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research-article2020
AJLXXX10.1177/1559827620912192American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine

vol. 14 • no. 5 American Journal of Lifestyle Medicine

Walter R. Thompson, PhD, FACSM, Robert Sallis, MD, FACSM,

Elizabeth Joy, MD, MPH, FACSM,

Analytic Carrie A. Jaworski, MD, FAAFP, FACSM,

Robyn M. Stuhr, MA, ACSM-CEP, RCEP,
and Jennifer L. Trilk, PhD, FACSM, DipACLM

Exercise Is Medicine

P
Abstract: There is overwhelming hysical inactivity underlies many T2DM are unhealthy lifestyle behaviors
evidence in the scientific and medical of the chronic conditions that (poor nutrition and insufficient physical
literature that physical inactivity is a affect people worldwide, has an activity leading to overweight and
major public health problem with a astonishing array of harmful health obesity). In addition to T2DM, an
wide array of harmful effects. Over 50% effects, and is associated with escalating unhealthy lifestyle (including tobacco
of health status can be attributed to health care costs. For example, 7 cancers use, excessive alcohol intake, poor sleep,
unhealthy behaviors with smoking, diet, have been linked to a physically inactive and stress) underlies prevalent and costly
and physical inactivity as the main lifestyle.1 Depression affects 17 million chronic diseases (eg, heart disease and
contributors. Exercise has been used Americans2 and has been directly linked cancer) leading to premature morbidity
in both the treatment and prevention to insufficient physical activity.3 and mortality.
of a variety of chronic conditions such Alzheimer’s disease and related While other determinants of health
as heart disease, pulmonary disease, dementias are increasing at a frightening (genetics, environment, and medical
diabetes, and obesity. While the
negative effects of physical inactivity
are widely known, there is a gap While other determinants of health
between what physicians tell their
patients and exercise compliance. (genetics, environment, and medical
Exercise is Medicine was established
in 2007 by the American College of care) influence health outcomes, by
Sports Medicine to inform and educate
physicians and other health care
far the most important factor
providers about exercise as well as contributing to health outcomes is
bridge the widening gap between health
care and health fitness. Physicians have individual lifestyle and behavior.
many competing demands at the point
of care, which often translates into
limited time spent counseling patients. rate. By 2025, the number of people care) influence health outcomes, by far
The consistent message from all health aged 65 years and older with Alzheimer’s the most important factor contributing to
care providers to their patients should disease is expected to reach 7.1 million health outcomes is individual lifestyle
be to start or to continue a regular people. In the United States alone, more and behavior. Efforts aimed at addressing
exercise program. Exercise is Medicine than 30 million adults are estimated to behaviors, and specifically physical
is a solution that enables physicians to have diabetes,4 95% of whom have type inactivity, are likely to have the greatest
support their patients in implementing 2 diabetes (T2DM). Considering that a impact on the health of populations. A
exercise as part of their disease new case of diabetes is diagnosed every 2015 article from JAMA Internal
prevention and treatment strategies. 21 seconds, it is no surprise that diabetes Medicine6 states, “There is no medication
is the most expensive disease in America, treatment that can influence as many
Keywords: inactivity; exercise; vitals; coming in at a price tag of $327 billion organ systems in a positive manner as
behaviors; referral annually.5 Underlying the vast majority of can physical activity.” Physical activity

DOI: 10.1177/1559827620912192. From College of Education & Human Development, Georgia State University, Atlanta, Georgia (WRT); UC Riverside School of Medicine,
https://doi.org/

Fontana, California (RS); University of Utah School of Medicine, Salt Lake City, Utah (EJ); University of Chicago Pritzker School of Medicine, Chicago, Illinois (CAJ); Exercise Is
Medicine®, Indianapolis, Indiana (RMS); Lifestyle Medicine Education University of South Carolina School of Medicine Greenville, Greenville, South Carolina (JLT). Address
correspondence to: Walter R. Thompson, PhD, FACSM, College of Education & Human Development, Georgia State University, 30 Pryor Street, Suite 1000, Atlanta, GA 30303;
e-mail: [email protected].
For reprints and permissions queries, please visit SAGE’s Web site at www.sagepub.com/journals-permissions.
Copyright © 2020 The Author(s)

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 American Journal of Lifestyle Medicine Sep • Oct 2020

