Exercise is medicine: translating evidence into practice

INTRODUCTION

Ever since the 1961 landmark study by Heady et al.[1] highlighting the increased risk of sudden death from coronary heart disease in London bus drivers compared to conductors, evidence supporting the benefits of physical activity and exercise in well populations, as well as those with non-communicable chronic diseases, has grown exponentially. A search on PubMed with the keywords ‘benefits’ and ‘exercise’ returned 33,016 results for publications between 2015 and 2025. In 2009, the World Health Organization (WHO) Global Health Risk Report ranked physical inactivity as the fourth leading risk factor for global mortality, responsible for more than 3 million deaths worldwide.[2] In a more recent 2022 report, the WHO reaffirmed that physical inactivity remains a significant global health concern, adding that inactive individuals have a 20% to 30% increased risk of death.[3] To address this, the American College of Sports Medicine and the American Medical Association co-launched ‘Exercise is Medicine (EIM)’, a global health initiative that underscores the importance of exercise in the prevention and management of chronic diseases and advocates the inclusion of physical activity as a standard component of medical treatment.[4]

A survey conducted in 2011 (unpublished) on primary care physicians in Singapore revealed that 86.5% of doctors would advise or prescribe exercise to at least one patient in the course of the day’s clinic sessions. However, only 20% of patients exiting the doctor’s consultation room reported receiving exercise advice or an exercise prescription. This discrepancy perhaps shows that although the doctors were aware that exercise should be a part of the disease management plan, they were not advocating or prescribing exercise to all patients who could benefit from it. The top two reasons cited for not prescribing exercise were ‘time constraints’ and ‘insufficient expertise/knowledge’. Limitations in the clinic setting represent only one of the many obstacles to getting our patients to exercise regularly. To leverage the benefits of exercise in preventing and managing chronic disease, and, hence, improve clinical outcomes, we need to identify the barriers and systematically overcome them.

OVERCOMING BARRIERS TO EXERCISE

Barriers to exercise present in many forms, including Singapore’s tropical heat and seasonal monsoon rains, the built environment, access to parks and exercise facilities, physical literacy, social factors, morbidity, and cost, among others. As such, the approach to increasing physical activity levels and, hence, population health would necessarily be multipronged.

To set the physical activity goals for the nation, Sport Singapore and the Health Promotion Board jointly publish the Singapore Physical Activity Guidelines, the latest being the 2022 edition, tailored to six sub-populations, from children to older adults and persons with disabilities.[5] Supplementing these goals and to inculcate good exercise habits in the context of sedentary behaviour and sleep, holistic 24-hour activity guidelines were developed for preschoolers,[6] children and adolescents.[7]

Singapore’s Sports Facilities Master Plan aims to provide Singaporeans with accessible space for sports, with a majority within a 10-minute walk from their homes, by 2030.[8] Cycling paths are incorporated in the plans for new housing estates. Covered walkways encourage higher step counts. Singapore’s ubiquitous high-rise housing offers stair climbing as an exercise. Playgrounds and fitness corners are found in all housing estates. Corporations may provide gym memberships as one of the staff benefits, if not an in-house gym. There is no shortage of commercial gyms, together with personal trainers. To improve physical literacy, the number of physical education classes in Singapore’s schools has been increased from one to two a week. With such a comprehensive approach, Singapore has kept its total regular sport and exercise participation rate (at least once a week) above 70% from 2021 to 2023.[9] While this is commendable, it lags behind leading nations, and those who exercise once a week still fall short of the Singapore Physical Activity Guidelines.

The above physical activity initiatives were led by various government agencies, including Sport Singapore, the Urban Redevelopment Authority, the Land Transport Authority, the Housing Development Board, the National Parks, the Ministry of Education, and the Health Promotion Board. Given that physical activity is a key pillar in the prevention and management of many non-communicable diseases, the healthcare sector would arguably be the most crucial among the collaborating stakeholders. The COVID-19 pandemic disrupted the physical activity routines of the general public worldwide, and this especially affected patients on rehabilitation programmes, including patients in Singapore.[10] In the 2023 Hamburg Declaration, healthcare organisations worldwide acknowledged that they must do more, including collaboration with all stakeholders in the community, to achieve health goals for patients.[11]

