Abstract and Introduction

Abstract

The promotion of physical activity is at the top of our national public health agenda. Although regular exercise reduces subsequent cardiovascular morbidity and mortality, the incidence of a cardiovascular event during exercise in patients with cardiac disease is estimated to be 10 times that of otherwise healthy persons. Adequate screening and evaluation are important to identify and counsel persons with underlying cardiovascular disease before they begin exercising at moderate to vigorous levels. This statement provides recommendations for cardiovascular screening of all persons (children, adolescents, and adults) before enrollment or participation in activities at health/fitness facilities. Staff qualifications and emergency policies related to cardiovascular safety are also discussed.

Introduction

The message from the nation's scientists is clear, unequivocal, and unified: physical inactivity is a risk factor for cardiovascular disease,^[7,18] and its prevalence is an important public health issue. New scientific knowledge based on epidemiological observational studies, cohort studies, controlled trials, and basic research has led to an unprecedented focus on physical activity and exercise. The promotion of physical activity is at the top of our national public health agenda, as seen in the publication of the 1996 report of the U.S. Surgeon General on physical activity and health.^[20]

The attention now being given to physical activity supports the goals of Healthy People 2000^[10] and should lead to increased levels of regular physical activity throughout the U.S. population, including the nearly one fourth of adult Americans who have some form of cardiovascular disease.^[3] Although regular exercise reduces subsequent cardiovascular morbidity and mortality,^[7,17,18] the incidence of a cardiovascular event during exercise in patients with cardiac disease is estimated to be 10 times that of otherwise healthy persons.^[8] Adequate screening and evaluation are important to identify and counsel persons with underlying cardiovascular disease before they begin exercising at moderate to vigorous levels.

Moderate (or higher) levels of physical activity and exercise are achieved in a number of settings, including more than 15,000 health/fitness facilities across the country. A latest survey of 110 health/fitness facilities in Massachusetts found that efforts to screen new members at enrollment were limited and inconsistent.^[14] Nearly 40% of responding facilities stated that they do not routinely use a screening interview or questionnaire to evaluate new members for symptoms or history of cardiovascular disease, and 10% stated that they conducted no initial cardiovascular health history screening at all.

This statement provides recommendations for cardiovascular screening of all persons (children, adolescents, and adults) before enrollment or participation in activities at health/fitness facilities. Staff qualifications and emergency policies related to cardiovascular safety are also discussed. Health/fitness facilities are defined here as organizations that offer health and fitness programs as their primary or secondary service or that promote high-intensity recreational physical activity (e.g., basketball, tennis, racquetball, and swim clubs). Ideally such facilities have a professional staff, but those that provide space and equipment only (e.g., unsupervised hotel exercise rooms) are also included. A health/fitness facility user is defined as a dues-paying member or a guest paying a regular daily fee to use the facility specifically to exercise. These recommendations are intended to assist health/fitness facility staff, healthcare providers, and consumers in the promotion and performance of safe and effective physical activity/exercise.

The writing group based these recommendations on a review of the literature and the consensus of the group. Earlier statements from the American Heart Association (AHA) and the American College of Sports Medicine (ACSM) are highlighted and supplemented. These recommendations were peer reviewed by selected authorities in the field representing the AHA, the ACSM, the American College of Cardiology, the International Health Racquet and Sports Clubs Association (IHRSA), and the Young Men's Christian Association. The recommendations are not mandatory or all-encompassing, nor do they limit provision of individualized care by practitioners exercising independent judgment. With this statement the AHA and the ACSM assume no responsibility toward any individual for whom this statement may be applied in the provision of individualized care. Specific details about exercise testing and training of persons with and without cardiovascular disease and those with other health problems are provided elsewhere.^[2,6,8,21] The ACSM has published comprehensive guidelines for operating health/fitness facilities.^[19] Although issues in competitive sports are beyond the scope of this statement, the 26th Bethesda Conference^[28] on sudden cardiac death in competitive athletes and the AHA^[12] provide specific recommendations for the screening and evaluation of athletes for congenital heart disease, systemic hypertension, and other cardiovascular diseases before participation in competitive sports.

Cardiovascular Screening

Rationale. Regular exercise results in increased exercise capacity and physical fitness, which can lead to many health benefits. Persons who are physically active appear to have lower rates of all-cause mortality, probably because of a decrease in occurrence of chronic illnesses, including coronary heart disease. This benefit may be the result of an improvement in cardiovascular risk factors in addition to enhanced fibrinolysis, improved endothelial function, decreased sympathetic tone, and other as yet undetermined factors.^[7] Regular endurance exercise leads to favorable alterations in the cardiovascular, musculoskeletal, and neurohumoral systems. The result is a training effect, which allows an individual to do increasing amounts of work while lowering the heart rate and blood pressure response to submaximal exercise. Such an effect is particularly desirable in patients with coronary artery disease because it allows increased activity with less ischemia.^[7]

The Centers for Disease Control and Prevention,^[18] the ACSM,^[18] and the AHA^[6] recommend that every American participate in at least moderate-intensity physical activity for ≥ 30 min on most, if not all, days of the week. Unfortunately, many Americans are sedentary or perform too little physical activity; only 22% of adult Americans engage in regular exercise ≥ 5 times a week.^[20] The prevalence of physical inactivity is higher among culturally diverse segments of the U.S. population, low-income groups, the elderly, and women.^[20] It is important for healthcare providers to educate the public about the benefits of physical activity and to encourage more leisure-time exercise, particularly for those who are underactive. Consumers should seek information about safe and effective ways to increase physical activity and initiate and maintain a regular program of exercise.