and associated improvements in physical active lifestyle on physical and mental was suggested earlier, it is obvious that if
fitness are key strategies to improving health. It builds on the data that such compelling evidence had been
health. informed the first guidelines in 2008 and developed around a pill or surgical
Dr Steve Blair wrote in the British incorporates new research from over the procedure, every doctor around the
Journal of Sports Medicine in 2009 that past 10 years. The power and world would want to prescribe it to their
“physical inactivity is the biggest public contribution of physical activity and patients; in fact, it would be malpractice
health problem of the 21st century.”7 exercise on overall health, quality of life, not to prescribe it to every patient, every
(p. 1) This statement was based on the and disease-specific prevention and visit, regardless of medical specialty.
results of the Aerobic Center treatment is staggering (Table 1). A A national launch for the EIM initiative
Longitudinal Study, which found that meta-analysis of studies evaluating the was held on November 5, 2007, at the
fitness was more important than fatness; relative effectiveness of pharmaceutical National Press Club in Washington, DC.
that improvements in cardiorespiratory versus physical activity interventions This launch was chaired by then ACSM
fitness reduced premature mortality to a found that regular exercise was just as President-Elect Robert Sallis, MD, and
greater extent than improvements in effective as commonly prescribed incoming American Medical Association
blood glucose or cholesterol levels. medications in the secondary prevention President, Ron Davis, MD. Also attending
Despite all pharmacologic interventions of coronary heart disease, treatment of the launch was the acting US Surgeon
for diabetes or hypercholesterolemia, heart failure, prevention of diabetes, and General, Dr Steven Galson, who was also
simply improving aerobic fitness through even more effective than medication in a strong advocate for promoting physical
regular physical activity had the greatest the rehabilitation of patients after a activity to influence health, along with
impact on longevity, indicating that stroke.10 Melissa Johnson (then Executive Director
exercise is indeed medicine. To manage spiraling health care costs of the President’s Council on Physical
Three years later (2012), Lee and associated with lifestyle-related chronic Fitness and Sports), and Jake Steinfeld
colleagues,8 in The Lancet, reported, “In diseases, health care is moving toward (Chairman of the California Governor’s
view of the prevalence, global reach, and value-based and population health Council for Physical Fitness and Sports).
health effect of physical inactivity, the models of care. Lifestyle interventions The first 5 years of EIM mainly involved
issue should be appropriately described that provide guidance and support to getting the word out, building
as pandemic, with far-reaching health, help patients with common chronic infrastructure, and establishing
economic, environmental and social conditions to successfully adopt and collaborations. During the past several
consequences.” (p. 219) The authors maintain a habit of regular physical years, there have been a variety of efforts
concluded that physical inactivity causes activity will be instrumental. to move EIM forward in an increasingly
1 in 10 premature deaths worldwide. If Imagine a pill that conferred the complex and changing health care
inactivity decreased by 25%, more than established health benefits of exercise landscape, including education,
1.3 million deaths worldwide could be and/or regular physical activity with partnerships, outreach, and policy work.
averted every year. Furthermore, deaths minimal adverse effects and a multitude Some key highlights include the following:
attributable to a physically inactive of positive effects causing patients to
lifestyle were nearly equal to those from “feel better, function better, and sleep 1. Building an EIM global health
smoking, giving rise to the saying, better.”9 Physicians would surely network, including regional centers
“Sitting is the new smoking.”8 prescribe that pill to every patient, that coordinate EIM partnerships in
Exercise is a “medicine” that can pharmaceutical companies would countries around the world. These are
prevent and treat chronic disease; those produce and market it, health plans linked by a robust website designed
who “take it” live longer and with a would surely pay for it, and every patient to enhance communication and
higher quality of life. In 2018, the would ask for it. collaboration across the network.
Physical Activity Guidelines Advisory 2. Establishment of the World Congress
Committee (https://health.gov/ on Exercise is Medicine as a central
Exercise Is Medicine
PAGuidelines/) released a Scientific component of the ACSM annual
Report that would be the foundation for The Exercise is Medicine (EIM) meeting and as a place to share the
the second edition of the Physical initiative was founded in 2007 by the latest research and build
Activity Guidelines for Americans9 issued American College of Sports Medicine collaborations across the country and
by the US Office of Disease Prevention (ACSM) with the goal of making physical around the world.
and Health, Centers for Disease Control activity assessment and exercise 3. Growth of a vibrant EIM on-campus
and Prevention, the National Institutes of prescription a standard part of the network that is now strong and
Health, and the President’s Council on disease prevention and treatment expanding, including 275 college and
Sports, Fitness and Nutrition. This report paradigm for all patients. Certainly, university campuses around the
summarized the scientific evidence evidence calls for nothing less than a world.
regarding the benefits of a physically global initiative to make this happen. As

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Table 1.
Physical Activity–Related Health Benefits for the General Population and Selected Populations.a,b

Children
  3 to <6 years •  Improved bone health and weight status
  6 to 17 years •  Improved cognitive function
•  Improved cardiorespiratory and muscular fitness
•  Improved bone health
•  Improved cardiovascular risk factor status
•  Improved weight status or adiposity
•  Fewer symptoms of depression
Adults, all ages
  All-cause mortality Lower risk
  Cardiometabolic conditions • Lower cardiovascular incidence and mortality (including heart disease
and stroke)
•  Lower incidence of hypertension
•  Lower incidence of type 2 diabetes
 Cancer Lower incidence of bladder, breast, color, endometrium, esophagus,
kidney, stomach, and lung cancers
  Brain health •  Reduced risk of dementia
•  Improved cognitive function
•  Improved cognitive function following bouts of aerobic activity
•  Improved quality of life
•  Improved sleep
•  Reduced feelings of anxiety and depression in healthy people and
in people with existing clinical syndromes
•  Reduced incidence of depression
  Weight status •  Reduced risk of excessive weight gain
• Weight loss and the prevention of weight regain following initial weight
loss when a sufficient dose of moderate-to-vigorous physical activity is
attained
• An additive effect on weight loss when combined with moderate dietary
restriction
Older adults
 Falls •  Reduced incidence of falls
•  Reduced incidence of fall-related injuries
  Physical function •  Improved physical function in older adults with or without frailty
Individuals with preexisting medical conditions
  Breast cancer •  Reduced risk of all-cause and breast cancer mortality
  Colorectal cancer •  Reduced risk of all-cause and colorectal cancer mortality
  Prostate cancer •  Reduced risk of prostate cancer mortality
 Osteoarthritis •  Decreased pain
•  Improved function and quality of life