EMPOWERING THE HEALTHCARE SECTOR TO PROMOTE PHYSICAL ACTIVITY

Behavioural change in patients is undeniably challenging, be it obesity management or complying with treatment plans. To tackle this challenge, we need to go ‘upstream’ to understand the behaviours of our clinicians. The 2011 primary care survey cited the above identified time constraints and insufficient expertise as hurdles. These can be addressed by empowering our doctors through exercise prescription courses aimed at equipping them with the necessary knowledge and skills (e.g., risk stratification, exercise tailored to the chronic disease, health coaching), while providing a prescribing ‘template’ to make the process time-efficient. Exercise is Medicine Singapore (EIMS), the national chapter of the global EIM initiative by the American College of Sports Medicine, has been conducting such courses for our primary care physicians. Changi General Hospital serves as the host for the EIMS National Centre. As exercise prescription is directly relevant to the vast majority of specialties, EIMS also tailors the course for specialists in disciplines such as cardiology, endocrinology, orthopaedic surgery, rehabilitation medicine, geriatrics, oncology and bariatric surgery. To date, EIMS has trained and certified 1256 doctors. Despite the relevance of exercise prescription to healthcare, it is rarely taught in the undergraduate medical curriculum worldwide. To address this, EIMS has introduced exercise prescription modules to all three undergraduate medical schools in Singapore, so that doctors can start prescribing exercise upon graduation.

Doctors cannot do it alone — clinic assistants can help counsel patients on exercise, dieticians can prescribe exercise to complement meal plans and pharmacists can remind patients that exercise supplements many drugs. Well-being coordinators and Health Peers (lay volunteers recruited to promote physical activity to their neighbours and friends) can assist clinicians to get patients to exercise. Personal trainers in commercial gyms can supervise clients based on the exercise prescription from the doctors. Hence, EIMS also runs tailored courses for nurses, allied health professionals, fitness professionals and other lay persons, and has trained and certified 822 individuals to date.

A systems approach is necessary to move the needle in our complex healthcare ecosystem. Taking an exercise history serves as a good first step. In 2009, Kaiser Permanente Southern California led the healthcare sector by routinely capturing exercise history (the Physical Activity Vital Sign, PAVS) in its electronic medical records system, and this was subsequently adopted in all Kaiser Permanente regions.[12] A longitudinal cohort involving 1.5 million visits by 696,267 adults to 1,196 primary care providers at Kaiser Permanente Northern California demonstrated that collecting exercise history was associated with significantly greater referrals (e.g., for exercise programmes, nutrition and weight loss consultation), weight loss in overweight patients and HbA1c decline in patients with diabetes mellitus, compared to visits without collecting exercise history.[13]

PARTNERSHIPS WITH COMMUNITY PROVIDERS

When a gap between exercise levels and physical activity recommendations is identified, exercise counselling and prescription follow. Most patients can embark on the prescribed exercise independently, but some (depending on the risk stratification) require supervision ranging from an in-hospital cardiac rehabilitation programme to engaging a personal trainer. While in- and outpatient healthcare facilities are well-equipped with rehabilitation centres, physiotherapists, occupational therapists and even clinical exercise physiologists, the same cannot be said in the community.

With such a large demand for exercise supervision among the clinical population, the bulk of exercise supervision should be undertaken in the community. EIMS has partnered with Sport Singapore’s network of nine Active Health Labs (AHLs) to train and certify their trainers in supervising clinical populations in the gym, reviewed their exercise protocols for various clinical populations (e.g., those with musculoskeletal limitations and those with metabolic diseases) and established referral pathways from clinicians (both public and private) to AHLs’ gym trainers and vice versa. Personal trainers have also been trained and certified by EIMS to supervise clinical populations at commercial and public gyms as well as public spaces, under the guidance of the referring doctor. EIMS-certified fitness professionals are trained to undertake a risk assessment, referring their clients to doctors where necessary, to stabilise their medical conditions before commencing moderate or strenuous exercise. This proven framework, reinforced by social prescribing, needs to be scaled up to advance a key goal of Healthier SG — Singapore’s national healthcare transformation initiative — namely, the prescription of holistic management plans (which almost invariably encompasses exercise and physical activity) to enrolled patients.

CONCLUSION

The evidence expounding the benefits of exercise in the prevention and management of chronic diseases is overwhelming. Yet, many patients are not getting the exercise they need, for reasons ranging from resistance to change on the part of both healthcare givers and patients to capacity limitations in and out of the hospital. To ensure that patients exercise appropriately and thereby optimise health outcomes, the healthcare sector, together with community partners, needs to systematically undergo training in prescribing and supervising exercise in clinical populations, routinely capture exercise history to identify patients who fall short of national or clinical physical activity guidelines, prescribe exercise to patients who require it, mobilise community resources to increase access to exercise facilities and avail the necessary supervision.

Conflicts of interest

Tan B is a member of the SMJ Editorial Board and was thus not involved in the peer review and publication decisions of this article.

Funding Statement

Nil.