Physicians are committed to heal the sick and prevent disease. However, modern medicine is reactive in nature and fails to deter disease development. This is best evidenced by our failure to integrate one of the most efficacious treatments available for our patients: physical activity (PA).

I admitted a middle-aged female with an non-ST segment elevation myocardial infarction (NSTEMI). She had a high Body Mass Index (BMI) and lived a sedentary life, but recently started healthy eating to lose weight. The patient had many questions regarding the development of her disease, especially given her recent healthy lifestyle changes. How could she have a heart attack even though she was middle-aged, eating healthy, and losing weight? I explained modifiable versus non-modifiable risk factors and the chronicity of coronary artery disease (CAD). We also discussed PA as one of the best therapies in preventing the progression of CAD. She endorsed trying to start PA for years but was unsure where to begin. The patient had sought guidance from her primary care provider but did not receive recommendations or an effective plan outside the standard “30 min of daily exercise to meet at least 150 min a week”. Despite her motivation, she unfortunately did not know how to proceed.

This patient is not alone in suffering the consequences of inadequate PA and lack of guidance from healthcare providers. In the United States (US) and around the world, physical inactivity is a leading cause of morbidity, disability, and premature mortality. Despite the importance of PA, approximately 80% of US adults and adolescents are insufficiently active, adding to the growing epidemic of obesity and chronic disease[1]. PA may provide the greatest benefit of all the medications and therapies. An analysis of over 100,000 people over 30 years found that individuals who performed consistent PA had significantly lower all-cause mortality (ACM) (Figs. 1) [2]. Participants who met the US Department of Health and Human Services’ recommended 150–300 min/week of moderate PA had an observed 20–21% reduced ACM. Individuals who performed two to four times the recommended amount of PA were observed to have further declines in mortality. There were also reductions in cardiovascular disease (CVD) mortality by almost 40%. No harmful cardiovascular health effects were found among the study population. These findings align with others in the medical literature, supporting PA as a highly effective and safe therapy that significantly improves CVD mortality and ACM[3].

Reproduced from: D. Lee et al. “Long-Term Leisure-Time Physical Activity Intensity and All-Cause and Cause-Specific Mortality: A Prospective Cohort of US Adults.” Circulation. 2022 Aug 16;146(7):523–534.2https://www.ahajournals.org/doi/. The Creative Commons license does not apply to this content. Use of the material in any format is prohibited without written permission from the publisher, Wolters Kluwer Health, Inc. Please contact permissions@lww.com for further information

Dose–response relationship of long-term leisure-time moderate physical activity and vigorous physical activity with all-cause mortality.

While the importance of PA is known, there is a disconnect in how we are translating it to our patients. This disparity may be a result of insufficient training in PA prescription. In 2001, a national survey found only 10% of graduating medical students could recommend an exercise prescription[4]. This finding is unsurprising given only 13% of medical schools in the United States (US) provided an exercise curriculum in 2002[5]. However, nearly 20 years later, only 10% of medical students received formal exercise education and less than half are confident in creating an exercise routine for patients[6]. We are taught to diagnose and manage various pathologies, typically with medications or procedures, yet ineffective at guiding our patients to stay healthy through consistent PA. This may be due to poor PA education during undergraduate and graduate medical education.

Despite the paucity of PA prescription education and competence, there are ample resources within the community. Exercise is Medicine (EIM) was founded in 2007 by the American College of Sports Medicine to make PA a standard part of disease prevention and the treatment model for patient care[7]. Their initiative offers healthcare providers and patients with the resources to effectively optimize PA for those under our care[8]. The medical community needs to become leaders in motivating and providing the tools necessary for patients to start PA. As such, undergraduate and graduate medical education must similarly prioritize PA as medicine and integrate relevant teachings, such as those from EIM, within standard curriculum. The rapidly declining health of Americans calls for our healthcare system to place importance on lifestyle changes to offer the most optimal patient outcomes. This change starts within the medical education of students, residents, and practicing physicians.

Curriculum and its workload is extremely saturated in both undergraduate and graduate medical education. To maximize the benefits of EIM curriculum, its integration must also be efficient in order to minimize altering other vital aspects of the educational program. To address this, the American Medical Society for Sports Medicine (AMSSM) formed a group to develop curricular guidance for exercise medicine and physical activity prescriptions for medical school, residency, and fellowship levels of training[9]. Using a modified Delphi process, a group of sports and exercise medicine (SEM) experts created three training level-specific curricula regarding EIM, which was further reviewed by further SEM experts, fellowship directors, and the AMSSM board of directors (Tables 1 & 2). This proposed curriculum could be utilized broadly by medical schools, residencies, and fellowships to address the major deficit in prescribing PA. Its competencies, learning areas, and practical elements (how the curriculum is being learned) could be supplemented within standard curriculum without increasing workload or removing other curricular objectives. It is time for physicians to take an active role in optimizing patient lifestyle and helping prevent or mitigate chronic diseases.

Before discharge, I reassured my patient that her newly prescribed medications are effective and efforts to eat healthy were beneficial. I assessed her baseline level of PA, then recommended she uptitrate her aerobic activity to 30 min sessions five days a week, with strength training across two of the weekly sessions. I provided education on basic exercises and resources, helping her to set an achievable goal for reassessment in one month[10]. She was excited and motivated to begin. With proper education and specific instructions on how to start and sustain PA, patients leave our care feeling more confident they can improve their health. To improve the health and lives of our patients, it is vital that we integrate PA prescriptions within medical education and clinical practice.