With a push from Jessica Butts, a family and sports medicine doctor, Penn State Health has joined a small group of health systems that now have a new vital sign: physical exercise.
Since 2019 she has been working to get her health system to adopt this goal of the American College of Sports Medicine (ACSM), which has been arguing for more than a decade that “exercise is medicine” and should be a routine topic of doctor-patient discussions along with measures like blood pressure and weight.
“If we could take all of the things that exercise can do for you physically, it would be a magic pill,” Butts said. “We know all this about exercise, but we don’t use it.”
Exercise can help prevent a host of chronic diseases, from diabetes and heart disease to dementia. It improves mood and sleep. A recent study found that exercisers who caught COVID-19 were less likely to die or have severe symptoms than the sedentary. Even cancer patients have better outcomes when they exercise, Butts said.
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Her efforts stalled during the early wave of the pandemic, but gained momentum last summer when colleagues were eager to take on a positive, forward-looking project. “It was like welcomed with open arms,” she said.
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Penn State now is testing the new initiative at clinics in Middletown and Palmyra. Butts hopes it will be operating in all family practice offices within six months. Typical vital signs — height, weight, blood pressure, temperature, pulse and respiratory rate — are recorded. Patients are also screened for smoking, depression and physical activity, including how often and vigorously they exercise. These items get prominent placement when doctors look at online charts.
Liz Joy, a former president of ACSM who is senior medical director of wellness and nutrition at Utah-based Intermountain Healthcare, believes Penn State is the nation’s sixth health system to join the vital-sign movement and the only one in Pennsylvania. Intermountain began assessing physical activity as a vital sign in 2013. Others, she said, include the University of South Carolina School of Medicine and clinics at the University of Washington and Harvard University.
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Kaiser Permanente, another big western health system, started in 2009. Robert Sallis, also an ACSM past president, has championed the exercise vital sign at Kaiser and nationally. He thinks there may be up to 15 health institutions that regularly ask patients how much they move. He said studies have found that about one-third of patients do nothing and a third meet federal guidelines to do 150 minutes of moderate exercise or 75 minutes of vigorous exercise per week.
What initially interested Sallis, who runs Kaiser’s sports medicine fellowship, was the contrast between the research that documented how helpful exercise can be and the many inactive, chronically ill patients in his practice. Why weren’t doctors telling patients to move more?
“This is so much more powerful than any medicine I can prescribe, yet health care has just resisted doing that,” he said. “I don’t get it.”
Sallis, Joy and Butts say a variety of factors may have made the health world, which is often slow to embrace new ideas, unenthusiastic. There’s nothing in it for drug companies and insurers often don’t cover preventive care. Older doctors and patients are accustomed to treating medical problems with medicines. Electronic medical records don’t have questions about exercise built in, and modifying them takes work. Plus, doctors are already pressed for time, and it can be tough to broach behavior change with defensive patients. Some worry that patients will lie about how much they exercise anyway, although advocates counter that patients can also lie about how much they smoke and drink.
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Butts said many patients think of exercise as way to lose weight, but it’s not very effective for that. The best way to lose weight is to eat fewer calories. But exercise can improve health regardless of your size.
“When we’re talking about exercise, this has nothing to do with your weight or how you look,” she said.
“This is totally about health. … Being physically active can really change your life regardless of what your weight does.”
Supporters of the exercise vital-sign idea have not yet studied whether asking about physical activity changes behavior. Butts hopes that just bringing it up will lead to change. If nothing else, researchers will now have more data to bolster the case for exercise.
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“You have to have a starting point, and asking about it is the first step,” Sallis said.
As part of its initiative, Penn State has also started physical activity consultation clinics at three locations to help patients get started safely and connect with community resources like pools and gyms.
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Michelle Segar, director of the University of Michigan’s Sport, Health, and Activity Research and Policy Center, questions whether telling sedentary patients that physical activity will improve their health will do the trick. She studies how to sustain health behavior change and has been saying for 30 years that medicine has a marketing problem. Doctors and a few patients may find a rational argument that exercise is medicine compelling, but advertisers have known for years that the promise of positive emotions is what really rules.
The current approach to exercise — film of sweaty, beautiful, thin and toned athletes — sets most people up for failure. She thinks doctors need to start by asking patients what kind of exercise makes them feel good and give them permission to do it in small doses. Walking is fine. The goal is for exercise to be pleasurable, or at least “palatable and not punishing.”
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She has created a prescription form called Choose to M.O.V.E that asks patients to focus on positive experiences they hope to achieve from activity like less stress and anxiety or a clearer head. Not everyone will feel fantastic while they’re walking around the block, Segar said, but “the science shows that how we frame a behavior influences how we experience it and we think about it and what we notice.”
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It’s too soon for most people to be talking about 150 minutes, she said. “We’ve got to get people in exercise kindergarten,” she said. “We’ve got to get people to just move. Anything is better than nothing.“
The exercise-is-medicine advocates have their own prescriptions, which focus less on emotion and more on specific action. They also allow patients to start very slowly.
Doctors said patients generally respond well to the conversations. “I think it’s much less threatening than telling them they’re morbidly obese,” Sallis said.
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