From COVID to Couch Potato: The Importance of Physical Activity Promotion and Education

As society adjusts to the COVID-19 pandemic, we are still reeling from effects that may have lasting consequences for the health and well-being of our communities. While the immediate fear and uncertainty of the pandemic appear to be in the rear-view, we are emerging to face new challenges and potential crises that could have lasting effects for the health of our patients. One dilemma is the resulting behavioral changes we are accustomed to following extended lock downs, work and school from home, and decreased involvement in public gatherings, which have promoted sedentarism and compromised our involvement in regular physical activity. ¹ A recent JAMA Pediatrics article summarized that during the lockdowns of the COVID-19 pandemic, physical activity among pediatric populations declined 20%. ² Similar trends are reflected in adult populations. ¹, ³ The potential health implications of these changes are significant, especially considering the detrimental effects of increased sedentary time on an individual’s health. ⁴ The health benefits of regular physical activity are immense, yet there are still significant barriers to regularly achieving the aerobic and strength training recommendations of the US Physical Activity Guidelines. ⁵ While the root causes of these barriers are complex, the COVID-19 pandemic and resulting societal changes have likely highlighted the socioeconomic and cultural barriers that prohibit our patients from reaping the health benefits of regular physical activity.

How can we as a specialty address this discrepancy and promote healthier lifestyles for our patients? While there is no simple solution, we need to be more conscious of discussing positive lifestyle measures, including physical activity, and their impact on health with every patient we see. The truth is that we don’t do a good job of addressing this—only about 30% of physicians routinely counsel their patients on lifestyle issues despite the value that patients place on physician recommendations. ⁶ Cited barriers for this include insufficient training, knowledge, motivation, and time. ⁷

Making meaningful interventions to improve the levels of physical activity for our patients must go beyond simply stating “you must exercise more.” Intervention is needed at multiple levels, engaging the family physician, the patient, and their community, while collectively addressing barriers and creating individualized strategies.

As educators, we must be sure to incorporate effective lifestyle curricula at all levels of medical education, including the topics of physical activity, nutrition, mental health, sleep and substance use, emphasizing the value of healthy lifestyles to promote and maintain health, as well as a part of comprehensive disease management for many common chronic conditions. Very few medical schools or residency programs have a dedicated curriculum that addresses lifestyle topics. ⁸, ⁹ A lack of faculty knowledge or comfort in teaching and counseling patients on behavior change is an often-cited reason for lacking this curricular model in residency education. ¹⁰ Creating didactic materials for residents and faculty, to teach the principles of screening for physical inactivity and clinical interventions (eg, the exercise vital sign) is a practical step. The American College of Lifestyle Medicine (https://lifestylemedicine.org/project/lifestyle-medicine-residency-curriculum/) and American Medical Society for Sports Medicine (https://www.amssm.org/) both have modules designed for resident learners on the topics of physical activity promotion. Additionally, there are published curricular guidelines and models for all levels of medical education to gain confidence and ability to carry these skills into their future practice. ¹¹, ¹²

Much like health care systems utilize standardized screening tools for tobacco use and depression, the utilization of a validated tool for physical activity can aid in identifying those patients who are at risk for physical inactivity and potential complications. ¹³, ¹⁴ If sitting is the new smoking, then why should we not stress collective screening to identify patients who are at risk, provide interventions and create systems to assist those with the most need? The exercise vital sign is a validated tool that is incorporated in numerous health care systems and electronic medical records. ¹³ It is practical and efficient to have patients review their exercise vital sign with each continuity visit. It can be collected in a few seconds and provide valuable information to identify high-risk patients. This can be completed as part of the rooming process with a medical assistant and integrated into the medical record for longitudinal tracking. While a similar tool has not been validated in pediatric populations, several organizations have created screening tools for children that both assess volume of physical activity, as well and the extent of physical activity achieved in daily actives, such as transportation and physical education within school. ¹⁵

For those patients who screen for physical inactivity, the utilization of a tool at the point of care can be one effective means for creating an individualized approach to addressing physical inactivity. An exercise prescription, created based on the patient’s current health goals, preferences, and available resources, is a quick and reliable method to emphasize the role of physical activity for overall health. With the ease that physicians can prescribe medications, they should be able to confidently provide exercise prescriptions. Residency programs can collaborate with community organizations, such as fitness centers, nursing homes, exercise specialists, physical/occupational therapists as referral sources, as well as partners to help deliver didactics, participate in group visits, and help patient meet their fitness and lifestyle goals. The American College of Sports Medicine’s Exercise is Medicine program (https://www.exerciseismedicine.org/) has many resources for patients and providers, as well as practice standards for incorporating physical activity, that are used by practices across the county.

Communities, particularly those of minorities and low incomes, often have insufficient resources and infrastructure, such as safe parks and sidewalks, to allow residents the means to regularly participate in physical activity. ¹⁶ As family physicians, we have a responsibility to be advocates for our patients and can work with communities and governmental officials the local, state, and national levels, to create programs and legislation that address these, and many more, of the socioeconomic barriers present in our communities. We can start by meeting with community leaders to address the barriers patients have and develop sustainable and safe solutions that alleviate barriers. Several residency programs and medical schools have partnered with organizations such as Walk With a Doc to engage with their patients and participate in physical activity in their community. ¹⁷

A final opportunity effective role modeling. Physicians who regularly participate in physical activity are more likely to council and educate patients on the health benefits of physical activity. ¹⁸, ¹⁹ Promoting physician wellness and being able to care for oneself, while sharing our own struggles and challenges with patients, is often a way to connect with patients and empower them in their journey to achieving their health goals. Furthermore, a healthy and engaged workforce, with particular focus on those in training or at risk for burnout, is critical to build a productive and resilient health care system. Time constraints, access to equipment, fatigue, and variable schedules are all factors that limitresident physicians’ ability to achieve regular exercise. ²⁰ Inadequate levels of self-care, including physical activity, is also attributed to emotional exhaustion, depersonalization, and depressive symptoms among resident physicians. ²¹ Physical activity can be conducted as a part of a clinical team. Having a 5-minute burst of activity with squats, jumping jacks, or other simple exercises following a daily huddle can be a way to get the entire clinic team involved. Other ideas to improve accessibility in physician work environments include support gyms or walking trails close to health care facilities and creating systems to promote more physical activity through the day, such as walking treadmill desks or participating collectively in local recreational events as an organization.

Ultimately, physical activity is only one of many factors in a patient’s lifestyle that physicians can effectively counsel and intervene, yet it is critically important for physicians to address given the significant health benefits.. However, without education, integrated systems, and promotion within the discipline, we will allow some of the habits created through the lockdown phases of COVID-19 to persist and further compromise the health of our communities.