(continued)

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Table 1.  (continued)

 Hypertension •  Reduced risk of progression of cardiovascular disease

•  Reduced risk of increased blood pressure over time
  Type 2 diabetes •  Reduced risk of cardiovascular mortality
•  Reduced progression of disease indicators: hemoglobin A1c, blood
pressure, blood lipids, and body mass index
  Multiple sclerosis •  Improved walking
•  Improved physical fitness
 Dementia •  Improved cognition
  Some conditions with impaired executive •  Improved cognition
function
a
Benefits in boldface are those added in 2018; benefits in normal font are those noted in the 2008 Scientific Report. Only outcomes with strong or moderate
evidence of effect are included in the table.
b
Source. Office of Disease Prevention and Health Promotion. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Integrating the Evi-
dence, 2018. health.gov/paguidelines/second-edition/report, pp. D5 to D6.

4. Development of a global EIM disease prevention and treatment more specific guidelines, modifications,
Continuing Medical Education course paradigm for all patients and to connect and precautions.15 These are provided in
to teach health care providers how to health care with evidence-based physical the “EIM Rx for Health” series of patient
assess, counsel, and refer patients for activity resources. The initiative proposes handouts (www.exerciseismedicine.org/
physical activity prescription to treat that physical activity assessment and rx-for-health-series).16 In addition, digital
and prevent chronic disease. promotion be the standard of care for and print materials to promote physical
5. Creation of an EIM Credential to every patient, at every visit and as part of activity to various segments of the
recognize qualified and certified every treatment plan.11 population can be found as part of the
fitness professionals who are It is recommended that physical activity US Office of Disease Prevention and
prepared to receive and work with be recorded as a vital sign, just as other Health’s “Move Your Way” campaign
patients referred from health care modifiable risk factors are routinely (https://health.gov/paguidelines/
providers. assessed (eg, blood pressure, weight, moveyourway/).
6. Successful piloting of the EIM smoking).11-14 Two or 3 simple questions While the assessment and promotion of
Solution model (linking clinical care/ can be integrated into the health history physical activity fits naturally into the
Physical Activity Vital Sign [PAVS]) to form/electronic health record (EHR) to “whole patient” medical management
community networks) at the identify those patients who are not model provided in primary care/family
Greenville Health System (now meeting the federal guidelines for medicine, the message should be
Prisma Health) and the Greenville physical activity. This allows patients to delivered by every health care provider,
(South Carolina) YMCA. be identified for population health regardless of specialty, since the effects of
7. EIM partnerships with various health interventions or physical activity advice physical activity (or lack of it) contribute
care associations and fitness or referral. Patients are advised to meet to an abundance of medical conditions.
organizations that have helped drive the recommended amount and types of EIM is best delivered efficiently using
important programs to improve physical activity and, at a minimum, every member of the health care team,
physical activity including the encouraged to reduce sedentary time by including medical assistants, nurses, nurse
Surgeon General’s Call to Action on integrating short bouts (of any duration) practitioners, physician assistants, physical
Walking, the Every Body Walk of light to moderate intensity physical therapists, exercise physiologists, dietitians,
Collaborative, Walk with a Doc, Park activity over the course of the day (eg, diabetes educators, health coaches, and
Rx America, and the Prescription for taking stairs, walking when possible, even front desk staff in specific roles. An
Activity Task Force. standing frequently during seated tasks). “EIM Health Care Provider Action Guide”17
The 2018 Physical Activity has been developed to assist physicians
The vision of EIM is to make physical recommendations are summarized in and other health care providers in
activity assessment and exercise Table 2. Patients with various chronic integrating EIM into the clinical setting
prescription a standard part of the medical conditions may benefit from (https://exerciseismedicine.org/).

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Table 2.
2018 Physical Activity Guidelines for Americans.

The Miracle Drug:

Exercise is Medicine®
In an era of spiraling health care expenditures, getting patients to be more active may be the ultimate low-cost therapy for
achieving improved health outcomes. Studies show that regular physical activity (PA) has health benefits at any body
weight and is critical for long-term weight management. Decades of research have shown that exercise is as effective as
prescription medication in the management of several chronic diseases. Just as weight and blood pressure are addressed at
nearly every health care visit, so should attention be given to PA.
Assessment: Use the Physical Activity Vital Sign to Assess Weekly PA Levels
Add these 2 simple questions to the health history form and electronic health record to determine if the patient is meeting the
PA guidelines:
1. On average, how many days per week do you engage in ____ Days
moderate to vigorous PA (like brisk walking)?
2. On average, how many minutes do you engage in PA at this level? ____ Minutes
  Total Activity (days/week x minutes/day) = ___minutes/week
Brief Advice/Prescription: Basic Exercise Recommendations
• Encourage your patient to meet the PA guidelines (see chart). At minimum, adults should be more active over the course of
a day (ie, take frequent breaks from sitting, walk the dog, use the stairs). Every minute counts! Children and adolescents
should engage in sports, dance, outdoor recreation, and active games.
• Provide the EIM “Sit Less. Move More” handout to your patients. The EIM Rx for Health Series also provides condition-
specific handouts.
2018 Physical Activity Guidelines for Americans
Age (years) Aerobic Activity Recommendations Muscle Strengthening Recommendations
 6-17 60 minutes of moderate or vigorous physical 3 days/week and included as part of the 60
activity (PA)/day including at least 3 days of minutes of daily PA. Also include bone-loading
vigorous PA/week activity.
 18-64 150-300 minutes of moderate PA/week Muscle strengthening activities at moderate or
75 minutes of vigorous PA/week or greater intensity (all major muscle groups) on 2
equivalent combination spread throughout the or more days/week
week
 65+ Same as adults, or be as active as abilities and Same as adults, but include balance training and
health conditions allow combination activities (strength and aerobic
training together)
  All ages Sit less. Move more. All physical activity counts.
Referral and Resources
• Advise patients to take advantage of local parks and recreation programs. Develop referral relationships with fitness
facilities and exercise professionals who can provide support and guidance.
• Visit the EIM website at www.exerciseismedicine.org for the EIM Health Care Provider Action Guide.