Efforts to promote physical activity will result in an increasing number of persons with and without heart disease joining the more than 20 million persons who already exercise at health/fitness facilities.^[16] Current market research indicates that 50% of health/fitness facility members are older than 35 yr, and the fastest-growing segments of users are those older than 55 yr and those aged 35-54 yr.^[16] With increased physical activity, more people with symptoms of or known cardiovascular disease will face the cardiovascular stress of physical activity and possible risk of a cardiac event. More than one fourth of all Americans have some form of cardiovascular disease.^[3] The prevalence of coronary heart disease for American adults aged 20 yr and older is 7.2% in the general population, 7.5% for non-Hispanic whites, 6.9% for non-Hispanic blacks, and 5.6% for Mexican Americans.^[3] The prevalence of myocardial infarction in older Americans aged 65-69 yr is 18.0% and 9.7% for men and women, respectively.^[3]

Moderately strenuous physical exertion may trigger ischemic cardiac events, particularly among persons not accustomed to regular physical activity and exercise. Siscovick et al.^[23] examined the incidence of primary cardiac arrest in men aged 25-75 yr after excluding those with a history of clinically recognized heart disease. Although the risk was significantly increased during high-intensity exercise, the likelihood for primary cardiac arrest during such activity in a clinically healthy population was estimated at 0.55 events/10,000 men per year. Maron et al.^[13] studied causes of sudden death in competitive athletes. In persons younger than 35 yr, 48% of deaths were due to hypertrophic cardiomyopathy. Coronary artery anomalies, idiopathic left ventricular hypertrophy, and coronary heart disease each accounted for 10-20% of deaths. In those over 35, coronary artery disease accounted for approximately 80% of all deaths. Overall, the absolute incidence of death during exercise in the general population is low.^[25,26,29]Each year approximately 0.75 and 0.13/100,000 young male and female athletes^[29]and 6/100,000 middle-aged men die during exertion.^[25] No estimates are available for middleaged women or the elderly.

Cardiovascular events other than death during exercise have also been studied. Data from the Framingham heart study indicate that the baseline risk of myocardial infarction in a 50-yr-old man who is a nonsmoker and does not have diabetes is approximately 1% per year, or approximately 1 chance per million per hour.^[4] Heavy exertion [≥ 6 METs (metabolic equivalents)] within 1 h of symptomatic onset of acute myocardial infarction has been reported in 4.4-7.1% of patients.^[15,31] The adjusted relative risk is significantly greater in persons who do not participate in regular physical activity, with an approximate threefold increase in risk during the morning hours. The relation of physical activity to acute myocardial infarction in the thrombolytic era was examined among 3339 patients in the TIMI II trial,^[27] in which moderate or marked physical activity preceded myocardial infarction in 18.7% of patients.

Van Camp et al.^[30] reported the incidence of major cardiovascular complications in 167 randomly selected cardiac rehabilitation programs that provided supervised exercise training to 51,000 patients with known cardiovascular disease. The incidence of myocardial infarction was 1 per 294,000 person-hours; the incidence of death was 1 per 784,000 person-hours.

Screening Prospective Members/Users.All facilities offering exercise equipment or services should conduct cardiovascular screening of all new members and/or prospective users. The primary purpose of preparticipation screening is to identify both those not known to be at risk and those known to be at risk for a cardiovascular event during exercise. latest evidence suggests that screening by health/fitness facilities is done only sporadically.^[14] In Canada, evidence from the Canadian Home Fitness test and its screening instrument, the Physical Activity Readiness Questionnaire (PAR-Q), suggests that even simple screening questionnaires can effectively identify many persons at high risk and increase the safety of nonsupervised exercise.^[22] Current knowledge of the relation between identifiable risk factors, the incidence of cardiovascular disease, and the triggering factors for acute myocardial infarction suggests that screening is both reasonable and prudent.

The cost-effectiveness of preparticipation screening is an important consideration. Exercise testing is comparatively expensive. The incidence of false-positive findings when testing asymptomatic persons^[9] and the need to follow up abnormal results can lead to subsequent and more costly procedures. A thorough and mandatory screening process that might prove optimally sensitive in detecting occult cardiovascular disease might be so prohibitive to participation that fewer persons would engage in a fitness program. Such a result would be counterproductive to the goal of maximizing physical activity. Because most of the health benefits of exercise accrue at moderate levels of intensity,^[18] in which the risks are probably low, recommendations that would inhibit large numbers of persons from participating in exercise programs are not justified. Preparticipation screening should identify persons at high risk and should be simple and easy to perform. Public health efforts should focus on increasing the use of preparticipation screening.

Two practical tools for preparticipation screening are likely to have an effect on identifying high-risk individuals without inhibiting their participation in exercise programs. The PAR-Q^[24] (Table 1) is a self-administered questionnaire that focuses primarily on symptoms that might suggest angina pectoris. Participants are directed to contact their personal physician if they answer "yes" to ≥ 1 questions. The PAR-Q also identifies musculoskeletal problems that should be evaluated before participation because these might involve modification of the exercise program. The questionnaire is designed to be completed when the participant registers at a health/fitness facility. In unsupervised fitness facilities (e.g., hotel fitness centers), the PAR-Q can be self-administered by means of signs prominently displayed at the main entry into the facility. Although less satisfactory than documenting the results of screening, use of signs and similar visual methods are a minimal recommendation for encouraging prospective users to assess their health risks while exercising at any facility.

