strohecker L.
      • Compton M.T.
      • Katz D.L.
      Physical activity counseling in adult primary care setting: position statement of the American College of Preventive Medicine.
      • McPhail S.
      • Schippers M.
      An evolving perspective on physical activity counseling by medical professionals.
      • Douglas F.
      • Torrance N.
      • van Teijlingen E.
      • Meloni S.
      • Kerr A.
      Primary care staff's views and experiences related to routinely advising patients about physical activity.
      • Hébert E.T.
      • Caughy O.
      • Shuval K.
      Primary care providers' perceptions of physical activity counseling in a clinical setting: a systematic review.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.
      • Persson G.
      • Ovhed I.
      • Hansson E.E.
      Simplified routines in prescribing physical activity can increase the amount of prescriptions by doctors, more than economic incentives only: an observational intervention study.
      • Sargent G.M.
      • Forrest L.E.
      • Parker R.M.
      Nurse delivered lifestyle interventions in primary health care to treat chronic disease risk factors associated with obesity: a systematic review.
      Especially, methods including more than brief advising on ET are recommended to be used selectively on patients with increased risk of diseases and having factors favoring considerable potential to gain from the measures.
      • Moyer V.A.
      U.S. Preventive Services Task Force
      Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement.
      Another means to increase the willingness of health care personnel to offer PA/ET advising and to improve its applicability and effectiveness is to develop structured but feasible protocols tailored to local conditions. The protocols should include the whole chain of measures: recording patients' PA as a vital sign; assessing patients’ needs, risks, and resources for ET; individualized ET prescriptions; rules and processes of ETR; necessary materials; tools for monitoring and self-monitoring ET; and providing information about sites and services for PA and ET until following up adherence to the program and assessing its effects.
      • McPhail S.
      • Schippers M.
      An evolving perspective on physical activity counseling by medical professionals.
      • Schmid M.
      • Egli K.
      • Martin B.W.
      • Bauer G.F.
      Health promotion in primary care: evaluation of a systematic procedure and stage specific information for physical activity counseling.
      • Khan K.M.
      • Weiler R.
      • Blair S.N.
      Prescribing exercise in primary care.
      • Persson G.
      • Ovhed I.
      • Hansson E.E.
      Simplified routines in prescribing physical activity can increase the amount of prescriptions by doctors, more than economic incentives only: an observational intervention study.
      • Leijon M.E.
      • Bendtsen P.
      • Nilsen P.
      • Festin K.
      • Ståhle A.
      Does a physical activity referral scheme improve the physical activity among routine primary health care patients?.
      • Mozaffarian D.
      • Afshin A.
      • Benowitz N.L.
      • et al.
      Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association.
      A simple, widely used, and valid protocol in behavioral counseling is the 5As (ask, advise, assess, assist, arrange).
      • Carroll J.K.
      • Antognoli E.
      • Flocke S.A.
      Evaluation of physical activity counseling in primary care using direct observation of the 5As.
      The advising would be faster and its quality would be better if practitioners would have valid and readily available tools to review the background and rationale for PA/ET for specified indications and modifiable model advice to be given to their patients. On this basis, a Web-based tool, Exercise Medicine (Liikuntaa Lääkkeeksi in Finnish), was developed by one of us (I.M.V.). The tool consists of a complete, but concise, package of reliable information to support prescribing PA for 35 indications. The information includes the following indication-specific sections, each to be viewed on one screen page: connection of PA to the indication giving the rationale for PA; clinically relevant and patient-centered benefits of PA in prevention, treatment, and secondary prevention/rehabilitation as appropriate; risks and potential adverse effects of PA; advisability and limitations of PA; rationale/basis for planning an appropriate PA regimen; and ready-written 1-page advice (recommendation, prescription) for appropriate PA for the person and for the given indication to be printed or e-mailed as needed. The prescriber can make changes to the advice. The tool is readily available free of charge for medical professionals on the website of the Finnish Medical Association, and for the public by using a link in the Web journal for patients of the Finnish Medical Journal.

      Exercise medicine. Potilaan Lääkärilehti website. http://www.potilaanlaakarilehti.fi/palvelut/liikuntalaake. Accessed May 3, 2013.