Health care providers who are more active, are more likely to counsel patients regarding physical activity. It’s not enough to
“talk the talk,” you have to literally “walk the walk.” YOU will feel better and move better as well.

Copyright © 2019 Exercise is Medicine.

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EIM recommends that health care Southern California demonstrated that

providers refer patients to appropriate within the first year of implementation, Figure 1.
community resources to help them they were able to capture an EVS on 85% Kaiser Permanente exercise vital
integrate physical activity into their lives. of eligible patients.18 This compares sign (EVS).
These include programs, places, and favorably with the implementation of a
professionals (the 3 Ps) in their smoking status query (95%) recorded in
communities or self-directed resources an EHR.19
such as activity trackers, mobile phone At the same time, KP has made a big
apps, websites, bike share programs, and push to encourage physicians and staff
local parks. Each patient is likely at a to be role models of an active lifestyle
different stage of readiness to engage in for their patients. This started with their
exercise or physical activity and presents long running marketing campaign
with unique health and environmental called “Thrive.” The tag line for this
challenges, so customizing exercise or campaign is, “At Kaiser Permanente, we
physical activity recommendations is want you to live well, be well and
beneficial. Because most clinicians do thrive.”. This has been both an external
not have the time nor the expertise to and internal campaign and encourages
provide in-depth physical activity all KP employees to live the brand. In
counseling, they should begin to expand keeping with this message, internal
their reach of care by merging the health campaigns called “Thrive Across for KP to implement the EVS in their
care industry with the fitness industry. America” and “KP Walk” have EHR and clinical practices, and
The fitness industry must take steps to encouraged staff to join together to be Intermountain Healthcare launched the
clearly differentiate and support those more active and to get out and walk. PAVS in 2013 (Figures 1 and 2). Like
qualified fitness professionals who have At the same time, past KP Chairman body weight or blood pressure, the EVS
the education, certification, training, and and CEO George Halvorson launched a or PAVS is collected and recorded at
experience to work with referred patients campaign called “Every Body Walk!” every visit, providing an opportunity for
at various levels of risk or with common (www.everybodywalk.org) in January health care providers to discuss the
chronic medical conditions. 2011. This was a nonbranded campaign importance of physical activity in the
One of the early adopters of EIM was designed to get America walking that promotion of health and the prevention
Kaiser Permanente (KP). The Exercise eventually led the US Surgeon General and management of disease.
Vital Sign (EVS) was launched in Kaiser to issue a Call to Action to Promote Successful promotion of physical activity
Permanente’s Southern California Walking and Walkable Communities in health care settings not only starts with
region in October 2009 to routinely (https://www.cdc.gov/physicalactivity/ the PAVS but is also dependent on the
assess the exercise habits of patients at walking/). Featuring an interactive PAVS. The PAVS is a self-reported
all visits. Founded in 1945, KP is one of website at the hub of the campaign, it measure, asked by a medical or clinical
the nation’s largest health plans, contains numerous videos and articles assistant at the start of a clinical
serving almost 12 million members. As designed to inspire and inform patients encounter. It is recorded in the EHR for
a staff model health maintenance about how and why they should start the physician to review and interpret.
organization, KP members pay a walking. Based on the minutes per week and
monthly premium and receive all of intensity of physical activity reported, the
their health care from KP physicians physician can provide advice to start,
Physical Activity Vital Sign
and staff at KP facilities. Therefore, KP increase, maintain, or modify current
has a tremendous incentive to invest in Drs Steve Blair and Tim Church, physical activity levels, provide a
disease prevention and keep patients recommended in their JAMA publication personalized physical activity prescription,
healthy, thereby avoiding the costs in 2002 that the recommended and refer the patient to a fitness
associated with caring for more accumulation of 30 minutes of moderate- professional for education, coaching, and
advanced medical conditions. For this intensity physical activity at least 5 days support. The PAVS serves as a prompt for
reason, helping patients become more a week as weight be addressed in some health care providers to address physical
physically active is a key priority in the manner at nearly every physician visit, activity during clinical encounters.
organization’s quest to help patients just as weight is.20 These forward- Whether that visit is for diabetes, high
achieve total health. thinking scientists also stated that the blood pressure, low back pain, mental
The EVS has been a tremendous “medical community needs to lead in illness, or a physical examination,
success at KP and has spread to virtually communicating the importance of knowing that person’s physical activity
all Kaiser territorial regions. A study of physical activity for health and weight level, and providing counseling, is a key
2.1 million adult patients from KP in maintenance.” However, it took 7 years strategy to improving health.21

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Figure 2.
Intermountain Healthcare physical activity vital sign.

often overlooked. Even brief physical environmental, safety, or financial issues.

