Physical Activity and Lifestyle Medicine

In fact, if one looks at the risk factors for both cardiovascular disease and all-cause mortality, inactivity is a stronger risk factor for these entities than any other single habit or practice.

The theme of the current issue of the American Journal of Lifestyle Medicine is physical activity and rightly so. Regular physical activity is one of the major and most important pillars of lifestyle medicine. Although there are many habits and practices that affect health, physical activity is clearly one of the key factors. In fact, if one looks at the risk factors for both cardiovascular disease and all-cause mortality, inactivity is a stronger risk factor for these entities than any other single habit or practice. This does not mean that other pillars of lifestyle medicine such as sound nutrition, stress reduction, adequate sleep, and positive psychology are not important. Physical activity, however, is an area where the data are overwhelming and one which, in my opinion, practitioners of lifestyle medicine have been less involved in than in many of the other pillars.

The literature related to physical activity and its health-promoting benefits continues to explode. New studies in this area are published every day. We have been blessed in the past few years with the publication of the Physical Activity Guidelines for Americans 2018 Scientific Report.¹ This report is an exhaustive compilation of data that existed up to 2018 related to the various aspects of physical activity and health. This document, or at least its Executive Summary, should be part of the basic toolbox for every practitioner of lifestyle medicine.

The important health benefits of a physically active lifestyle are beyond dispute. For example, when inactive individuals are compared with active individuals, the inactive individuals increase their risk of cardiovascular disease by between 150% and 240%.

An important study done a number of years ago by the Centers for Disease Control (CDC) compared individuals who met CDC standards for physical activity with inactive individuals. By the criteria utilized in this study (which are also the same activity criteria utilized by the Physical Activity Guidelines for Americans 2018), 80% of individuals in the United States did not meet the criteria of at least 150 minutes of moderate-intensity physical activity per week, whereas 60% were “very inactive.” When the risk of heart disease among active people was compared with that for very inactive people, the risk of heart disease in the inactive segment was twice that of individuals in the active population. To put this in perspective, as the authors of this study did, this means that individuals who choose to be inactive accept the same increased risk of heart disease as individuals who smoke a pack of cigarettes a day! Unfortunately, 15% of the adult population in the United States still smoke a pack of cigarettes a day, and 60% to 80% are either not adequately active or completely inactive. Thus, inactivity carries the same risk as cigarette smoking a pack of cigarettes per day and is between 4 and 5 times more prevalent! Clearly, we need to do more to engage the American public in ways to become more physically active to combat the adverse health effects of the epidemic of inactivity in the United States!

Despite the enormous amount of information available on the links between physical activity and health, the medical community has been slow to incorporate this information into the routine practice of medicine. Studies have shown that less than 40% of physicians routinely counsel people on physical activity. This is an unfortunate, wasted opportunity given that 70% of individuals in the United States see their primary care physician at least once per year.

My interest in physical activity and health comes from a variety of sources. First, as a cardiologist, I have been long aware of the profound linkage between physical activity and cardiovascular health. Second, as a researcher, my team and I at Rippe Lifestyle Institute have performed numerous studies on the interface between physical activity and health. In fact, the studies that we did in the early 1980s on walking have been credited with sparking the fitness walking movement around the world.

Third, on a personal level, I have been a long-time regular exerciser. I can count on one hand the number of days in any given year when I do not engage in some form of physical activity for at least 30 minutes. In fact, it is usually much more. I walk regularly, swim, play various active sports, and strength train 3 to 4 times per week. I have seen the benefits of these activities in my own life, not only for cardiovascular health, but also for weight control and stress reduction.

There are some encouraging signs that physical activity will become a stronger part of the lifestyle medicine movement. In addition to the profoundly important Physical Activity Guidelines for Americans 2018 Scientific Report, there is also the important Exercise is Medicine² movement, which was launched by the American College of Sports Medicine (ACSM) in 2007 and continues to grow around the world.

The American College of Lifestyle Medicine (ACLM) has also forged partnerships to emphasize the pillar of physical activity, including a partnership with the ACSM and a new Physical Activity Alliance, which is composed of multiple national stakeholder organizations in the area of physical activity. It is also significant that the newly elected President of ACLM, Dr Cate Collings, has a background in exercise physiology, which stimulated her to pursue a professional career in cardiovascular medicine.

There are important tools available to lifestyle medicine practitioners to increase their emphasis in the area of physical activity. For example, the Exercise is Medicine movement has provided prescription pads for including an exercise prescription in every health care encounter. The emphasis on physical activity as a vital sign is also an important and welcomed initiative. Utilizing the 2-question initial physical activity assessment developed by researchers at Stanford University is an excellent way to begin to emphasize to all patients the importance of physical activity as a health-promoting behavior.

I have also made a personal commitment to continue bringing impactful information to the lifestyle medicine community in the area of physical activity. In fact, my next book Increasing Physical Activity: A Practical Guide, which was published in November 2020,³ is an attempt to summarize the key issues related to physical activity and health, in a motivational way, to the broadest segment of health care practitioners.

It is time for those of us in the lifestyle medicine community to get off of the sidelines and include physical activity in every patient encounter. Let us make a commitment to do this in 2021 and beyond!

One final word, “Physician heal thyself.” I know that many lifestyle medicine practitioners are already deeply involved in their own physical activity. It is time for every lifestyle medicine practitioner to adopt this habit and experience its benefits. A number of studies have shown that clinicians who are physically active are more likely to recommend physical activity to their patients.

A number of years ago, my friend Dr Joseph Alpert, who is a Professor of Medicine at the University of Arizona, was asked how often people should exercise. He responded simply “you should exercise every day that you eat!” I couldn’t have said it better myself!

The time for action is now. Let us commit to making 2021 and beyond the decade of increased physical activity in lifestyle medicine!

James M. Rippe, MD Editor-in Chief, American Journal of Lifesytle Medicine
Founder and Director, Rippe Lifestyle Institute, Shrewsbury, Professor of Medicine, Massachusetts
University of Massachusetts Medical School, Worcester, Massachusetts