PHYSICAL ACTIVITY AS A VITAL SIGN

By: Edrick Purnomo Putra

In 2020, data from the World Health Organization (WHO) indicated that physical inactivity ranked fourth among the leading global risk factors for mortality.1 A lack of physical activity (PA) is associated with up to 3% of total direct healthcare expenditures in developing countries.2 Additionally, the absence of PA contributes to numerous chronic diseases, accounting for more than 50 billion dollars in global economic burden.3 There is strong evidence demonstrating that PA significantly reduces the risk of cardiovascular diseases (CVD), type 2 diabetes, hypertension, stroke, hyperlipidemia, and depression. It also contributes to improvements in body mass index, quality of life, cardiorespiratory fitness, muscular fitness, bone health, and cognitive function.4

The WHO released new guidelines in 2020 recommending that all adults should engage in physical activity regularly. This should include at least 150-300 minutes per week of moderate-intensity aerobic exercise, or at least 75-150 minutes per week of vigorous-intensity aerobic exercise, or an equivalent combination of both, to reap health benefits.5 Additionally, muscle-strengthening activities involving major muscle groups at moderate or greater intensity are recommended on two or more days per week.5 The benefits of PA occur in a dose-response manner, with a 4% reduction in the risk of mortality for every additional 15 minutes of PA per day, within the range of 15-100 minutes of moderate to vigorous PA daily.4 However, in reality, almost half of U.S. adults2 and one-third of In-donesians6 fail to meet these recommendations.

Efforts to find a solution for insufficient physical activity (PA) have been ongoing for a long time. In 2007, the Exercise is Medicine (EIM) initiative was launched in the U.S. through a collaboration between the American Medical Association (AMA) and the American College of Sports Medicine (ACSM). EIM aims to encourage clinicians to evaluate a patient’s PA level during every clinical encounter, refer to the PA guidelines, and provide counseling or referrals based on the patient’s current PA level. With these objectives, measuring PA level has been proposed as one of the vital signs and an important component of standard medical service. Assessing PA as a vital sign during clinic visits has the potential to reduce or manage chronic diseases affected by a lack of physical activity and sedentary behavior.7

When discussing the measurement of PA as a vital sign, various tools have been explored in studies to record moderate-to-vigorous PA. These include the Exercise Vital Sign (EVS), Physical Activity Vital Sign (PAVS), Speedy Nutrition and Physical Activity Assessment (SNAP), General Practice Physical Activity Questionnaire (GPPAQ), and Stanford Brief Activity Survey (SBAS).8 EVS and PAVS are the most commonly applied in the US and have shown validity for use in primary care as measures to identify patients not meeting PA guidelines.4 Both tools essentially include two questions: one about the number of days per week the patient performs moderate-to-vigorous PA, and another about the average duration of these activities each day. Both EVS and PAVS can be administered and calculated in less than 30 seconds.8 PAVS also optionally includes a question about the frequency of muscle-strengthening activities.9

Several studies with promising results have been conducted regarding the implementation of PA vital signs in clinical settings. A 2022 study on the implementation of PAVS in primary care revealed that patients reporting as inactive also had a higher burden of chronic diseases, indicating that PAVS is a useful screening tool in primary care. It helps physicians understand the PA level of patients and identify those who may benefit from physical activity counseling and prescription.10 A 2021 study implemented PAVS in an electronic health record in an academic preventive cardiology clinic, concluding that PAVS is a feasible, quick, and scalable electronic tool to assess PA and aid providers in discussing and counseling on this CVD risk factor.2 A study in youth and adolescent populations found that PA declines significantly with age and is associated with increased obesity prevalence. PAVS is a simple tool for measuring PA and guiding interventions, which has yet to be examined in the pediatric population.3

PA vital sign tools also have limited studies regarding their accuracy compared to the gold standard objective measure of PA, accelerometry.4 Both EVS and PAVS are modestly associated with accelerometry, and the norm for self-reported PA measures often shows moderate associations.8 Although cardiorespiratory fitness is a strong predictor of mortality, its measurement is not feasible in most clinical settings due to logistical, cost, and time constraints. Hence, EVS can be used as an alternative tool to measure and promote PA.11