Another simple, self-administered device that aims to identify high-risk individuals without negatively impacting participation is a questionnaire patterned after one developed by the Wisconsin Affiliate of the American Heart Association^[11] (Table 2). The one-page form is slightly more complex than the PAR-Q and uses history, symptoms, and risk factors (including age) to direct prospective members to either participate in an exercise program or contact their physician (or appropriate healthcare provider) before participation. Persons at higher risk are directed to seek facilities providing appropriate levels of staff supervision. The questionnaire can be administered within a few minutes on the same form participants use to join or register at the facility. It identifies potentially high-risk participants, documents the results of screening, educates the consumer, and encourages and fosters appropriate use of the healthcare system. In addition, it can guide staff qualifications and requirements. This instrument is also simple enough to be adapted for use as self-screening signs posted in nonstaffed facilities.

Health appraisal questionnaires should preferably be interpreted by qualified staff (see next section for criteria) who can limit the number of unnecessary referrals for preparticipation medical evaluation, avoiding undue expense and barriers to participation.

In view of the potential legal risk assumed by operators of health/fitness facilities, it is recommended that all facilities providing staff supervision document the results of screening. Screening, particularly for participants for whom a medical evaluation is recommended, requires time, personnel, and financial resources. Individual facilities can determine the most cost-effective way to conduct and document preparticipation screening.

Every effort should be made to educate all prospective new members about the importance of obtaining a health appraisal and-if indicated-medical evaluation/recommendation before beginning exercise testing/training. The potential risks inherent in not obtaining an appraisal should also be emphasized. Without an appraisal, it is impossible to determine whether a person may be at significant risk of severe bodily harm or death by participating in an exercise program. The same is true of persons who undergo a health appraisal, are identified as having symptoms of or known cardiovascular disease, and refuse or neglect to obtain the recommended medical evaluation yet seek admission to a health/fitness facility program. Due to safety concerns, persons with known cardiovascular disease who do not obtain recommended medical evaluations and those who fail to complete the health appraisal questionnaire upon request may be excluded from participation in a health/fitness facility exercise program to the extent permitted by law.

Persons without symptoms or a known history of cardiovascular disease who do not obtain the recommended medical evaluation after completing a health appraisal should be required to sign an assumption of risk or release/waiver. Both of these forms may be legally recognized in the jurisdiction where the facility is located. When appropriate guidelines are followed, it is likely that the potential benefits of physical activity will outweigh the risks. Persons without symptoms or a known history of cardiovascular disease who do not obtain recommended medical evaluations or sign a release/waiver upon request may be excluded from participation in a health/fitness facility exercise program to the extent permitted by law. Persons who do not obtain an evaluation but who sign a release/waiver may be permitted to participate. However, they should be encouraged to participate in only moderate- or lower-intensity physical activities and counseled about warning symptoms and signs of an impending cardiovascular event.

The major objectives of preparticipation cardiovascular screening are to identify persons with known cardiovascular disease, symptoms of cardiovascular disease, and/or risk factors for disease development who should receive a medical evaluation/recommendation before starting an exercise program or undergoing exercise testing. Screening also identifies persons with known cardiovascular disease who should not participate in an exercise program or who should participate at least initially in a medically supervised program, as well as persons with other special needs.^[8,19]

Screening also serves another purpose. One of the trends in cardiac rehabilitation is to "mainstream" low-risk, clinically stable patients to community facilities rather than specialized, often costly cardiac programs. Facility directors should expect that an increasing percentage of their participants will have health histories that warrant supervision of exercise programs by professional staff.

When a medical evaluation/recommendation is advised or required, written and active communication with the individual's personal physician (or healthcare provider) is strongly recommended. The trial letter and medical release form in Table 3A and B, can be used or modified for such purposes.

Characteristics of Participants. Intensity of physical activity is measured through endurance- or strength-type exercise as defined in Table 4. Health appraisal questionnaires should be used before exercise testing and/or training to initially classify participants by risk for triage and preliminary decision making (Table 5), namely, apparently healthy persons (Class A-1), persons at increased risk (Classes A-2 and A-3), and persons with known cardiovascular disease (Classes B, C, and D). Apparently healthy persons of all ages and asymptomatic persons at increased risk (Classes A-1 through A-3) may participate in moderateintensity exercise without first undergoing a medical examination or a medically supervised, symptom-limited exercise test. Apparently healthy younger persons (Class A-1) may also participate in vigorous exercise without first undergoing a medical examination and a medically supervised exercise test. It is suggested that persons classified as Class A-2 and particularly Class A-3 undergo a medical examination and possibly a maximal exercise test before engaging in vigorous exercise. All other persons (Classes B and C) should undergo a medical examination and perform a maximal exercise test before participation in moderate or vigorous exercise unless exercise is contraindicated (i.e., Class D). Data from a medical evaluation performed within 1 yr are acceptable unless clinical status has changed. Medically supervised exercise tests should be conducted in accordance with previously published guidelines.^[8]

Using Screening Results for Risk Stratification. With completion of the initial health appraisal and, if indicated, medical consultation and supervised exercise test, participants can be further classified for exercise training on the basis of individual characteristics detailed below. The following classifications have been modified using existing AHA^[8] and ACSM^[2] guidelines and are recommended (Table 5):

