The Surgeon General's Report: A Prime Resource for Exercise Advocates

Robert J. Roos

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 4 - APRIL 97

In Brief: The surgeon general's report on physical activity and health, released last July, is an important step toward convincing Americans that even moderate physical activity yields major health benefits. The report's ultimate impact may depend on its influence on public policy and healthcare spending, and on whether healthcare professionals preach—and do—what it recommends.

Amid the hoopla of the Olympic Summer Games and the presidential election campaign, many Americans may not have noticed that the nation passed a milestone in public health policy last year. It came on July 11, 1996, when federal officials released Physical Activity and Health: A Report of the Surgeon General (1), the US Government's first comprehensive review of the health effects of exercise.

The report marks the federal health establishment's biggest step yet to convince Americans of the importance of an active life—and gives physicians an outstanding reference tool to use in promoting physical activity (see "The Surgeon General's Report: A Profile," and "A Tool for Physicians," both at the end of this article). Further, the document amplifies the scientific community's full endorsement of the still fairly novel idea that moderate activity is sufficient to improve health.

"This really is the first time the government has addressed the issue of physical activity as an extremely important public health issue," says Terry Bazzarre, PhD, a staff scientist with the American Heart Association (AHA) in Dallas and a member of the planning board for the report. He says that while the report does not present new information, it lends new authority to the idea that physical activity is important for good health.

Official exhortations to exercise are not new, of course. The President's Council on Physical Fitness and Sports has been pushing fitness for decades, and the Department of Health and Human Services has included physical activity in its public health objectives for years. Also, the Centers for Disease Control and Prevention in Atlanta (CDC) joined with the American College of Sports Medicine (ACSM) in 1993 to publicize the value of regular moderate activity.

But the Surgeon General's Report (SGR) marks the first time the government has backed its advice about physical activity with a highly publicized, full-scale scientific review of the topic. Its key message is that moderate activity yields major health benefits, which almost everyone can attain. Activity that is more vigorous is even better, the report says, but the emphasis is that moderate activity pays off in a big way for the previously inactive.

Scientific Consensus

The essence of the 278-page report is that exercise is good preventive medicine. "Many Americans may be surprised at the extent and strength of the evidence linking physical activity to numerous health improvements," the foreword states. Activity helps prevent not only heart disease, but also type II diabetes, hypertension, and colon cancer; it also enhances mental and musculoskeletal health and helps older adults keep their independence. The scientific evidence for these benefits is laid out in a 70-page chapter titled "The Effects of Physical Activity on Health and Disease." With its 22 pages of references, this chapter forms the core of the report. (For an outline of each chapter, see "The Surgeon General's Report: A Profile" at the end of this article.)

The report covers a lot of ground, but it doesn't attempt to address all aspects of the subject. For example, while the document suggests that activity is helpful for treating as well as preventing disease, it doesn't deal specifically with exercise as therapy. The main reason for that was a lack of time, according to Steve Blair, PED, senior scientific editor of the report. "To do a thorough job in that area probably requires another report of the same length," he says. "It certainly wasn't that we think it's not important." Blair is director of research and of epidemiology and clinical applications at the Cooper Institute for Aerobic Research in Dallas, and president of the ACSM.

The report also focuses primarily on endurance activity rather than on resistance exercise, since endurance activity has been studied far more. Some findings about strength exercise are discussed, but a thorough review of the topic was considered beyond the scope of the report, the introduction states. Also, the authors do not discuss exercise for pregnant women or for people who have disabilities.

The Recommended Dosage

More than 60% of Americans do not exercise regularly, according to the report. This sedentary majority could realize "significant health benefits" by doing "a moderate amount of physical activity (eg, 30 minutes of brisk walking, 15 minutes of running, or 45 minutes of playing volleyball) on most, if not all, days of the week," the report states.

Other conclusions state that vigorous activity yields greater benefits; that almost half of American youth aged 12 to 21 perform no regular vigorous activity; that activity declines during adolescence; and that the proportion of high school students in daily physical education classes sagged from 42% in 1991 to 25% in 1995.