Implementing PA vital signs in clinical practice is not without challenges. For providers, barriers include time constraints, staff unfamiliarity with the tool, lack of motivation, inadequate knowledge, skills, competencies, and facilities related to PA, and providers’ personal PA practices.7,10 Patients face barriers such as a lack of understanding of the questions asked by the tool and the type of visit (first visit, annual visit, or acute case visit).7,10 In the healthcare system itself, barriers identified include a lack of incentives for providers, non-standard coding for PA and its interventions, and the absence of PA measurement in medical records.7

To improve implementation, several strategies can be applied. Consistent measurement of the PA vital sign should be a regular routine at every visit, just like measuring blood pressure and heart rate.7,10 It should also be recorded and integrated into the medical record system. Collective commitment by all providers in the clinical setting is necessary, along with proper training. A standard code for PA interventions should be established, and incentives should be given to providers for their time spent counseling and prescribing exercise. From a social perspective, governments and stakeholders should collaborate to create an environment that encourages PA with supportive infrastructure and community access. Technological integration may also motivate patients to participate in PA.7 Personalization is crucial in counseling and individual exercise prescription, taking into account patients’ affective responses, motivation, and behavioral science.12 Collaboration and referrals with qualified exercise professionals should be properly established to ensure patient safety and success.13

PA is a well-known management strategy in many diseases, especially for managing chronic conditions, but it is often overlooked in daily clinical practice. Routine inclusion of a physical activity vital sign in medical records is encouraged. More longitudinal research is needed to understand how regular use of PA vital sign tools affects health risk outcomes. However, for now, regular measurement of PA is a promising way to make EIM applicable in clinical practice. By simply asking two questions that take less than 30 seconds, clinicians can identify a lack of PA, raise awareness, provide counseling or referrals, and potentially change a patient’s health trajectory. Treating PA as a vital sign will motivate patients and clinicians to recognize the importance of regular PA engagement. Personalization should be customized to the patient’s needs and conditions when it comes to counseling and individual exercise prescription.

References

  1. WHO. WHO Guidelines on physical activity and sedentary behaviour. WHO. Geneva: WHO; 2020.
  2. McCarthy MM, Fletcher J, Heffron S, Szerencsy A, Mann D, Vorderstrasse A. Implementing the physical activity vital sign in an academic preventive cardiology clinic. Prev Med Reports [Internet]. 2021;23:101435. Available from: https://doi.org/10.1016/j.pmedr.2021.101435
  3. Nelson VR, Masocol R V., Asif IM. Associations Between the Physical Activity Vital Sign and Cardiometabolic Risk Factors in High-Risk Youth and Adolescents. Sports Health. 2020;12(1):23–8.
  4. Wald A, Garber CE. A Review of Current Literature on Vital Sign Assessment of Physical Activity in Primary Care. J Nurs Schol-arsh. 2018;50(1):65–73.
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  6. Kementrian Kesehatan RI. Hasil Utama Riskesdas 2018. 2018.
  7. Bowen PG, Mankowski RT, Harper SA, Buford TW. Exercise Is Medicine as a Vital Sign: Challenges and Opportunities. Transl J Am Coll Sport Med. 2019;4(1):1–7.
  8. Golightly YM, Allen KD, Ambrose KR, Stiller JL, Evenson KR, Voisin C, et al. Physical Activity as a Vital Sign: A Systematic Review. Prev Chronic Dis. 2017;14:1–11.
  9. Exercise is Medicine, American College of Sports Medicine. Physical Activity Vital Sign. 2021.
  10. Lin CY, Gentile NL, Bale L, Rice M, Lee ES, Ray LS, et al. Implementation of a Physical Activity Vital Sign in Primary Care: Associations Between Physical Activity, Demographic Characteristics, and Chronic Disease Burden. Prev Chronic Dis. 2022;19:1–9.
  11. Langland JT. The Exercise Vital Sign as a Potential Alternative to Determining Cardiorespiratory Fitness. Mayo Clin Proc [Internet]. 2020;95(3):613. Available from: https://doi.org/10.1016/j.mayocp.2019.12.005
  12. Segar ML, Guérin E, Phillips E, Fortier M. From a Vital Sign to Vitality: Selling Exercise So Patients Want to Buy It. Curr Sports Med Rep. 2016;15(4):276–81.
  13. Cowan RE. Exercise Is Medicine Initiative: Physical Activity as a Vital Sign and Prescription in Adult Rehabilitation Practice. Arch Phys Med Rehabil [Internet]. 2016;97(9):S232–7. Available from: http://dx.doi.org/10.1016/j.apmr.2016.01.040
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