Class A: Apparently Healthy. There is no evidence of increased cardiovascular risk for exercise. This classification includes 1) "apparently healthy" younger persons (Class A-1) and 2) irrespective of age, persons who are "apparently healthy" or at "increased risk" (Classes A-2 and A-3) and who have a normal diagnostic maximal exercise test. Submaximal exercise tests are sometimes performed at health/fitness facilities where permitted by law for nondiagnostic purposes, including physical fitness assessment, exercise prescription, and monitoring of progress.^[2] Such testing is also useful for educating participants about exercise and for motivating them. Nondiagnostic exercise testing should be conducted only for persons in Class A and only by appropriately qualified, well-trained personnel (see section on staffing below) who are knowledgeable about indications and contraindications for exercise testing, indications for test termination, and test interpretation. All health/fitness facilities, including those where exercise testing is performed, should have an emergency plan (see section on emergency policies and procedures below) to ensure that emergencies are handled safely, efficiently, and effectively. No restrictions other than provision of basic guidelines are required for exercise training. No special supervision is required during exercise training.

Class B: Presence of known, Stable Cardiovascular Disease with Low Risk for Vigorous Exercise but Slightly Greater than for Apparently Healthy Persons. This classification includes clinically stable persons with 1) coronary artery disease (myocardial infarction, coronary artery bypass surgery, percutaneous transluminal coronary angioplasty, angina pectoris, abnormal exercise test, or abnormal coronary angiogram); 2) valvular heart disease; 3) congenital heart disease (risk stratification for patients with congenital heart disease should be guided by the 26th Bethesda Conference recommendations^[28]); 4) cardiomyopathy (includes stable patients with heart failure with characteristics as outlined below but not latest myocarditis or hypertrophic cardiomyopathy); and 5) exercise test abnormalities that do not meet the criteria outlined in Class C below. The clinical characteristics of such persons are 1) New York Heart Association (NYHA) Class I or II (Table 6); 2) exercise capacity > 6 METs; 3) no evidence of heart failure; 4) free of ischemia or angina at rest or on the exercise test ≤ 6 METs; 5) appropriate rise in systolic blood pressure during exercise; 6) absence of nonsustained or sustained ventricular tachycardia; and 7) ability to satisfactorily self-monitor intensity of activity. For these persons, activity should be individualized with exercise prescription by qualified personnel. Medical supervision is recommended during prescription sessions and nonmedical supervision by appropriately qualified staff for other exercise sessions until the participant understands how to monitor his or her own activity. Subsequent exercise training may be performed without special supervision.

Class C: Those at Moderate to High Risk for Cardiac Complications during Exercise and/or who are Unable to Self-regulate Activity or Understand the Recommended Activity Level. This classification includes persons with 1) coronary artery disease with the clinical characteristics outlined below; 2) acquired valvular heart disease; 3) congenital heart disease (risk stratification for patients with congenital heart disease should be guided by the 26th Bethesda Conference recommendations^[28]); 4) cardiomyopathy (includes stable patients with heart failure with characteristics as outlined below but not latest myocarditis or hypertrophic cardiomyopathy); 5) exercise test abnormalities not directly related to ischemia; 6) a previous episode of ventricular fibrillation or cardiac arrest that did not occur in the presence of an acute ischemic event or cardiac procedure; 7) complex ventricular arrhythmias that are uncontrolled at mild to moderate work intensity with medication; 8) threevessel or left main coronary artery disease; and 9) ejection fraction < 30%. One or more of the following clinical characteristics are also present: 1) two or more previous myocardial infarctions; 2) NYHA Class III or greater; 3) exercise capacity < 6 METs; 4) ischemic horizontal or down-sloping ST depression ≥ 1 mm or angina at a workload ≤ 6 METs; 5) a fall in systolic blood pressure with exercise; 6) a medical problem that the physician believes may be potentially life-threatening; 7) a previous episode of primary cardiac arrest; and 8) ventricular tachycardia at a workload < 6 METs. Physical activity should be individualized, and exercise should be prescribed by appropriately qualified medical personnel. Medical supervision, monitoring for adverse signs and symptoms, electrocardiographic monitoring of heart rate and rhythm, and blood pressure monitoring are recommended during exercise sessions until safety is established. Subsequent exercise training should be supervised by appropriately qualified personnel.

Class D: Unstable Conditions with Activity Restriction. This classification includes those with 1) unstable ischemia; 2) heart failure that is not compensated; 3) uncontrolled arrhythmias; 4) severe and symptomatic aortic stenosis; 5) hypertrophic cardiomyopathy or cardiomyopathy from latest myocarditis; 6) severe pulmonary hypertension; or 7) other conditions that could be aggravated by exercise (for example, resting systolic blood pressure > 200 mm Hg or resting diastolic blood pressure > 110 mm Hg; active or suspected myocarditis or pericarditis; suspected or known dissecting aneurysm; thrombophlebitis and latest systemic or pulmonary embolus). In this population no physical activity is recommended for conditioning purposes. Risk stratification for patients with congenital heart disease should be guided by the 26th Bethesda Conference recommendations.^[28]

These classifications are presented as a means of beginning exercise with the lowest possible risk. They do not consider accompanying morbidities (for example, insulindependent diabetes mellitus, morbid obesity, severe pulmonary disease, complicated pregnancy, or debilitating neurological or orthopedic conditions) that may constitute a contraindication to exercise or necessitate closer supervision during exercise training.