What Can Busy
activity counseling can take 3 to 5 Despite these perceived barriers,
Physicians Do to
minutes, and is typically not feasible, physicians need to be encouraged to
Encourage Physical
let alone reimbursable. think creatively to find ways to connect
Activity?
Additionally, physicians often lack these patients with the appropriate
Despite the overwhelming evidence confidence in their abilities to prescribe means to be physically active within the
supporting the fact that physical activity exercise as most have not had any formal constraints of their situation. Frequently,
is an essential element in both the education related to physical activity in local malls can provide safe areas to
prevention and management of medical school. In 2015, Cardinal et al25 walk. Schools will share their facilities
numerous medical conditions, physicians studied curricula of 170 allopathic and before school, after school, and on the
typically have a poor track record when osteopathic medical schools and found weekends, and many community
it comes to promoting physical activity that only 21.2% had one course related programs exist that offer opportunities to
with their patients. In 2009, Katz et al22 to physical activity available for their be active in ways that resonate with a
highlighted that only 45% of patients medical students and only 12.2% had a patient group. Having preprinted lists of
admitted for chest pain received required course. Typically, these courses no cost and low-cost community
counseling on physical activity. Overall, focused on exercise physiology or sports resources available can make physician
physicians insufficiently use physical medicine with only 8.1% and 4.7% referrals to these programs a seamless
activity as either a treatment modality or educating on preventive or lifestyle process in the midst of a busy day. EIM
preventative tool in the care of their medicine, respectively.25 offers a Physical Activity Resources
patients. The National Health Interview A recognized area of weakness in template that can be customized for a
Study found that only 32% of patients medical training, newer schools are given practice or community (www.
receive advice from their physician or embracing the concept of teaching exerciseismedicine.org).
other health care professional to exercise medical students about maintaining their Several proposed approaches exist in
or continue being physically active own well-being through physical activity, terms of creating time to discuss physical
during their visit with a physician.23 nutrition, and stress management. By activity in the context of a busy clinical
The most commonly cited reason that training young medical professionals in practice. A physician or other health care
physicians list for not including physical these concepts early in their careers, the provider does not need to commit an
activity counseling in their practice is a hope is that future generations of entire visit to counseling on physical
lack of time.24 With many competing physicians will be more likely to apply activity, but rather can tailor the amount
demands forced upon today’s physicians, these concepts to the care of their of time to what is available in the
as well as the fact that most physicians patients.26 situation (Figure 3). Alternatively, busy
work in a productivity-based health care Another potential barrier to addressing physicians can enlist the help of their
model that rewards physicians for seeing physical activity is the physician’s staff to do the bulk of the heavy lifting
more patients, the utilization of any perception of patient resistance to when it comes to exercise counseling. A
behavioral counseling in a practice is physical activity based on cultural, brief acknowledgement of a patient’s

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 American Journal of Lifestyle Medicine Sep • Oct 2020

Figure 3.
Making time to counsel on physical activity.

Sports Medicine departments can offer fitness and physical activity in health care
Figure 4. exercise prescription counseling that is within individual health care systems.
Kaiser Permanente Rx pad. covered by insurance provided that the Numerous success stories exist on how
patient has one or more chronic medical systems that include fitness and physical
conditions that can be used as their activity as part of their approach see
billing diagnosis. Patients are typically improved health care measures in
scheduled for visits billed for by time, addition to decreased health care costs.
and the visit is often a combined visit Nguyen et al27 performed a 2-year study
between the Sports Medicine physician that demonstrated a reduction in health
and an Exercise Physiologist who can care utilization and spending using a
review prescribed exercises with the health-plan sponsored health club
patient. Another option is to collaborate membership in older adults with diabetes.
with those in the community such as Examples of larger scale initiatives include
personal trainers, nurse educators, the KP, Intermountain Healthcare, and
dietitians, and exercise scientists. Prisma Health (formerly Greenville Health
System and Palmetto Health) initiatives
that have integrated the use of the PAVS
Integrating Fitness
within their systems to have physical
Into Health Care
activity be at the forefront of all medical
Integrating fitness into health care on a encounters. These systems have provided
large scale has been a challenge in most valuable insights for others in terms of
current activity level followed by having US health systems. Currently, traditional successful implementation strategies,
a nurse or medical assistant review ways US medical systems have operated on a methods to engage providers, and
to begin the process of becoming active fee-for-service model of health care with marketing the concept to patients.28
still can be extremely impactful in the little to no incentive to promote fitness At the individual practice level,
lives of patients. Physicians can also and physical activity to improve health physicians should begin by using the
make use of the prescription pad/form to and manage or prevent chronic illness. PAVS as a first step in championing the
promote physical activity (Figure 4). As the system shifts to pay for value process for their own health systems. By
Medical providers should also consider with a focus on population health, there role modeling the concept, physicians
partnering with those in their health will hopefully be both a shift for can build traction in establishing the
system and/or communities who have a increased administrative support to routine measurement of PAVS as the
passion for and expertise in physical incorporate physical activity and fitness standard of care for all health care
activity counseling. A Primary Care in ways that those in lifestyle and sports providers. In addition, the routine use of
Sports Medicine physician is often the medicine would desire. the PAVS results in higher levels of
best option in a medical group based on Until such time where fitness is fully exercise counseling documentation and
their training and their belief in integrated into the US health care model, more exercise referrals being placed for
promoting exercise for patients. Many it is necessary to champion the role of patients.26 Health care providers should

