You may have noticed by now that whenever I recommend exercise in my posts, I also follow the recommendation up with a disclaimer to check in with a healthcare professional beforehand.
This is not unique to me, and you may have noticed that others who give exercise and health recommendations also tend to follow up with a line on seeking medical advice before.
Why is this and is it really necessary? Is starting exercise actually dangerous?
The truth is, many times you won’t really need to visit a doctor and today I’d like to discuss the intricacies of this dilemma, particularly as they relate to heart health.
In full disclosure, I, personally, will always recommend that you visit a healthcare professional beforehand for a number of reasons.
- I have not personally met you and therefore cannot make tailor-made recommendations that will suit you.
- I am a researcher, not a healthcare professional. This means I can only explain what doctors have recommended in published articles, but cannot provide medical advice myself.
- You may not be aware that you have a contra-indicated condition when you begin exercising, which may be dangerous to your health.
- The paper I will be discussing here only offers recommendations pertaining to certain conditions, so other conditions, e.g. musculoskeletal issues or injuries, will need to be managed appropriately too.
With all that said, today I’d like to draw your attention to a paper that was released in 2015, and spend a little time discussing it. 2015 is not exactly last week, so no breaking news here. But while it might be 10 years old, it’s the most up-to-date version of the American College of Sports Medicine’s or ACSM’s guidelines for exercise participation that we have, and it’s worth having a look through it if you’re interested.
Essentially, the ACSM begin by acknowledging that exercise has numerous health benefits for the majority of people. It can help reduce the risk of cardiovascular disease, type 2 diabetes, some forms of cancer and even all-cause mortality (summarised by Garber et al., 2011). The problem is that if you already have a cardiovascular condition, performing vigorous exercise or exercise you are unaccustomed to may result in an adverse health event (something like a heart attack, for example).
The ACSM previously had other recommendations for screening for people who were at increased risk of exercise-related cardiovascular events, but these recommendations were too stringent. Following them meant that too many people required doctors’ referrals to begin exercising, even if they didn’t really need them.
For this reason, the ACSM has updated its guidelines in an attempt to still catch those people who are at increased risk, but not deter those for whom it is safe to exercise from taking up the pastime. They hoped to avoid creating a backlog of people seeking medical clearance to exercise and delaying those who are healthy from exercising. They wanted to remove unnecessary barriers and encourage regular physical activity.
Here are the main points of the paper.
Exercise benefits versus its risks
The benefits of physical activity are well-known. Despite this, physical inactivity is pervasive in today’s western society and this is contributing to a great deal of disease. Yes, it’s true it is possible for exercise to cause cardiovascular events, but these are rare and are often preceded by warning signs like chest pain, dizziness, or shortness of breath.
Current screening barriers
Current ACSM guidelines for exercise participation recommend a screening process of medical exams or diagnostic testing, based on risk factors for cardiovascular disease (CVD). However, this often results in unnecessary referrals, false positives in tests and additional testing, which could dissuade people from exercising altogether!
Key findings from research
While vigorous-intensity exercise does temporarily increase the risk of a cardiovascular event, the absolute risk remains extremely low (Rognmo et al., 2012; Albert et al., 2000, Thompson et al., 1982).
Exercise-related cardiovascular events are low even during vigorous activity. This is particularly true in the case of people who don’t have CVD symptoms. Sudden cardiac death is so rare that it occurs once every 1.51 million episodes of vigorous physical exertion in men (Albert et al., 2000) and once every 36.5 million hours of moderate-to-vigorous exertion in women (Whang et al., 2006).
The good news is that if you regularly participate in physical activity, your risk of a cardiovascular event is reduced (Albert et al., 2000; Whang et al., 2006), even during vigorous activity! In fact, those who are at the highest risk of cardiac events in general and during exercise are those who are normally inactive. If you don’t exercise at all, your risk of a cardiac event is higher (Berlin & Colditz, 1990), and if you are normally sedentary and then engage in a one-off bout of vigorous activity, you’re also at increased risk (Mittleman et al., 1993).
Changes to the ACSM guidelines
Firstly, the ACSM has removed the CVD risk factor assessment from their pre-exercise screening. This assessment would check for things like cholesterol and hypertension, however, these are not good predictors of rare exercise-induced cardiac events.
Instead, the ACSM have decided to focus on three main factors:
1. current physical activity level, meaning ‘are you habitually active?’