Using Screening Results for Exercise Prescription. For individuals considered to be in Class A, exercise training intensity (Table 4) may be prescribed using the rating of perceived exertion alone and/or specific target heart rates. A suggested rating of perceived exertion for such persons is 12-16 (moderate to hard) on the Borg scale of 6-20 and/or an intensity level that corresponds to 50-90% of maximum heart rate or 45-85% of maximum oxygen uptake or heart rate reserve. Heart rate reserve is defined as maximum heart rate minus resting heart rate. For persons taking medications that affect heart rate (e.g., β-adrenergic blockers), these heart rate methods do not apply unless guided by an exercise tolerance test.

In the absence of atrial fibrillation, frequent atrial or ventricular ectopy, a fixed-rate pacemaker, or similar conditions, exercise intensity should be prescribed for persons with cardiovascular disease (Class B or C) using target heart rates and perceived exertion ratings in accordance with previously published guidelines.^[2,8] For these persons, target heart rates should be prescribed using data obtained during exercise testing performed while the participant is taking his or her usual cardioactive medications. In the absence of myocardial ischemia or other significant exercise test abnormalities, a target range of 50-90% of peak heart rate or 45-85% of peak measured oxygen uptake or heart rate reserve is recommended. This intensity level corresponds to 12-16 (moderate to hard) on the Borg scale. In the presence of myocardial ischemia (i.e., ischemic ST-segment depression > 1 mm, chest discomfort believed to be angina pectoris, or other symptoms believed to be an anginal equivalent), significant arrhythmia, or other significant exercise test abnormalities (e.g., a fall in systolic blood pressure from baseline, systolic blood pressure > 240 mm Hg, or diastolic blood pressure > 110 mm Hg), the target training intensity is derived from the heart rate associated with the abnormality. If this occurs at a high level of exercise, the above target heart rate recommendations are applicable, provided that the upper limit of the range is at least 10 beats per minute (bpm) below the level at which the abnormality appears. Other-wise, the recommended upper limit of training heart rate is 10 bpm less than that associated with the abnormality.

Staffing

Health/fitness facility personnel involved in management or delivery of exercise programs must meet academic and professional standards and have the required experience as established by the ACSM.^[2,19] Such personnel include the general manager/executive director, medical liaison, fitness director, and exercise leader. In general, health/fitness facility personnel should have the formal training and experience needed to ensure that clients are provided with safe, effective programs and services. The levels of education and experience needed to ensure effectiveness and safety vary with the health status of the client population. The kinds of personnel who should be employed at health/fitness faciliies serving various types of clients are summarized in Table 5.

The general manager/executive director is responsible for the overall management of the facility and should have competencies in business as well as design and delivery of exercise programs.

The medical liaison reviews medical emergency plans, witnesses and critiques medical emergency drills, and reviews medical incident reports. In level 2 and 3 facilities (Table 5), the medical liaison may be a licensed physician, a registered nurse trained in advanced cardiac life support, or an emergency medical technician. In level 4 and 5 facilities (Table 5), the medical liaison must be a licensed physician.

The fitness director manages the facility's exercise and activity programs and is responsible for program design and the training and supervision of staff. He or she must have a degree in exercise science, another health-related field, or equivalent experience, and knowledge of exercise physiology, exercise programming, and operation of exercise facilities. The fitness director must hold professional certification at an advanced level by a nationally recognized health/fitness organization. In level 3 facilities this certification should be comparable to ACSM health fitness instructor certification. In level 4 and 5 facilities the fitness director should be certified at a level that correlates with ACSM exercise specialist certification. The exercise specialist typically holds a master's degree in exercise science or a related field and has extensive experience in exercise testing and leadership in clinical populations. He or she must be trained in cardiopulmonary resuscitation (CPR) and should have at least 1 yr of supervisory experience in the fitness industry.

The exercise leader works directly with program participants and provides instruction and leadership in specific modes of exercise. He or she also helps program participants master the behavioral skills needed to adhere to exercise programs. In level 1, 2, and 3 facilities the exercise leader as a minimum must have a high school diploma or equivalent and entry-level or higher professional certification from a nationally recognized health/fitness organization (comparable to ACSM exercise leader certification). In level 4 facilities, the exercise leader should have education and experience corresponding to that required by ACSM health fitness instructor certification. In level 5 facilities, the exercise leader should be either an exercise specialist or a health fitness instructor directly supervised by an exercise specialist. In all cases the exercise leader must be trained in CPR and should have prior supervised internship or work experience in the health/fitness industry.

Some health/fitness facilities provide services in allied health fields such as nutrition, stress management, and physical therapy. Personnel providing such services should meet current accepted professional standards in those fields and should be certified as recommended by relevant professional organizations and licensed by or registered with the state as required by law.

Emergency Policies and Procedures

All health/fitness facilities must have written emergency policies and procedures that are reviewed and practiced regularly. Such plans will correspond to the type of facility and risk level of its membership outlined in Table 5. All fitness center staff who directly supervise program participants should be trained in basic life support. Health/fitness facilities must develop appropriate emergency response plans and must train their staff in appropriate procedures to provide during a life-threatening emergency. When an incident occurs, each staff member must perform the necessary emergency support steps in accordance with established procedures. It is important for everyone to know the emergency plan. Emergency drills should be practiced once every 3 months or more often with changes in staff; retraining and rehearsal are especially important. When new staff are hired, new team arrangements may be necessary. Because life-threatening cardiovascular emergencies are rare, constant vigilance by staff and familiarity with the plan and how to follow it are important.