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Figure 5.
Health care providers referral mechanism.

also utilize the many free resources that lists options for patients, physicians support but should consider the
available within the EIM website that owe it to their patients to have these integration of health care into health
includes patient handouts on exercise resources available. By taking the time to fitness by adopting the EIM model.
with a variety of chronic medical start physical activity counseling with A second challenge is for fitness
conditions as well as information on the patients, the physician is acknowledging professionals to consider changing their
exercise prescription itself (www. their belief in the importance of physical focus from clients to patients, from “abs
exerciseismedicine.org). activity on health. Going the extra step to and buns” to “hearts and lungs.” This
provide ways to implement the change in emphasis from routine
suggestions and/or receive additional personal training or group training will
Creating Meaningful
counseling on how to start an exercise require the fitness professional to learn
Communication and
program demonstrates that they are ready new skills and have knowledge of
Seamless Referrals
and willing to be part of the process. chronic diseases and how to develop the
Between Health Care
right exercise program for this client
Professionals and Health
(patient) population. Together, the health
Fitness Professionals A Challenge to the Health
care industry and the health fitness
Club and Fitness Industry
As physicians begin the process of industry should merge into a single and
discussing physical activity in their Traditionally, the focus of health club seamless referral system. Health care
practices, it is essential that they also membership has been the 25- to 35-year- providers can choose to provide patients
establish ties with fitness professionals in old demographic with little attention paid with self-directed physical activity
their community in order to provide to potential members who may have or programs (like walking, biking, and
patients with resources to continue that are recovering from a chronic illness or swimming) or they can choose to send
important conversation and implement medical condition. In fact, many their patients to physical activity
exercise recommendations or commercial clubs turn away potential intervention programs delivered at
prescriptions. It is rarely possible for the members if they reveal on medical recognized clubs by credentialed fitness
busy clinician to outline an entire program histories heart attacks, strokes, pulmonary professionals (Figure 5).
with their patients, nor should they feel disease, or diabetes. Commercial clubs
obligated to do so. Rather, they should (for-profits) seem to have locked into
Fitness Professional
look to those fitness professionals in their young and healthy members while
Credential Verification
communities who can take the lead on seemingly ignoring a growing population
and Locator Services
implementing physical activity strategies. of baby boomers who may have a
Whether that be through direct referrals to chronic medical condition. Clubs should In 2008, national certification agencies
specific providers or a preprinted handout not ignore their base of membership that are accredited by the National

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 American Journal of Lifestyle Medicine Sep • Oct 2020

