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An ever growing number of studies have shown that regular physical activity (PA) lowers the risk for cardiovascular and metabolic disease, as well as lowering the risk of cardiovascular and all-cause mortality.1 ,2 Furthermore, PA has positive treatment/and or preventive effects on a multitude of other conditions such as mental health, colon and breast cancer, osteoporosis, risk of falls and quality of life. Today, the great challenge is to translate the known health and well-being benefits of PA into practical use, ultimately making PA a regular treatment and prevention modality in the healthcare system.3
Existing approaches to promoting increased levels of PA in patients vary from providing simple oral advice to more structured advice. The Swedish Council on Technology Assessment in Health Care (SBU) report4 concluded that general ‘short’ advice on PA could increase the level of PA up to 50% at 6 months. With more intense counselling, supported by pedometers, written advice and/or follow-ups, the level of PA may increase a further 15–50% in 6 months’ time.4 Unfortunately, only a minority of patients seem to obtain additional support beyond the traditional advice on PA.
More structured advice uses established behavioural strategies to help individuals change their lifestyle behaviour. PA could also be delivered as part of an exercise referral scheme, provided ‘on prescription’ or as part of a structured in-hospital scheme (eg, as part of cardiac rehabilitation). However, among others, the US Preventive Service Task Force stated that there was insufficient evidence for the efficacy of behavioural strategies on the PA level.5 In the system of exercise referrals, the patient typically is referred to a specified centre for a period of exercise counselling. The level of PA seems to increase in the short term, but more studies are needed to confirm the efficacy of these schemes.6
In physical activity on prescription, the counselling is structured, resulting in an individualised prescription on activity, ideally taking into consideration which disorder to treat; potential or real barriers to exercise; possible contra-indications; any concomitant diseases and medications. The extent of the intervention varies greatly, as does who is the actual prescriber (doctors, nurses, PTs) and whether the prescription is written or not. In addition, the type of activity prescribed, as well as the possible use of additional support, may also vary.
A Swedish success STORY: FYSS-PHYSICAL activity for prevention and treatment
The Swedish version of the physical activity on prescription method uses the reference book ‘Physical activity in the prevention and treatment of disease (FYSS)’.7 This book collects the available evidence for treatment with PA in different diseases, including the known effect mechanisms, most effective dosage (type of activity, intensity, frequency and duration), side effects, as well as the possible contra-indications for PA. In clinical practice, the Swedish physical activity on prescription method has been found to increase the level of PA in patients in primary care, at 6 months as well as at 12 months.8 The self-reported adherence to the prescription was 65% at 6 months,9 figures similar to the known compliance rate of medications. In a randomised controlled study, physical activity on prescription significantly improved body composition and reduced metabolic risk factors.10
Next steps: focusing on health professionals
However, the use of PA as a treatment modality in healthcare is still underutilised. While physicians believe that advice on PA is important, only a minority of patients are actually given advice or counselling on PA in the clinical setting. At present, about 1/1000 of the Swedish healthcare visits results in a prescription of physical activity.11
This is in contrast to the existing international treatment recommendations highlighting the importance of PA for many conditions. In addition, patients state that they want and also expect the healthcare system to provide guidance on lifestyle behaviour and PA. In a Swedish study, 3/4 of the participants said that while the individual has the largest responsibility to being active, the healthcare system also has a responsibility to help patients increase their level of PA.12 The Swedish National Bureau of Health and Welfare recently produced national guidelines on methods to prevent disease,13 highlighting the importance of structured advice, with additional support and follow-up (equivalent to physical activity on prescription), to increase the PA-level in insufficiently active patients with different disease entities, such as obesity, diabetes and hypertension.
While the motivation of the patient is very important for lifestyle change to actually take place, the importance of motivating healthcare personnel to deliver lifestyle advice may have been underestimated. The FYSS book may help promote behavioural change in physicians by giving PA similar status as conventional medical treatment.
Implementation and ‘scaling up’: FYSS expands beyond Sweden
The FYSS book has been translated into English, Norwegian and Vietnamese3 and discussions are ongoing for other languages. The Vietnamese translation was part of a collaboration project that included education and training of healthcare personnel, awareness building through mass media campaigns as well as interaction with Vietnamese government agencies and the Ministry of Health.
A third and markedly different edition of FYSS is now being planned. Based on a Swedish end-user study, the format will be more user friendly and the PA recommendation format will be more standardised. Also, it will be designed to work seamlessly with the electronic health record (EHR) so that recommendations pop up as appropriate.
One of the main challenges may be that some physicians do not regard lifestyle issues to be their responsibility—possibly not fully realising the massive potential treatment effects of PA for many patients with non-communicable diseases, that is, most patients in everyday practice.
What's the solution?
In our opinion, successful implementation of PA in healthcare depends on a combination of a systems approach (socioecological model) and strengthening of individual motivation and capability. First, there needs to be general support from the political policymaker, healthcare leader and at the professional society levels. This should be expressed through national evidence-based recommendations and guidelines as well as educational programmes, all the way from undergraduation up to continuing medical education. Such measures increase awareness and legitimacy and help to enhance motivation. Second, to lower the barrier for the prescribing healthcare professionals, tools for execution and structure for delivery must be readily available. Examples include handbooks such as FYSS and physical activity on prescription systems. Also, IT support and EHRs with information on PA and other lifestyle factors registered as ‘vital signs’ and the development of International Classification of Diseases codes for reimbursement are important in this regard.
Thus, using FYSS may actually be self-contagious, inducing a behavioural change in the prescribing physician and not only in the patient.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.