It is essential to acknowledge that emergency equipment alone does not save lives. Equipment alone may offer a false sense of security if it is not backed up with appropriate staffing. The training and preparedness of an astute professional staff who can readily handle emergencies is paramount. This issue is particularly important if persons with certain medical conditions are recruited and encouraged to exercise in a specific health/fitness facility. Such a facility has the responsibility to offer appropriate coverage by personnel as outlined above and in Table 5. Acquisition of equipment for evaluation and resuscitation will depend on the risk level of participants, personnel, and medical coverage. All facilities must have a telephone that is readily accessible and available when emergency assistance is needed. It would be useful for all supervised facilities to have a sphygmomanometer and stethoscope readily available. Level 4 and 5 facilities that recruit members with known cardiovascular disease must have such equipment available, and level 5 (supervised cardiac rehabilitation) facilities should be fully equipped according to the recommendations of the AHA^[21] and the American Association of Cardiovascular and Pulmonary Rehabilitation.^[1] Such equipment includes a defibrillator, oxygen, and fully stocked crash cart. Delineation of specific equipment standards in such facilities is beyond the scope of these guidelines; such information is detailed in the documents above.^[1,21] Appropriately trained staff who are medically and legally empowered must be available to operate such devices during a facility's operational hours.

The emergency plan must address transportation of victims to a hospital emergency room and must include telephone access to 911 or the local emergency unit access system. Health/fitness facility personnel should be familiar with emergency transport teams in the area so that access and location of the center are clearly identified. Staff should greet the emergency response team at the entrance of the facility so that they can be promptly guided to the site of the emergency. A staff member should remain with the victim at all times. Prompt emergency transport is optimized by free and ready access to the victim within the health/fitness facility and assistance by designated staff.

General Considerations in Selecting a Health/Fitness Facility

In selecting a health/fitness facility, an individual should first consider his or her health status. Persons with a history of cardiovascular disease should seek facilities that provide or require a thorough medical evaluation of prospective members/users. Personnel should include nurses, exercise specialists, health/fitness instructors, and/or exercise leaders licensed or certified by the appropriate agencies, organizations, or authorities. They should be trained to recommend and supervise exercise in patients with cardiovascular and other chronic diseases. Persons at high risk for development of cardiovascular disease should seek facilities that require appropriate medical evaluation of clients and employ exercise leaders who are certified as competent to design and deliver exercise programs for high-risk persons. Table 5 summarizes personnel and safety recommendations for health/fitness facilities (levels 1 through 5) serving clients in various health categories (Classes A through C).

Persons seeking health/fitness facilities should select one that meets professional and industry standards. Facilities should be clean, well-maintained, and spacious enough to ensure the comfort and safety of program participants. Indoor facilities should be climate controlled, and changing rooms and showers should be provided. Flooring in areas where exercise is to be carried out should be designed to minimize risk of injury. Exercise equipment should be well-maintained. The variety, amount, and availability of exercise equipment should match individual needs and preferences, including time of day and preferred mode of exercise. For example, if aerobic dance is the preferred mode of exercise, individuals should seek a fitness center that offers this program at a convenient time and that provides an exercise leader who is competent in this activity and able to teach men and women of various age and fitness levels.

The programs and services of a health/fitness center should optimize participation. The location of the center should minimize time spent traveling to it. The social environment should be attractive and the staff competent in helping members/users master the behavioral skills needed to adopt and maintain a physically active lifestyle.

The Army is considering allowing soldiers who score a 540 or above on their Army Combat Fitness Test to be exempt from height and weight standards — which Sgt. Maj. of the Army Michael Grinston said Wednesday are not changing.

Grinston revealed the potential change at the annual Association of the U.S. Army conference in Washington, D.C. For a year now the Army has been conducting a study of its body composition program to ensure the height and weight requirements were accurate, and Grinston said Wednesday that they are. 

“What the study and the science has shown is that the height and weight tables are correct,” he said. 

The height and weight tables provide specific weight measurements for soldiers based on their height, gender, and age. Women who are 5’5” tall and within 21 and 27 years old, for example, can weigh a maximum of 152 pounds. Men who are 6 feet tall and within 17 and 20 years old can weight a maximum of 190 pounds. 

According to the Army regulation that mandates the service’s body composition program, AR 600-9, soldiers are screened “every 6 months, at a minimum.” If a soldier weighs outside the maximum allowance for their category, they do what is called a tape test. The tape test measures certain body parts and helps them determine their body fat percentage. 

But soldiers have raised issues with the standards in light of the new fitness test, which has soldiers building muscle in a way the previous fitness test did not. The ACFT, which became the official test of record for active duty soldiers on Oct. 1, includes a deadlift event, hand-release push-ups, standing power throw, and sprint-drag-carry, which includes running with two 40-pound kettlebell weights down and back a 25-meter lane, and pushing a 90-pound sled down and back. 

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Soldiers have said the additional muscle is negatively impacting them with the Army’s standards, particularly with the tape test. One Army major previously told Task & Purpose that they knew of soldiers who would “hit themselves in the neck thinking it will kind of cause it to swell up,” because if “you can get your neck bigger and your waist smaller, then you’re giving yourself every possible advantage.” And while Grinston maintained on Wednesday that the tape test was not a negative thing — “There should be no angst … if you go get taped,” he said — soldiers have said there is still a negative connotation associated with getting taped. 