Commission for Certifying Agencies Medicine Greenville), health care system management, goal setting, and social
(NCCA; https://www. (Prisma Health), and community support.
credentialingexcellence.org/ncca) organization (YMCA of Greenville) that Because of the partnership with the
organized the Coalition for the combines resources to educate YMCA of Greenville, no patient is turned
Registration of Exercise Professionals physicians on the clinical benefits of away for inability to pay for the program;
(CREP), which developed for the first exercise. The physicians connect patients in-need patients are provided
time the United States Registry of via identification, prescription, and scholarships to attend the program as
Exercise Professionals (USREPS; http:// referral from the health system to the well as to continue membership at the
www.usreps.org/). USREPS is a community for an evidence-based same rate on graduation. The
searchable database that physicians and clinical exercise-centered lifestyle overarching goal is to help patients begin
health care providers can use to identify program to improve outcomes for those to meet the national physical activity
certified fitness professionals in their experiencing or at-risk for chronic guidelines of 150 minutes of moderate-
communities. The database can also be diseases. The program was designed intensity exercise per week and 2+ days
used to verify employees’ certification based on a Population Health per week of strength training, as well as
and determine the international Management model to address multiple to create health behavior change for a
portability of certifications. The registry is levels across the Socio-Ecological Model more physically-active lifestyle and
searchable by name, credential, using the 3 stakeholders’ input. increase patient self-efficacy to
credential number, certification Physicians and other qualified health independently exercise at graduation
organization, name, city, state, and even care providers (NP, PA) work with an from the program.
zip code. With over 250 fitness-related interdisciplinary team (such as RNs, RDs, The EIMG experience begins at the
certifications varying in training, ranging and diabetes educators) to refer patients clinic visit with Prisma Health providers
from a credential purchased on the to EIMG where patients then undertake a using the EHR to capture the patient’s
internet to sitting for a written and supervised 12-week clinical exercise and EVS. Once the EVS is obtained,
practical examination, USREPS provides health behavior change intervention in physicians inform qualified patients
verification of certifications that are two 1-hour sessions per week with (ambulatory patients who lack 150
accredited by the NCCA, which holds qualified, credentialed EIMG minutes per week of moderate intensity
high standards for certification professionals (EIMG Pros) in an easily physical activity, and/or have or are at
organizations. accessible community-based setting. risk for one or more of the chronic
A much smaller database and one that The EIMG program was created as an conditions of T2DM, hypertension,
includes ACSM Certified Personal Trainer evidence-based, flexible, and adaptive dyslipidemia, and obesity) about EIMG.
(ACSM-CPT), ACSM Certified Exercise rolling enrollment, community-based Providers then review any risks, provide
Physiologist (ACSM-EP), Certified Clinical clinical exercise program guided by health education, electronically approve
Exercise Physiologist (ACSM-CEP), and social-cognitive theory, with 2 focused the EIMG order set, and refer the
ACSM Certified Group Exercise Instructor clinical exercise modules serving Prisma consenting patient to the EIMG Referral
(ACSM-GEI) is the ACSM ProFinder Health patients with (1) cardiometabolic Coordinator and EIMG RN Care
(https://www.acsm.org/get-stay-certified/ diagnoses or (2) musculoskeletal/pain Coordinator team (Figure 6). The
find-a-pro). The ACSM ProFinder is a problems. The rolling enrollment features Coordinator of the team contacts the
database searchable by name, allow patients to onboard in less than 10 patient, confirms eligibility and interest,
certification level, city, state, country, and business days (maximizing readiness), reviews the patient’s preferred location
zip code. The advantage of the ACSM and new patients can learn from more and ability to pay (or qualify for a
ProFinder over USREPS is the ability to established patients who have been scholarship), and then electronically
contact the fitness professional by using participating in the program. At every sends all pertinent information to the
a unique e-mail address. session, patients are also provided 1 of community fitness center site
24 EIMG Patient Education Handouts to coordinator, where the patient is
provide active health learning during the scheduled for onboarding. The loop of
The Exercise Is Medicine
EIMG class sessions. The patient communication is closed back to the
Greenville Experience
education handouts increase the patient’s referring provider through the EHR upon
One example of a multilevel understanding about the importance of patient graduation from the program or
partnership working to ameliorate the exercise and physical activity in chronic if the patient decides to not continue.
detrimental effects of physical inactivity disease prevention and management, Once patients are onboarded, the
at the patient and population health level and to assist the patient in applying that intervention is executed by the EIMG Pros
is Exercise is Medicine Greenville (EIMG) knowledge to encourage behavior in either Prisma’s medical fitness center
located in Greenville, SC. EIMG is the change. A variety of topics cover (“Life Center”) or 1 of 5 Greenville-based
first partnership across a medical school components of exercise and physical YMCAs. All EIMG Pros are required to
(University of South Carolina School of activity, diet and nutrition, stress have a bachelor’s degree or higher in

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2. EIMG staff procedures components of the program (health care

Figure 6. 3. EIMG program documents, and provider, project coordinator, and EIMG
Exercise is Medicine Greenville REDCap guide Pro) using a Likert-type scale (low = 1;
clinical workflow process. 4. Patient and EIMG Pro related high = 5) as highly satisfactory (4.56).
resources
5. EIMG Patient Education Handouts
EIM International
6. EIM Prescription for Health Series
Not long after EIM was launched in the
Continuing education at least once per United States, interest was expressed by
year is required for all EIMG Pros as a individuals from countries also facing an
means for improving program epidemic of physical-inactivity related
implementation. To accomplish this, diseases. There are currently EIM
EIMG hosts 2 EIMG Pro Training National Centers in 37 countries on 6
Workshops every year (Spring and Fall) continents (North America, South
to present various topics such as America, Asia, Europe, Africa, and
procedural review, operational updates, Australia), with 3 EIM Regional Centers
and clinical exercise physiology in Asia, Latin America, and Europe. An
exercise science or related field, possess a instruction. EIM Global Launch Guide (https://
minimum of a personal training An EIMG Advisory Board, composed of exerciseismedicine.org/) helps countries
certification (from a national certification stakeholders from participating partners, form a leadership team composed of an
organization that is accredited by the meets monthly to provide oversight of interdisciplinary group of stakeholders.
NCCA), and undergo the national ACSM the program for regular review and The EIM Global Network facilitates
EIM credentialing process (Level 2; http:// revisions. The EIMG Policies and communication, learning, and
www.acsm.org/get-stay-certified/ Procedures provide direction, guidelines, collaboration among colleagues around
get-certified/specialization/eim-credential). and boundaries for implementing the the world. Because the governmental,
For additional quality assurance in EIMG program and ensuring compliance academic, health care, and cultural
working with a clinical population, EIMG with the rules and regulations of the landscapes are different within each
Pros must then complete the following program for all parties involved. The country, EIM National Center Advisory
before they can begin actively teaching manual guides all major decisions and Boards establish goals and strategic
EIMG class sessions: actions for ethical execution and initiatives to guide efforts within their
operations of program principles as countries.
1. The EIMG Pro staff training webinars applied to working with clinical For example, EIM Singapore has taken
to orient EIMG Pros to the program populations. All EIMG staff are required a systematic approach to integrating EIM
design, implementing the program, to review the policies and procedures into disease management pathways.
and understand the policies, and sign an acknowledgement form They have designed a template and
procedures, and expectations prior to commencing work within the progressively incorporated the PAVS into
2. HIPAA and social media online EIMG program, and specifically with electronic case notes in various clinical
courses EIMG patients. departments at Changi General
3. National Institutes of Health The EIMG program is currently Hospital—with full adoption expected in
Protecting Human Subjects Research implemented across 18 clinics of 2020. They then plan to roll it out to the
online course to ensure the EIMG different departments of Prisma Health other 3 hospitals of the SingHealth
Pros understand ethical and safe Family Medicine, Internal Medicine, and Cluster. EIM Singapore is working with
practices for working with clinical in specialty clinics such as Oncology, specialties such as family medicine,
patients Bariatrics, Endocrinology, and Prisma’s cardiology, rehabilitation medicine,
4. REDCap data collection training for Diabetes Prevention Program. Graduation oncology, and obstetrics and gynecology
research rate is over 60% with currently over 170 to incorporate exercise interventions into
graduates. A small but statistically their respective disease management
An EIMG Fitness Professional Training significant improvement in body weight pathways. A mainstay of EIM Singapore’s
Manual, available to the EIMG Pro, has been observed after graduation, with mission is to train physicians in exercise
consists of all content included in the a strong and statistically significant prescription. They are also training
EIMG Pro Staff Training webinars, in improvement in both systolic and community health counsellors called
addition to the following: diastolic blood pressures observed in Health Peers (lay persons trained to
patients who onboarded due to a coach peers to adopt a healthy lifestyle)
1. The EIMG referral process and hypertension diagnosis. Patient graduates in prescribing exercise and working with
operational workflow who complete exit surveys score all community partners such as the Health

