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U.S. Preventive Services Task Force: Recommendations for Physical Exercise in Primary Prevention
JAMA Vol 261,No.24
Publication date: 06/23/1989
Table of Contents
Recommendations for Physical Exercise in Primary PreventionQuality of Evidence Recommendation for Efficacy to Include Target Condition Effectiveness Intervention --------------------------------------------------------------------------- Coronary heart disease . Adult men Grade 11-2 A . Adult women Grade 11-2 C - Hypertension(all adults) Grade 11-2 A - Non-insulin-dependent diabetes mellitus(all adults) Grade III C - Osteoporosis - Prevention of bone loss . Post menopausal women Grade I A . Pre menopausal women Grade III C - Prevention of hip fracture . Postmenopausal women Grade III C - Obesity (all adults) Grade I A - Mental health (all adults) . Affect Grade I C . Self-esteem Grade I B ------------------------------------------------------------------------- Exercise electrocardiogram to identify individuals at risk for cardiac offset during physical activity Grade 11-2 D - Physical activity counseling by physicians as a primary preventive intervention to increase physical activity Grade 11-2 D levels --------------------------------------------------------------------------- Rules of Evidence The effectiveness of intervention was graded according to the quality of evidence obtained, as follows: I Evidence obtained from at least one properly randomized, controlled trial. II-1 Evidence obtained from well-designed controlled trials without randomization. II-2 Evidence obtained from well-designed cohort or case-controlled analytic studies, preferably from more than one center or research group. II-3 Evidence obtained from multiple time series studies with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin in the 1940s) could also be regarded as this type of evidence. III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Categories of Recommendations On the basis of these considerations, the US Preventive Services Task Force makes a clear recommendation for each condition as to whether it should be specifically considered in a periodic health examination. Recommendations are classified as follows: A There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. B There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. C There is poor evidence regarding the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. D There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. E There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
RecommendationAll patients should be counseled to engage in a program of regular physical activity tailored to their health status and personal life-style. All patients should be provided with information on the role of physical activity in disease prevention and assisted in selecting an appropriate type of exercise. Factors that should be considered in designing an appropriate exercise program include medical limitations and activity characteristics that improve health and enhance compliance. Instructions should be given on how to perform the exercise safely to reduce the risk of injuries. Beginners should emphasize regular rather than vigorous exercise, with the goal of engaging in an exercise like walking at least three times per week for at least 30 minutes at a brisk pace.
Current Burden of sufferingAbout 40% of the US adult population is estimated to be predominantly sedentary (1,2). Physical inactivity has been associated with a number of debilitating medical conditions in the United States, including coronary artery disease (CAD),hypertension, non-insulindependent diabetes mellitus, and osteoporosis. The leading cause of death in the United States is CAD, accounting for about 1.5 million myocardial infarctions and more than 520,000 deaths each year (3,4). Non-insulin- dependent diabetes mellitus, which affects about 6 million Americans, is an important risk factor for CAD, cerebrovascular disease, retinopathy, and hypertension (5). Osteoporosis is responsible for an estimated 1.3 million fractures each year (6) and more than $7 billion per year in direct and indirect costs (7).
Efficacy of Risk ReductionMen who are physically active on a regular basis have a lower overall mortality rate than those who are physically inactive (8,9). Exercise seems to be especially effective in improving health status in six disease-specific areas: CAD, hypertension, obesity, non-insulin- dependent diabetes mellitus, osteoporosis, and diminished psychological well-being. Physically inactive persons are twice as likely to develop CAD as are persons who engage in regular physical activity (10). No intervention trials have been done to show the role of physical activity in preventing CAD. A large body of epidemiologic evidence supports an association between physical activity and weight control, even after controlling for dietary factors (11). Cohort studies suggest that physically inactive persons have a 35% to 52% greater risk of developing hypertension than those who exercise; this effect seems to be independent of other risk factors for hypertension (12,13). Physical activity also is associated with increased insulin sensitivity and glucose clearance (14, 15). Weight-bearing physical activity also may reduce bone loss in postmenopausal women. A commonly mentioned benefit of regular exercise is improved affect (18,19).
Effectiveness of Exercise CounselingEvidence of the effectiveness of counseling to alter physical activity habits has many limitations. Most studies have been done in selected settings for selected populations and have evaluated only short- term compliance with exercise recommendations. The generalizability of these findings to general patient care populations is largely unknown. Noncompliance with physical activity programs is typically 50% after the first 6 months and is similar to that seen for other health-related behavioral interventions, such as smoking, substance abuse, and diet modification (20).