That pressure to avoid being taped can lead to unhealthy eating and exercise habits, that soldiers and experts alike described as a wide-spread phenomenon within the military as a whole.

“Fundamentally, the Army system for height and weight is broken,” an Army captain told Task & Purpose last year. “And the Army has a very toxic understanding of health, weight, and fitness.” 

The potential exemption from height and weight standards is still being explored to nail down what exactly it would look like. For example, there may be required minimums of events that soldiers would have to meet within their score to get exemption. The change is one of four that Grinston said are being proposed as a result of the body composition program study. 

“We need more time,” Grinston said Wednesday. “We’re going to have to study this a little bit. But what we found is it’s pretty accurate, if you score there, and you were to be overweight, you may not be overweight.” 

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Saxon Fit

A program run through our Exercise Prescription class for senior-level students, Saxon Fit provides an experiential learning opportunity, fusing classroom concepts with hands-on, independent application. Senior-level students work with Alfred University faculty and staff members to achieve individual physical fitness and wellness goals through individualized personal training.

Students meet with their clients to obtain baseline information before developing a vetted program that runs for several weeks before conducting post testing to determine effectiveness and improvement. This program has already generated immense interest and students leave with a sense of accomplishment and understanding of how to apply classroom information.

Spring Health & Wellness Tips

As a community service and health/wellness promotional ideal, students in Health Promotion Program Design create weekly "Health and Wellness Tips" which are shared with the campus community via the University's internal daily electronic newsletter, Alfred today.

The task allows students to provide sound information about all things health and wellness. The students also learn how to reach broad populations while making information visually desirable and easy to access.

Field Experience

Each Fall semester, students enrolled in the Health Fitness Management Field Experience course (HFMT 305) are tasked with earning observation hours with industry professionals and assisting in aspects pertaining to the daily operation of the profession.

Parents Night Out: Kids Skill Competition

The 2020 cohort paired with the Hornell YMCA again in the Fall of 2018. They put together a proper warm-up and stretching routine with a skills competition for ages that included a teaching module, a reinforcement and skills practice and, finally, a competition in that skill. A variety of skills, such as passing (football), shooting (soccer and basketball), hand-eye coordination, along with stretching and recovery were put to the test in a "free-range" atmosphere.

The community activity was paired with the existing program "Parents Night Out" to increase attendance and sports exposure. Overall, it was a great event and kept the students active and engaged while allowing for free play after the initial program. Our students were able to gain valuable experience in community pairing and small/large group child/adolescent coaching.

Age Avengers

The 2019 cohort worked with the Hornell YMCA on program development in hopes of engaging current patrons and enticing current non-members to consider the importance of physical activity in their daily lives.

Their program, Age Avengers, brought together multiple generations from caregivers to children, to promote the joy and importance of physical activity and healthy lifestyles. Through initial development to meetings with YMCA staff, the students created and conducted the program on November 10^th, with the hope that the Hornell YMCA will continue this program on a monthly basis.

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Enrollees can receive personal health coaching, personalized workout plans, live-streamed social classes, and access to 20,000+ fitness centers and 8,600+ home workout videos in 2023

SAN DIEGO, Oct. 13, 2022 /PRNewswire/ -- The Silver&Fit^® Healthy Aging and Exercise Program, a popular fitness program provided through many Medicare Advantage plans, provides Medicare beneficiaries more options for getting fit and staying fit in 2023. The program already provides members access to 15,000+ standard and 5,000+ premium fitness centers. Offerings include national name brand chains, YMCAs, and boutique fitness studios. For those who prefer to work out at home, the program provides more than 8,600 on-demand exercise videos, including cycling, dance, Pilates, cardio, strength, yoga, HIIT, and meditation. Members can also schedule phone, video, or chat sessions with a certified health coach to support their lifestyle, nutrition, stress, sleep, or exercise goals. Other features include the ability to personalize workout plans and choose a 14-day exercise program that best fits the member's needs. Through the Silver&Fit Connected!™ program, members can monitor and track their steps and activity via a variety of wearable fitness trackers or apps, then earn rewards for their steps and activity.

Starting in 2023, members of the Silver&Fit program will have access to the Silver&Fit Well Being Club, a social club resource network through which members can learn new skills by joining live-streaming classes and events. There will also be an enhanced offering of 11 home fitness kits, such as a Pilates kit that includes gear like a Pilates ball and towel; strength training kits with dumbbells and exercise bands; and yoga kits with yoga blocks and straps.

"We're very proud to be offering new program features for millions of Medicare-eligible Americans as part of our 15^th anniversary," said George DeVries, chairman and CEO of American Specialty Health Incorporated (ASH), which launched the Silver&Fit program in 2007. "More than 4.9 million people in the United States are eligible to participate in the Silver&Fit program, and of the members we serve, we are honored that they deliver us high marks, with a 97% satisfaction rating. We hope to further Strengthen that score in 2023 with the rollout of these truly valuable benefits to help members age in even more healthy ways."

The Silver&Fit program is one of the nation's premier healthy aging and exercise programs. To learn more about healthy aging, sign up for the Silver&Fit Blog or try one of dozens of free online workout classes at https://www.facebook.com/SilverandFit/ or https://www.youtube.com/user/silverandfit/videos.