In urging 30 minutes of moderate activity daily, the report concurs with other recent physical activity recommendations, including the recent CDC-ACSM statement (2) and the National Institutes of Health Consensus Conference Statement on Physical Activity and Cardiovascular Health (3) of 1996. The latter two reports note that the 30 minutes of moderate activity can be done either all at once or in several bouts of 8 to 10 minutes each. In its major conclusions, the SGR does not mention using short bouts, but that approach is endorsed elsewhere in the report.

Arthur Leon, MD, MS, coauthor of the report's central chapter on the connections between physical activity and health, says that the great majority of reviewers of the draft report agreed: Moderate activity yields the biggest health benefits for previously sedentary people. "There is a small group of investigators who insist that you have to do vigorous activity in order to reduce your risk of cardiovascular disease," he says. "So, that emphasis is mentioned, but the bulk of the evidence suggests otherwise." Leon is Henry L. Taylor Professor and director of the Laboratory of Physiological Hygiene and Exercise Science, Division of Kinesiology, at the University of Minnesota in Minneapolis.

In addition to the major conclusions, the report notes several other points on which major health organizations agree:

People who have cardiovascular disease or other chronic health problems and want to exercise should be examined by a physician and given an appropriate individualized exercise prescription.
Previously inactive men older than 40 and women older than 50, and those at risk for heart disease, should see a physician before starting a vigorous activity program.
Strength exercises should be done at least twice a week, and should include one or two sets of 8 to 12 repetitions for the major muscle groups.

What Took So Long?

Most people already know in a general way that exercise is good for them. In fact, since the scientific case for exercise has been building for decades, many may wonder why the feds didn't weigh in with a surgeon general's report on the topic years ago. By comparison, the famous 1964 report on the risks of cigarette smoking probably came earlier in relation to the buildup of evidence on the topic, and it almost certainly came as more of a surprise to the public.

Blair concedes that the 1996 report came later than some other surgeon general's reports in relation to the data. "We've kind of been the poor stepchild," he says. "I think it took more evidence accumulating to get the government interested in physical activity than it did in smoking or cholesterol. In 1964, most of the public didn't really know the health risks of smoking, whereas people have been generally aware of the health benefits of exercise," he says.

There's more to the story, though. If the focus had been strictly on the relationship between activity and cardiovascular disease, Blair says, a surgeon general's report could have been written 10 or 15 years ago. But the evidence about various other diseases was much sparser then than it is today, he says. For example, there is convincing evidence now on the risk of type II diabetes for sedentary people, whereas "I wouldn't have felt comfortable making a strong statement about that 10 years ago....Certainly this report is more comprehensive and has more conclusions about the effects of a sedentary way of life than would have been the case 10 or 15 years ago."

Moreover, Blair adds, "A very important difference that wouldn't have been endorsed even 3 years ago is the emphasis on the value of moderate physical activity. It's just within the past 3 or 4 years that it's gained broad currency in the scientific community. And that's good news for public health."

Indeed, the report itself cites the new faith in moderate activity as the prime stimulus that brought the report into being: "This report grew out of an emerging consensus among epidemiologists, experts in exercise science, and health professionals that physical activity need not be of vigorous intensity for it to improve health," the introduction states. And the hope, it adds, is that many more people, knowing that moderate activity pays off and that many different activities fit the prescription, will become active.

How Much Impact?

It's much too early to assess the impact of the SGR on the nation's exercise habits, and even the immediate publicity impact of the report's release is difficult to gauge. After what authors describe as a hectic 18-month campaign of writing and reviewing, the report was unveiled at a Washington press conference just 8 days before the start of the Olympic Summer Games. The hope was that media attention focused on the Olympics would spill over onto the exercise recommendations. But some think that tactic backfired.

"They thought [the timing] would add to the effect, but I think it got lost," says Robert J. Johnson, MD, chair of the Minnesota Governor's Council on Physical Fitness and Sports. He says other members of the council also were disappointed in the publicity generated by the report's release. Johnson is director of primary care sports medicine at Hennepin County Medical Center in Minneapolis and an editorial board member of The Physician and Sportsmedicine.