2. presence of cardiovascular, metabolic, or renal disease, or any symptoms related to them
3. the exercise intensity one wishes to train at
These three factors inform whether or not you should begin exercising, and what intensity you should train at. The ACSM guidelines quite helpfully include a flow chart, which you can follow to come to your own conclusion regarding whether or not you should begin exercising without medical clearance. This is based on your risk level and the answers you give to the questions in the chart.
For copyright purposes, I won’t make a copy of the chart here, but if you follow this link, you can download the chart from the article. If you’d like to find it in the paper instead, it’s Figure 2.
Please keep in mind that if you have a known cardiovascular, metabolic or renal disease, you should seek medical clearance before beginning exercise or progressing in an exercise programme. However, if you sought medical clearance in the past year, you can continue to exercise, provided you have no new symptoms or experience a change in your health status.
If you develop signs or symptoms of cardiovascular, metabolic, or renal disease during exercise, you should stop and seek medical clearance before you continue to exercise.
Physical activity status and risks
If you’re physically inactive, you may begin light- or moderate-intensity exercise without medical clearance, unless you have a known cardiovascular, metabolic, or renal disease or signs and symptoms of these diseases. If you’re already physically active, you can continue to exercise and gradually increase the intensity of your exercise unless you develop signs of cardiovascular, metabolic, or renal disease.
Exercise prescription
Properly prescribing exercise can also help to reduce the risk of cardiac events.
The paper emphasises the importance of safe and effective exercise prescription where frequency, intensity, time, type, volume, and progression are specified. If you have a fitness instructor, it might be worth asking them to prescribe exercise in this way, and then stick to the guidelines they give you. This model of prescription is known as the FITT-VP principle and any fitness instructor who has undergone proper training will know what this is.
The paper states that exercise should also be progressive, with a transitional phase of 2-3 months to gradually increase duration and intensity. They also make a point of stating that it is important not to forget to warm up and cool down when you’re exercising.
The guidelines outline the importance of education on recognizing warning signs of cardiovascular events and suggest keeping an eye out for them. These include chest pain and shortness of breath, among others.
If you’re sedentary, the ACSM also encourages you to begin exercising by going on regular brisk walks, but to avoid any sudden, high-intensity physical activity.
Medical Clearance and Testing
The ACSM now hold that routine medical exams or exercise testing are no longer required for most individuals, especially those engaging in low- to moderate-intensity exercise. Medical clearance should be based on your health status, including the presence of signs or symptoms of cardiovascular, metabolic, or renal diseases, and your current level of physical activity, as well as your desired level of activity.
While some people may still need medical evaluation based on their health status, this is now more individualized and not based solely on age or CVD risk factors. Additionally, it may be necessary to check in with a medical professional if you would eventually like to undertake vigorous-intensity activity, particularly if you aren’t currently very active.
What about other diseases?
Surely those with respiratory conditions have to take special care too, right
Actually, individuals with pulmonary disease, particularly chronic obstructive pulmonary disease or COPD, are not automatically referred for medical clearance unless they also have signs or symptoms of CVD. COPD does not directly increase cardiovascular risks during exercise, however, the sedentary lifestyle that generally accompanies the respiratory condition may increase the risk of cardiovascular events.
Conclusion
So, what should your key takeaways from this paper be?
Well, if you’re currently physically inactive and have no known diseases or any related signs or symptoms, there’s really no reason not to get up and go out for a brisk walk right now. Yes, I always recommend consulting with a healthcare professional, but the likelihood is that beginning to exercise will have a more beneficial impact on your health than waiting to speak to somebody, and potentially forgoing exercise altogether. In general, the benefits of exercising far outweigh the risks!
These ‘new’ recommendations are grounded in the latest research available in 2015, which demonstrates that structured physical activity, tailored exercise prescriptions, and individualised medical clearance based on health status provide a safer and more effective path to improved cardiovascular health.
What the ACSM is trying to do here is make sure they catch those who are at risk without causing an unnecessary barrier to exercise for the majority of people. So take the time to follow their flow chart if you’re unsure of where you fall. If it’s safe for you to get started why not get going today? If you need medical clearance, I encourage you to book your appointment with a healthcare professional right after you read this post. It’s never too late to start exercising, but the sooner you do, the sooner you’ll become a healthier and fitter version of you.