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 American Journal of Lifestyle Medicine Sep • Oct 2020

Promotion Board, Sport Singapore, and fitness professionals, and even patients shtml#part_155029. Accessed December 4,
religious organizations to promote to get started. At a minimum, all health 2019.
physical activity. care encounters should include the PAVS, 3. Schuch FP, Vancampfort D, Firth J, et al.
In Poland, the EIM National Center regardless of specialty. Physicians are Physical activity and incident depression: a
meta-analysis of prospective cohort studies.
team has been working with the Polish trusted and respected professionals, and Am J Psychiatry. 2018;175:631-648.
Ministry of Health, the Ministry of Sport, a recommendation to be more active,
4. Centers for Disease Control and Prevention.
and the National Institute of Public accompanied by a prescription and National Diabetes Statistics Report, 2017.
Health to incorporate physical activity referral to a fitness professional has been Atlanta, GA: Centers for Disease Control
into health care systems. They are demonstrated to improve physical and Prevention, US Department of Health
educating medical students and fitness activity and health. A merger of health and Human Services; 2017.
professionals during annual conferences, care and fitness programs in 5. American Diabetes Association. Economic
lectures, and workshops, and have communities around the world is no costs of diabetes in the US in 2017.
Diabetes Care. 2018;41:917-928.
started 2 community-based projects, longer an option. Exercise is Medicine
“Walk for Health—Invite Your Doctor” that all patients need to take. 6. Manini TM. Using physical activity to gain
the most public health bang for the buck.
and “Active Family,” obtaining significant JAMA Intern Med. 2015;175:968-969.
media coverage for EIM. Authors’ Note 7. Blair SN. Physical inactivity: the biggest
EIM Latin America has focused efforts public health problem of the 21st century.
on educating medical students as well as This article is the result of a keynote presentation of Dr Walt
Thompson at Lifestyle Medicine 2019 held at the Rosen Br J Sports Med. 2009;43:1-2.
offering EIM workshops for health care Shingle Creek Resort, Orlando, Florida, on October 30, 2019. 8. Lee IM, Shiroma EJ, Lobelo F, Puska P,
providers and exercise professionals. Blair SN, Katzmarzyk PT; Lancet Physical
Chile has introduced an EIM Online Activity Series Working Group. Effects
Course as part of the Education Centre of Declaration of of physical inactivity on major non-
the Faculty of Medicine at the University Conflicting Interests communicable diseases worldwide: an
analysis of burden of disease and life
of Chile, one of the most recognized The author(s) declared no potential conflicts of interest with expectancy. Lancet. 2012;380:219-229.
universities in the country, reaching respect to the research, authorship, and/or publication of this
article. 9. Office of Disease Prevention and Health
hundreds of medical students and health Promotion. 2018 Physical Activity
care providers at different hospitals and Guidelines Advisory Committee scientific
health care centers. In spite of political Funding report. https://health.gov/sites/default/
and social challenges in the region, most files/2019-09/PAG_Advisory_Committee_
The author(s) received no financial support for the research, Report.pdf. Accessed March 9, 2020.
EIM National Centers are working with authorship, and/or publication of this article.
private and public health systems to 10. Naci H, Ioannidis JP. Comparative
effectiveness of exercise and drug
integrate physical activity as a way to interventions on mortality outcomes: meta-
promote health and treat/control chronic Ethical Approval
epidemiological study. Br J Sports Med.
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forces to implement public policies and studies with human or animal subjects.
11. Lobelo F, Young DR, Sallis R, et al.
update national physical activity Routine assessment and promotion
recommendations to combat the of physical activity in healthcare
Informed Consent
significant increase in obesity in adults settings: a scientific Statement from the
Not applicable, because this article does not contain any American Heart Association. Circulation.
and children in Latin America. studies with human or animal subjects. 2018;137:e495-e522.
12. Sallis RE, Matuszak JM, Baggish AL, et al.
Summary Call to action on making physical activity
Trial Registration assessment and prescription a medical
The evidence on the cost and health standard of care. Curr Sports Med Rep.
Not applicable, because this article does not contain any
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