The evidence summarized in these guidelines and more extensively presented in the 1996 Surgeon General’s Report (US Department of Health and Human Services, 1996) attests to the value of exercise and physical activity in reducing the incidence of coronary heart disease. Indeed, the original American Heart Association (AHA) Statement on Exercise in 1992 (Fletcher et al., 1996) was among the first documents to conclude that physical inactivity is a major coronary artery disease (CAD) risk factor. Because atherosclerotic vascular disease remains the major cause of death in many countries, it is important that health-care providers support the implementation and maintenance of exercise programs for their patients across the lifespan.
Health professionals should personally engage in an active lifestyle to familiarize themselves with the issues involved in maintaining lifelong physical activity and to set a positive example for patients and the public. This may increase the likelihood that health-care providers will recommend physical activity to their patients. Health-care providers should use their influence as parents and community members to encourage schools to provide physical education programs that teach the importance of, and the skills necessary for, developing and maintaining physically active lifestyles. There is growing recognition of the contribution of social support and the value of integrating behavioral changes into daily routines to sustain improvements in physical activity levels. For this reason, health-care providers should advocate changes in organizational practices within work sites and civic and recreational settings that encourage active living. Health professionals should also encourage their communities to make facilities for physical activity available to the public and to engineer environments conducive to safe physical activity. Such environmental engineering efforts should allow purposeful physical activities, such as walking to work and climbing stairs, to be used in lieu of labor-saving devices. Health professionals should support public health efforts that encourage these active lifestyles.
The importance of physical activity for health and the use of exercise training in managing selected disease states should be incorporated into the education of physicians and other medical professionals. A physical activity history is an important component of the health history, and health-care providers should include the patient’s habitual physical activity as part of the medical record. Health-care providers should identify for patients the importance of physical activity as primary or adjunctive therapy for such medical conditions as hypertension, hypertriglyceridemia, glucose intolerance, and obesity.
Health professionals should prescribe physical activity programs commensurate with those recommended by the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) (i.e., 30 minutes or more of moderate-intensity physical activity such as brisk walking on most, and preferably all, days of the week) (Pate et al., 1995). Patients should be encouraged to engage in a variety of physical activities and to progressively increase their activity as tolerated. Detailed guidelines for prescribing exercise in patients with and without cardiovascular disease are provided in the AHA Exercise Standards for Testing and Training (Fletcher et al., 2001). Recommendations are also available for the incorporation of resistance and flexibility exercise training (Pollock et al., 2000). Health-care professionals should provide an exercise prescription to patients and should familiarize themselves with behavioral change material available from the Provider-Based Assessment and Counseling for Exercise Program (PACE) (Calfas et al., 1996) and the Activity Counseling Trial (ACT) (King et al., 1998).
It is not necessary that all individuals beginning a moderate-intensity and moderately progressive exercise program undergo an exercise stress test, although this issue remains controversial. A Consensus Group from the AHA and the American College of Cardiology (Gibbons et al., 1997) considered routine exercise stress testing before the initiation of a vigorous exercise program in healthy men >45 and women >55 years of age as a Class IIb Recommendation (i.e., a condition in which the usefulness and efficacy is not well established). Selected exercise testing should be performed at the discretion of the physician before vigorous exercise in patients with known cardiovascular problems.
Health-care providers caring for patients with diagnosed cardiovascular disease should support the development of exercise programs to manage these patients and make appropriate referrals for treatment. There are also effective strategies to promote active lifestyles for whole communities that complement those designed for individuals. The Task Force on Community Preventive Services has completed an evidence-based review of these community strategies ("Increasing physical activity," 2001). The 6 strategies deemed effective were: (1) large-scale, intense, highly visible, community-wide campaigns; (2) point-of-decision prompts that encourage people to use the stairs instead of elevators or escalators; (3) physical education programs in schools; (4) social support programs (such as buddy systems and walking groups); (5) individually adapted behavior change programs; and (6) enhanced access to places for physical activity. For example, 12 studies have studied increasing access to places for physical activity, with a median effect size of a 26% increase in persons exercising at least 3 days per week.
