Physical Activity Implementation Guide
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Physical Activity Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of and changes regularly. See the Directory of published versions

Importance of Physical Activity

Page standards status: Informative

For many readers, the notion that physical activity is important to healthcare outcomes, and that prescribing increased physical activity will improve healthcare outcomes may be taken as a given. However, for those who are interested in some of the supporting research (perhaps to help make the case for implementing this implementation guide in their own organization), this page provides more detail about existing evidence, complete with citations.

NOTE: These references are largely U.S.-centric, however the conclusions are generally applicable to other countries, though the statistics may differ somewhat.

Physical Activity and Health

Being regularly physically active is one of the most important health behaviors people can engage in to maintain physical health, mental health, and well-being.1 Regular physical activity (PA) is both health-promoting and important for disease treatment and prevention with numerous benefits that contribute to a disability-free lifespan.2 New research shows that more than 110,000 lives could be saved annually if adults in the U.S. increased their PA by just ten minutes per day.3 However, to achieve this, policy makers and change leaders need to implement broad-reaching, evidence-based, equity-focused strategies (including policy and systems changes), increasing access to community spaces and infrastructure for PA , and inclusion of PA assessment, prescription, and referral into electronic health records and health care delivery for optimal patient care in the US.4 To further promote equitable access to the benefits of regular PA, policy and systems changes should address barriers like cost, access, time, and accessibility.4

PA reduces the risk of several of the leading causes of death and disability, including cardiovascular disease and colon, breast, and endometrial cancers.4, 5 PA is also important for improving outcomes for the approximately 2/3 of Americans who have a chronic condition. For example, PA improves survival from breast cancer6 and several aspects of quality of life for a broader range of cancers.7 Despite the many benefits of PA, we know that youth PA decreased during the COVID-19 pandemic.8 The overall prevalence of physical inactivity among adults in our nation is alarmingly high (25.3 percent), and significant disparities exist among race/ethnic groups (e.g., non-Hispanic Asian adults, 20.1 percent; non-Hispanic White, 23.0 percent; non-Hispanic American Indian/Alaska Native, 29.1 percent; non-Hispanic Black, 30.0 percent; and Hispanic adults, 32.1 percent).9

A woman holding an exercise ball being coached by a man

A systematic literature review indicated that physically active adults when diagnosed with COVID-19 have decreased risk of severe clinical outcomes.10 Other studies show that PA is associated with strong immune response, risk reduction from community-acquired infectious disease and mortality, and increased vaccine potency.11, 12, 13,14

During the pandemic, the U.S. saw anxiety increase 4-5 times and depression increased 2-5 times pre-pandemic monthly averages.15 An umbrella review of 97 systematic reviews and meta-analyses concluded that PA should be part of standard care for anxiety, depression, and psychological distress as it is highly beneficial for improving symptoms for all adults, including those with pre-existing mental health disorders and those with chronic disease.16 Regular PA also contributes to social connectedness, quality of life, and environmental sustainability.17 Currently in the U.S., only 26 percent of men, 19 percent of women, and 20 percent of adolescents report sufficient activity to meet the relevant guidelines for aerobic and muscle-strengthening activities.1 Even so, current population PA levels avert 3.9 million premature deaths globally and 140,200 premature deaths in the U.S. on an annual basis.18

If all Americans met current PA guidelines, Medicare could save $73.9 billion per year.19 In one study of older adults including over 50,000 patients, total average healthcare expenses were significantly reduced by 16% for fitness program participants compared to non-participating Medicare Advantage members.20 The study's findings showed total annual average health expenses, including medical and pharmacy, among program participants to be $4,463 compared to $5,303 for non-participants. The medical component of costs was decreased by 26%, driven primarily by reductions in hospitalization costs. Use of outpatient care was higher for participants combined with less acute care, indicating better health management among participants compared to non-participants. Participants also performed significantly better on key quality measures including all-cause 30-day readmissions, adherence to hypertension and cholesterol medications, diabetes care (HbA1c testing and eye exams), and many preventive screening measures including colonoscopy, depression, cholesterol, breast cancer, and prostate cancer screening when compared to non-participants.20

Low PA and low fitness pose immediate and long-term threats to our nation’s safety and security. At this time, 71 percent of Americans ages 17-24 fail to meet core eligibility requirements for entrance into the military, creating a serious recruiting deficit.21 Among those who do meet basic requirements for service, musculoskeletal injuries associated with low fitness levels have costed the Department of Defense hundreds of millions of dollars,22 and have been identified as the most significant medical impediment to military readiness.23

Importance of Measuring Physical Activity

Despite the abundance of evidence on the importance of PA for individuals of all ages, races and abilities,1 our current healthcare system lacks a set of standardized measures for PA that can be incorporated into electronic medical/health records and easily utilized by clinicians.2 As a result, millions of Americans lack appropriate counseling and prescription for active living that would prevent or manage most of the chronic diseases and their associated risk factors, some infectious diseases, and improve mental health and well-being.

Improving population levels of PA requires comprehensive efforts to maximize the potential benefits of setting-specific interventions under a coordinated multilevel approach across the healthcare system and community and home-based resources.24, 25 Numerous guidelines and recommendations, including the Physical Activity Guidelines for Americans,1 the US Preventive Services Task Force,26 the Healthy People 2030 Framework,27 the US National Physical Activity Plan,28 and the World Health Organization Guidelines on Physical Activity28 promote the importance of PA assessment, prescription, and referral as a standard of care in clinical practice.

In response to common barriers to effectively deliver complex PA counseling solely in clinical settings, programs have integrated referral of patients to community-based PA resources and programs.25 These exercise referral schemes have also shown effectiveness.30, 31 Compared with usual care, more patients who received referrals for exercise by their primary care providers achieved PA recommendations (relative risk, 1.16), and experienced reduced depression.31 Heath and colleagues32 examined the feasibility of a clinic-based Physical Activity Vital Sign (PAVS) assessment and referral protocol to YMCA exercise programming compared with PAVS alone in a sample of adult patients seen for primary care visits in a southeastern US health system. They found improvements in self-reported PA after 12 weeks in the PAVS plus referral group (P<0.02).32 The specific exercise vital sign measure proposed for this implementation guide has been tested and found to correctly identify the majority of adults and children/adolescents (5-18 years) who do and do not meet PA guidelines.33,34 Other meta-analyses and systematic reviews have shown that physician counseling (odds ratio, 1.42; 95% confidence interval, 1.17–1.73) and exercise referral systems (risk ratio, 1.20; 95% confidence interval, 1.06–1.35) promote improvements in patients’ PA for up to 12 months.31, 35, 36

People of varying age in a fitness room holding a yoga pose