Clinical InterventionPhysicians are in a unique position to maximize patient compliance by influencing many of the important determinants of adopting and adhering to an exercise program. Counseling of presently inactive patients should emphasize the initiation of regular physical activity, such as brisk walking, over more strenuous and life-style-intrusive activities. The key counseling points are related to the regular pattern of exercise activity that can be maintained with minimal disruption of other aspects of life but that will yield the desired benefits.
Research NeedsThe following kinds of research are needed to adequately answer remaining questions pertaining to the efficacy and effectiveness of physical activity in the prevention of disease:
- Studies of the effects of physical activity on primary prevention of CAD in population subgroups, eg, women and the elderly.
- Research to evaluate the optimal type and level of physical activity in the prevention of non-insulin-dependent diabetes mellitus, osteoporotic fractures, and mental health.
- Research to evaluate the optimal type and level of physical activity with regard to prevention of specific medical conditions, particularly the role of low-intensity activity.
- Research on the risks of injury and adverse effects associated with the types of physical activity engaged in by most of the population (as opposed to organized or competitive sports).
- Research to evaluate the effectiveness of exercise counseling by physicians and strategies to optimize patient compliance.
- Research on the role of physical activity during childhood on childhood health status as well as subsequent disease prevention and health status during adulthood.
- Stephens T, Jacobs DR Jr, White CC. A descriptive epidemiology of leisure time physical activity. Public Health Rep. 1985; 100: 147-158.
- Caspersen CJ, Christenson GM, Pollard RA. Status of the 1990 physical fitness and exercise objectives: evidence from NHIS 1985. Public Health Rep. 1986;101:587-592.
- National Center for Health Statistics. Advance Report of Final Mortality Statistics, 1986. Hyattsville, Md: Public Health Service; 1988. Publication (PHS) 88-1120.
- 1989 Heart Facts. Dallas, Tex: American Heart Association; 1988.
- Current Estimates From the National Health Interview Survey, United States, 1982. Washington, DC: National Center for Health Statistics; 1985. Publication (PHS) 85-1578.
- Osteoporosis. JAMA. 1984;252:799-802. Consensus Conference.
- Holbrook TL. The Frequency of occurrence, Impact and Cost of selected Musculoskeletal Conditions in the United States. Chicago, Ill: American Academy of Orthopedic Surgeons; 1984.
- Paffenbarger RS Jr, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Enel J Med. 1986;314:605-613.
- Leon AS, Connett J, Jacobs DR,Rauramaa R. Leisure-time physical activity levels and risk of coronary heart disease and death: the Multiple Risk Factor Intervention Trial. JAMA. 1987;258:2388-2395.
- Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health. 1987;8:253-287.
- Epstein LH, Wing RR. Aerobic exercise and weight. Addict Behav. 1980;5:371-388.
- Paffenbarger RS Jr, Wing AL, Hyde RT, Jung DL. Physical activity and incidence of hypertension in college alumni. Am J Epidemiol. 1983;117:245-257.
- Blair SN, Goodyear NN, Gibbons LW, Cooper KH. Physical fitness and incidence of hypertension in healthy normotensive men and women. JAMA. 1984;252:487-490.
- King H, Taylor R, Zimmet P, et al. Non-insulin-dependent diabetes in a newly independent Pacific nation: the Republic of Kiribati. Diabetes Care. 1984;7:409-415.
- Zimmet P, Faaiuso S, Ainuu J, Whitehouse S, Milne B, DeBoer W. The prevalence of diabetes in the rural and urban Polynesian population of Western Samoa. Diabetes. 1981;30:45-51.
- Smith EL, Reddan W, Smith PE. Physical activity and calcium modalities for bone mineral increase in aged women.Med Sci Sports Exerc. 1981;13:60-64.
- Krolner B, Toft B, Pors Nielsen S, Tbndebold E. Physical exercise as prophylaxis against involutional vertebral bone loss: a controlled trial. Clin Sci. 1983;64:541-546.
- Stephens T. Physical activity and mental health in the United States and Canada: evidence from four population surveys. Prev Med. 1988; 17:35-47.
- Folkins CH, Sime WE. Physical fitness training and mental health. Am Psychol. 1981;36:373-389.
- Dishman RK. Compliance/adherence in health-related exercise. Health Psychol. 1982;1:237-267.
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