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ACSM'S Health & Fitness Journal:
doi: 10.1249/FIT.0b013e3181aae059

Expanding the Process of Lifestyle Modification: From Physician to Exercise Physiologist

deJong, Adam M.A., FACSM

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Adam deJong, M.A., FACSM, is the assistant director of Preventive Cardiology and Rehabilitation at William Beaumont Hospital in Royal Oak, MI. He is also a faculty lecturer in the School of Health Sciences at Oakland University in Rochester, MI. He earned his Bachelor of Applied Arts and Master of Art degrees in Exercise Science from Central Michigan University. He currently serves on the American College of Sports Medicine's Committee on Certification and Registry Boards as chair for the Continuing Professional Education and International Certification subcommittees.

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Recent advances in technology, medicine, preventive strategies, and rehabilitation have resulted in a reduction of deaths from cardiovascular disease (CVD) in both men and women (7). Although focus has been on technological advances and the increased use of pharmacotherapy during the past decade as the major contributors to the decline in CVD-related deaths, the incorporation of exercise and lifestyle activity into contemporary medical treatment plans also has played a significant role in the progress seen to date. These efforts include a multifactorial approach, which includes a comprehensive lifestyle modification program and exercise intervention. Despite the identified benefits of lifestyle modification and physical activity, most Americans continue to lead a sedentary lifestyle (1).

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During the past 25 years, lifestyle interventions, when incorporated with and without concomitant pharmacological therapy, have shown significant benefits in the prevention and treatment of CVD. Furthermore, various clinical trials have validated the use of intensive lifestyle modification to control CVD risk factors. One such trial was the Lifestyle Heart Trial (13), which used comprehensive lifestyle modification aimed at improving cardiorespiratory fitness, reducing cholesterol levels, and smoking cessation. This trial demonstrated a reduction in coronary artery stenosis using intensive lifestyle intervention at 1 year and 5 years (13,14). In addition, in a study of dietary intervention and exercise training in men with chronic stable angina, the Heidelberg Trial showed long-term improvements in multiple risk factors, including an improvement in stress-induced myocardial ischemia (12,17). In addition, in one of the more recent lifestyle management trials(Leipzig Trial), the effectiveness of exercise training was compared with percutaneous coronary intervention (PCI) (8). In this trial, exercise training of only 20 minutes per day for a 12-month period demonstrated a higher event-free survival when compared with PCI and was associated with a higher exercise capacity and maximal oxygen uptake at half of the cost of PCI (8). These clinical trials strongly support the need to incorporate a comprehensive lifestyle modification program into primary and secondary prevention, yet the mechanism by which to accomplish this throughout the population remains unclear.

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The need for preventive education is well established, and through contact with millions of patients each year, physicians and other health care providers have a unique opportunity to favorably impact public health by improving diets, prescribing regular exercise, and increasing daily physical activity. Although some physicians have embraced exercise in the prevention and treatment of clinical conditions and chronic health problems (9), many continue to cite barriers to their ability to perform comprehensive risk reduction education and assessment (see Table) and often fail to discuss cardiovascular disease prevention strategies with their patients. In fact, 40% of internal medicine physicians reported assessing physical activity in patients, but only 25% reported actually writing activity plans. This participation dropped even further among nurse practitioners, who assessed physical activity and wrote exercise activity plans in only 30% and 14% of their patients, respectively (4,11). In addition, 50% of adults do not receive counseling on physical activity and exercise that is adequate to serve as an intervention or treatment for their cardiovascular disease risk (3,15). This is truly an opportunity missed and highlights the need to intensify efforts at identifying strategies to address cardiovascular risk factors.

TABLE Barriers for P...
TABLE Barriers for P...
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With the inability or unwillingness of physicians to adequately counsel their patients on physical activity in the primary care setting, additional mechanisms need to be identified to address lifestyle intervention and disease management. In fact, the U.S. Preventive Services Task Force identified a need for a multifaceted intervention strategy combining provider advice with behavioral interventions to facilitate and reinforce physical activity(18). Furthermore, such interventions include goal setting, written exercise prescriptions, individualized exercise interventions, and follow-up by specially trained professionals (6). Through these recommendations, an increased role for allied health professionals has been identified to assist physicians with disease prevention and treatment strategies. The clinical exercise physiologist is well suited for such a role, particularly in those patients with a history, or at increased risk, of CVD.

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Traditionally, clinical exercise physiologists have been viewed as personal trainers or cardiopulmonary specialists (5). However, the role of the clinical exercise physiologists has expanded to include employment in many settings, including medical fitness centers, cardiac and/or pulmonary rehabilitation centers, and physical therapy clinics, which may include working with individuals with various chronic diseases and debilitating medical conditions (5). As clinical exercise physiologists are required to have exceptional knowledge of acute and chronic responses and adaptations to exercise in healthy and unhealthy individuals, they are able to use exercise testing and training to evaluate and manage lifestyle changes in a broad spectrum of patients. In addition, time limitations placed on physicians and cost-containment initiatives have reduced the amount of education and lifestyle management provided by physicians, instead placing this responsibility on specially trained health care professionals (5).