      Within 1 month of offering this possibility, the tool was viewed approximately 11,000 times.
      The frequently mentioned barriers to PA/ET advising included a variety of items related to lack of adequate education and training of physicians and other health care professionals on the health-related aspects of PA and ET, the characteristics of the PA or ET needed for different indications, and the principles and methods of counseling. This education and training would not only increase knowledge but would also influence positively some other barriers, such as attitudes toward and perceptions of counseling, and improve the quality of the counseling services. Substantial improvement can be gained by providing educational materials, emphasizing use of the numerous clinical guidelines and recommendations on the use of ET as medicine,
      • Weiler R.
      • Feldschreiber P.
      • Stamatakis E.
      Medicolegal neglect? the case for physical activity promotion and exercise medicine.
      • Patrick K.
      • Pratt M.
      • Sallis R.E.
      The healthcare sector's role in the US national physical activity plan.
      • Leijon M.E.
      • Bendtsen P.
      • Nilsen P.
      • Ekberg K.
      • Ståhle A.
      Physical activity referrals in Swedish primary health care prescriber and patient characteristics, reasons for prescriptions, and prescribed activities.
      and attending short courses. It is important to communicate to physicians and other health care professionals, especially PHC physicians, that encouraging patients to be more active does not require a lot of detailed information. Current PA guidelines in many countries emphasize that “more activity is better than none” and “more is better than less, at least up to a point.” Walking is the most common PA in most individuals. The physician’s advice can be simply “sit less and try to walk more each day.” The current guidelines establish a target of 150 min/wk of moderate-intensity PA, such as walking, and this dose will produce important changes in health outcomes. An example of the benefit of even less PA in sedentary populations is the Dose-Response to Exercise in Postmenopausal Women study, which was a large randomized trial in sedentary postmenopausal women. In this study, important benefits were observed in the low-dose ET group, which was engaging in 72 minutes of moderate-intensity PA per week.
      • Church T.S.
      • Earnest C.P.
      • Skinner J.S.
      • Blair S.N.
      Effects of different doses of physical activity on cardiorespiratory fitness among sedentary, overweight or obese postmenopausal women with elevated blood pressure: a randomized controlled trial.
      • Church T.S.
      • Martin C.K.
      • Thompson A.M.
      • Earnest C.P.
      • Mikus C.R.
      • Blair S.N.
      Changes in weight, waist circumference and compensatory responses with different doses of exercise among sedentary, overweight postmenopausal women.
      However, a more sustainable and thorough solution would be to include PA and ET medicine in the core curriculum of medical schools and residency/fellowship programs.
      • Weiler R.
      • Feldschreiber P.
      • Stamatakis E.
      Medicolegal neglect? the case for physical activity promotion and exercise medicine.
      • Matheson G.O.
      • Klugl M.
      • DvorakJ
      • et al.
      Responsibility of sport and exercise medicine in preventing and managing chronic disease: applying our knowledge and skill is overdue.
      • Mozaffarian D.
      • Afshin A.
      • Benowitz N.L.
      • et al.
      Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association.
      An obvious need in the efforts to increase PA/ET counseling in the HCS based on consultation fees paid by individual patients is to make it a reimbursable item. Realization of this condition is supported by continuously improving the service, by producing further evidence of its effectiveness and cost-effectiveness, and by using this evidence persistently and skillfully in high-level advocacy.

      Alarming Trends in Daily Life

      In terms of daily EE, modern society has changed enormously during the past several decades. We have dramatically reduced EE in many aspects of life in highly developed countries. It has recently been reported that during the past 50 years, occupational PA has substantially declined in the United States (Figure 2, A),
      • Church T.S.
      • Thomas D.M.
      • Tudor-Locke C.
      • et al.
      Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity.
      and during the past 45 years there have been very marked reductions in household management EE (HMEE) in women (Figure 2, B).
      • Archer E.
      • Shook R.P.
      • Thomas D.M.
      • et al.
      45-year trends in women’s use of time and household management energy expenditure.
      These reductions in HMEE amount to greater than 1800 calories per week. During this period, the amount of time in screen-based media exposure has also increased, and although leisure time PA has slightly increased, this does not nearly make up for the very marked reductions in EE from reductions in HMEE. These data have very serious implications regarding the risk of obesity and other chronic diseases, particularly CVD, not to mention the potential downstream effect on the next generation. National guidelines in several countries call for 150 min/wk of moderate PA or 75 min/wk of vigorous PA,

      Department of Health and Human Services. 2008 Physical activity guidelines for Americans. http://www.health.gov/paguidelines/pdf/paguide.pdf. Accessed November 15, 2012.

      and the US Institute of Medicine has suggested that all individuals should do 60 min/d of total PA.
      Institute of Medicine
      Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients).
      Although currently very few are meeting these guidelines, even if these guidelines were met, it would not make up for the very marked reductions in HMEE and occupational PA.

      Conclusion

      We must continue to encourage increases in PA, which would lead to EE and improvements in physical fitness (cardiorespiratory and musculoskeletal fitness) and likely reductions in chronic diseases, especially CVD. The HCS and, particularly, physicians have important roles to play: to give an important signal and example of the necessity of PA/ET for health to the policy and decision makers and to the people and to use their means to encourage patients to increase their PA/ET. There is much potential to increase and improve PA promotion activities in the HCS by systematically exploring and applying the information available in the basic and applied behavioral and interventional research and by experimenting and applying new ways of organizing and performing the practical work.

      Supplemental Online Material

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