Bazzarre agrees that the timing didn't make for maximal exposure. "I know that the groups releasing it pushed as hard as they could to get it out earlier. But I think that the Olympics and the bombing there took a lot away from the impact—and then to have the national election following that, I think we lost some of the momentum."

Others close to the project, however, say they are pleased with the publicity the report has generated. For example, Leon says the report rated a page 1 story in his hometown newspaper. "I think it's gotten an excellent reception," he adds. "Hopefully it will have as big an impact as the first surgeon general's report on smoking did."

Elizabeth Howze, ScD, of the CDC, has tracked media response to the report. "As we've looked back and counted the stories in The New York Times and other large and moderate sized newspapers, we're really pleased with the reach of the story—and subsequently, the extent to which the message about moderate physical activity is continuing to be a thread through the media now," she says. Howze is associate director for health promotion in the CDC's Division of Nutrition and Physical Activity in Atlanta.

Blair says he thought the report got good coverage when it was released, though some were disappointed. "But its impact goes far beyond the immediate effects," he says. "The real impact of the 1964 report on smoking and health was that it stimulated further research and more reports, and spurred public health initiatives in the area of smoking control." He hopes that the physical activity report likewise will stimulate research and other follow-up efforts over the long haul.

Where Do We Go from Here?

In the long run, the report's impact on America's activity habits may depend largely on how it influences public policy and healthcare spending. Douglas B. McKeag, MD, a fervent believer in exercise as preventive medicine, welcomes the report but believes it ultimately won't make much of a difference unless it leads to policy changes. "We need governmental or other support to make exercise a top priority in healthcare," he says. "Otherwise it's not going to go very far."

McKeag would like to see, among other things, more funds for research on the effects of exercise in people with chronic disease, more exercise-related training for physicians, more physical education in the schools, and more promotion of exercise by managed care organizations. Exercise science is "just not there" in medical school curricula, he says. "If physicians, as products of medical schools, aren't well attuned to the concepts of exercise and its benefits, it's never going to get through to the general population." McKeag is a family physician and director of primary care sports medicine at the University of Pittsburgh and an editorial board member of The Physician and Sportsmedicine.

A coalition of organizations led by the ACSM, AHA, and the American Alliance for Health, Physical Education, Recreation and Dance is already taking steps to use the SGR in seeking policy changes related to physical activity, according to Bazzarre. The National Coalition for Promoting Physical Activity is setting up a nationwide advocacy network, he reports. So far, a leader has been appointed in each state, and the next step is to develop state committees and a director in each congressional district.

Bazzarre says the coalition plans to use the SGR as a "framework document" to promote policy initiatives at various levels. Objectives include such things as "rails to trails" developments, making public facilities for physical activity safer, and boosting physical education requirements in public schools. The coalition now has about 100 member organizations, he says.

The report itself says that health professionals need to work with others on the policy front to remove barriers to physical activity. William O. Roberts, MD, a family physician in White Bear Lake, Minnesota, and an editorial board member of The Physician and Sportsmedicine, agrees: "Physicians and scientists need to be politically active—and I think this report is a step in political activity. I also think the people who preach it should live it. We should be exercising."

The Surgeon General's Report: A Profile

Physical Activity and Health: A Report of the Surgeon General is a 278-page summary of research findings on the health benefits of physical activity, coupled with a recommendation that all Americans become at least moderately active. In a nutshell, the message is that an active lifestyle is available and beneficial to all. Below is a profile of the report.
Report Basics
Who wrote it: The US Centers for Disease Control and Prevention in Atlanta (CDC) in collaboration with the President's Council on Physical Fitness and Health and other government agencies, and in consultation with the American College of Sports Medicine, the American Heart Association, and the American Alliance for Health, Physical Education, Recreation, and Dance.
How to get a copy: Call (toll-free) 1-888-232-4674, or access the CDC home page at http://www.cdc.gov, where the report is listed under "publications and products." Copies cost $19.
When it was released: July 1996.
Why now? In the last few years, authorities have agreed that activity need not be vigorous to improve health—that moderate activity yields major benefits.
The Main Findings
The report concludes that regular physical activity:

greatly reduces the risk of dying of coronary artery disease;
reduces the risk of developing type II diabetes, hypertension, and colon cancer;
enhances mental health;
fosters healthy muscles, bones, and joints, and appears to reduce symptoms of osteoarthritis;
helps older adults maintain functional ability and preserve their independence;
is an effective adjunct to dietary measures for avoiding weight gain, or for losing weight.