Ideally, the clinical exercise physiologist will work within a team of health professionals, including physicians, to reinforce healthy behaviors and track progress of the exercise program. These professionals can then assist the physician through the design and implementation of exercise programs and provide outcomes relative to progress in modifying CVD risk factors. As the medical community begins to accept and incorporate the evidence that lifestyle modification is appropriate for the prevention and treatment of many disease states, the role of the clinical exercise physiologist will continue to expand. Their collective knowledge, skills, and abilities allow them to adequately assist physicians in the diagnostic and functional evaluation, education, and behavior modification of their patients (5). In addition, through the use of proven behavioral interventions, such as the social learning theory and the stages-of-change models (1,2,10,16,19), exercise physiologists can identify the potential benefit to be derived from the risk-reduction services. Although the health care community needs to increasingly facilitate lifestyle modification, current practice suggests an inability for physicians to accomplish this without additional support. Thus, a comprehensive education program must include a diverse group of professionals to address the disease risk factors and sedentary lifestyles. This comprehensive team, through a distinct plan and communication, can work together to address the individualized needs of the patient to be successful in a comprehensive lifestyle modification program.

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With exercise and lifestyle intervention identified as an important component in the prevention and treatment of CVD risk factors, future emphasis needs to be placed on developing a mechanism by which physicians and exercise physiologists can work together to deliver an effective product of patient eduction and risk reduction. Although the logical choice for the primary education and assessment remains with the physician, barriers continue to exist that prevent this from consistently occurring in physician practices. Exercise physiologists, however, have a unique opportunity to assist in the education and treatment of patients with or at increased risk for CVD. The exercise physiologist's unique combination of education and experience provides the appropriate mechanism by which the education and training of the patient can occur. By referring their patients to a program of exercise and education, physicians can help their patients identify exercise as medicine. By providing these services in a comprehensive and safe manner, the exercise physiologist can help bridge the gap of education and training that currently exists between fitness and medicine. Never before has the opportunity for a team intervention been greater, nor have the stakes been higher, for the chance to positively affect outcomes relative to the health of our nation.

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1. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia (PA): Lippincott, Williams and Wilkins; 2009.

2. Chambliss HO, King AC. Behavioral strategies to enhance physical activity participation. In: ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia (PA): Lippincott, Williams and Wilkins; 2009. pp. 696-708.

3. Cooper R, Cutler J, Sesvigne-Nickens P, et al. Trends and disparities in coronary disease, stroke, and other cardiovascular diseases in the United States: Findings of the national conference on cardiovascular disease prevention. Circulation 2000;102:3137-47.

4. Francis KT. Status of the year 2000 health goals for physical activity and fitness. Phys Ther. 1999;79:405-14.

5. Franklin B, Fern A, Fowler A, et al. Exercise physiologist's role in clinical practice. Br J Sports Med. 2009;43:93-8.

6. Franklin B, Gordon N. Contemporary Diagnosis and Management in Cardiovascular Exercise. Newton (PA): Handbooks in Healthcare; 2005.

7. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356:2388-98.

8. Hambrecht R, Walther C, Mobius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: A randomized trial. Circulation 2004;109:1371-8.

9. Lobelo F, Duperly J, Frank E. Physical activity habits of physicians and medical students influence their counseling practices. Br J Sports Med. 2008;43:89-92.

10. Napolitano MA, Lewis BA, Whitely JA, Marcus BH. Principles of Health Behavior. In: ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia (PA): Lippincott, Williams and Wilkins; 2009. pp. 710-23.

11. National Center for Health Statistics. Healthy People 2000 Review 1997. Hyattsville (MD): Public Health Service; 1997.

12. Niebauer J, Hambrecht R, Velich T, et al. Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: Role of physical exercise. Circulation 1997;96:2534-41.

13. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990;336:129-33.

14. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA 1998;280:2001-7.

15. Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135:825-34.

16. Prochaska JJ, Sallis JF. Channels for delivering behavioral programs. In: ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia (PA): Lippincott, Williams and Wilkins; 2009;735-41.

17. Schuler G, Hambrecht R, Schlierf G, et al. Regular physical exercise and low-fat diet. Effects on progression of coronary artery disease. Circulation 1992;86:1-11.

18. US Preventive Services Task Force: Behavioral counseling in primary care to promote physical activity. Ann Intern Med. 2002;137:205-7.

19. Whitely JA, Lewis BA, Napolitano MA, Marcus BH. Health behavior counseling skills. In: ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia (PA): Lippincott, Williams and Wilkins; 2009. pp. 724-34.

© 2009 American College of Sports Medicine


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