In addition, the report says that:

people can gain these health benefits by doing some moderate activity (such as 30 minutes of brisk walking or 15 minutes of running) all or most days;
longer or more vigorous bouts of activity yield greater benefits;
more than 60% of Americans do not exercise regularly, and, of that group, 25% don't exercise at all.

What isn't covered: The report does not describe in detail the evidence on the role of activity in treating or rehabilitating persons who already have a disease. Nor does it deal with exercise for pregnant women or people who have disabilities.
Chapter Summaries and Highlights
Chapter 1 provides an introduction, overall summary, and a list of the conclusions from each of the remaining chapters.
Chapter 2 traces the history of medical ideas about exercise from ancient times, explains terminology, traces the evolution of physical activity recommendations, and discusses the measurement of physical activity and fitness. Noteworthy: Pro-exercise quotes from authorities through the ages, plus a table that summarizes 33 different exercise recommendations issued by various US organizations between 1965 and 1996.
Chapter 3 describes the physiologic responses and long-term adaptations to exercise. Noteworthy: A table describing changes in the level of 14 important hormones during an exercise bout.
Chapter 4 discusses the effects of physical activity on health and disease. The longest chapter at about 90 pages, it covers overall mortality, chronic diseases, and adverse effects of physical activity. Noteworthy: Extensive tables summarizing the research on physical activity and disease prevention, plus an exhaustive reference list.
Chapter 5 reports on patterns and trends in physical activity in the United States and compares them with the goals set in the federal government's Healthy People 2000 report. Noteworthy: A table gives a state-by-state breakdown of the percentages of people who report no activity, regular activity, and regular vigorous activity.
Chapter 6 explores influences on people's physical activity participation and how to promote participation. Noteworthy: The report stresses that to increase physical activity, policies as well as individuals must change. Health professionals must work with people in other disciplines to "engage communities, schools, and worksites in creating opportunities and removing barriers to physical activity."

A Tool for Physicians

So far, close to half a million copies of summary materials and fact sheets about Physical Activity and Health: A Report of the Surgeon General have been distributed to people who have requested them or have a stake in exercise promotion, according to Elizabeth Howze, ScD, of the federal Centers for Disease Control and Prevention in Atlanta (CDC). But no specific targeting of physicians apparently has occurred yet.
Physicians should keep in mind, though, that "we do have evidence that doctors are an important source of health information," says Steve Blair, PED, senior scientific editor of the report. "That's how we've accumulated 50 million ex-smokers in this country. I think it will have a measurable effect if physicians get behind the idea of counseling patients about physical activity and use the report to support their recommendations. One person in 10 might start moving around a little more." Blair is with the Cooper Institute for Aerobics Research in Dallas, and is president of the American College of Sports Medicine (ACSM).
Physicians looking for ways to get patients to exercise should inquire with the CDC about Project PACE (Physician-Based Assessment and Counseling for Exercise), suggests Terry Bazzarre, PhD, an American Heart Association staff scientist and a planning board member for the surgeon general's report. PACE is a program specially designed to enable physicians and allied healthcare professionals with hectic schedules to motivate patients to exercise (see November 1994, page 45).
Also, the ACSM is working on plans to provide posters and brochures related to the surgeon general's report that physicians can use with their patients, according to Dave Ferrell, ACSM public information manager in Indianapolis. Some of the materials are expected to be available this summer, he says.

References

US Department of Health and Human Services: Physical Activity and Health: A Report of the Surgeon General. Atlanta, DHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996
Pate RR, Pratt M, Blair SN, et al: Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-407
National Institutes of Health Consensus Development Panel on Physical Activity and Cardiovascular Health: Physical activity and cardiovascular health. JAMA 1996;276(3):241-246

Mr Roos is a senior editor of The Physician and Sportsmedicine.

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