Medicare's Annual Enrollment Period runs from October 15 to December 7, 2022 and provides Medicare beneficiaries the opportunity to enroll in a Medicare Advantage (MA) plan if they are not already in one. Additionally, the MA Open Enrollment Period, which runs from January 1 – March 31, 2023, allows MA members to change their MA plan. For information about whether a specific Medicare plan includes the Silver&Fit program, consumers can contact their health plan, call 1-800-MEDICARE, or view the list of participating Silver&Fit Medicare plans here: https://www.silverandfit.com/health-plans.

ASH Fitness, a subsidiary of American Specialty Health Incorporated (ASH), provides a growing number of flexible fitness solutions for Medicare, Medicare Supplement, and commercial health plans, as well as employer groups, associations, and others. Fitness program offerings include the Silver&Fit^®, Active&Fit Enterprise^™, Active&Fit Direct™, and the consumer-direct Active&Fit Now™ programs. ASH is one of the nation's premier independent and privately-owned specialty health services organizations. For more information, visit ASHCompanies.com or call 800-848-3555.

Lisa Freeman
Silver&Fit
lisaf@ashn.com
310-422-9200

View original content to get multimedia:https://www.prnewswire.com/news-releases/the-silverfit-program-offers-new-fitness-and-well-being-benefits-through-medicare-advantage-plans-during-this-open-enrollment-season-301648144.html

SOURCE American Specialty Health Incorporated

Image source: Getty Images

You may be surprised at the benefits you're entitled to.

Key points

• Many people's health insurance plans leave them stuck with hefty bills
• Your insurance plan might actually come with hidden benefits that do the opposite.
• Look for savings on gym memberships, medications, and mental health services.

Without health insurance, the cost of receiving medical care can be truly astronomical -- enough to potentially lead to bankruptcy. But unfortunately, even with health insurance, you might still wind up with a host of medical bills due to limited coverage or needing services outside of your provider network.

But while a lot of people with health insurance can still get stuck with costly bills, some insurance plans offer a host of hidden benefits that can actually result in a nice amount of savings. Here are a few perks that may be lurking in your plan without you even realizing it.

1. Gym membership reimbursement

You might love going to the gym and staying fit, but you may not enjoy the $80 monthly credit card charge your membership results in. You may not have to pay any or all of that if your health insurance plan offers reimbursement for gym memberships.

Some plans with this feature do require you to submit records showing that you actually went to the gym. You'll need to look at your plan details to figure out how to qualify. There may also be a cap on how much reimbursement you're eligible for. For example, your plan might reimburse you up to $800 a year and if you spend more than that, the rest is on you. But still, it's better than footing that entire bill yourself.

2. No-cost medications

Many people are used to visiting the pharmacy and being charged a copay for medications. Yours might be $5, $20, or $80, depending on the type of medication you need and whether it's a brand-name drug versus the generic version. But some health insurance plans offer no-cost medications. If you need things like birth control or pills to control your cholesterol, you may find that you're entitled to them without having to fork over a copay at all.

Furthermore, you may be entitled to bulk supplies of medications at no cost -- for example, a 90-day supply of the pills you take daily. In some cases, that may require you to use a mail order service, but it's worth getting the details so you can reap the savings.

3. A wide range of mental health services

Some health insurance plans are quite generous when it comes to mental health services. You may be entitled to things like group counseling, individual therapy, free access to mental health apps, or other services that promote strong mental health.

Know what benefits you're entitled to

Reading through the rules of your health insurance plan may not seem like the most fun way to spend an afternoon. But it's important that you familiarize yourself with that information so you can not only avoid extra bills, but also take advantage of the perks that are available to you. And if you have any questions about your benefits, don't hesitate to pick up the phone and call the number on the back of your card. Sometimes, speaking to an genuine person is the best way to get the information you need.

How can health and fitness coaches reach a broader market in order to keep costs down and help more people live healthier lives? Software-as-a-service start-up FitBudd, which is today announcing a $3.4 million seed funding round, thinks it has the answer. Its platform provides a means for coaches and clients to work together at far greater scale than ever before.

FitBudd was born out of the personal experience of Saumya Mittal, CEO of the business, and her fellow founders, Pranav Chaturvedi and Naman Singhal. “I was trying to regain my fitness after having children, but I didn’t get the results I wanted until I started working with a personal trainer,” Mittal recalls. “It made me realise how important it is to have someone who keeps you on your toes and holds you accountable.”

The unusual thing about Mittal’s coach was that he was based in the US, while Mittal herself lived in India. The relationship was conducted entirely online – and Mittal and her co-founders had their eureka moment. “Having a personal coach makes all the difference in terms of getting results, but most people can’t afford this option, or simply don’t have access to it,” she says. “We started talking to coaches about whether we could help them solve the problem.”

FitBudd is the culmination of those conversations. Health and fitness coaches based anywhere in the world can sign up to the platform by paying a monthly subscription fee. It provides them with capabilities such as customer relationship management, payments systems, analytics and video calling, through which they can run their businesses. Suddenly, they can serve a global client base, offering a combination of personal face-to-face sessions conducted over the platform and additional materials such as work-out instructions and nutrition plans that clients can get at their leisure. The platform also links with clients’ own fitness devices so coaches can monitor how they are performing.

FitBudd’s vision is of a sector where coaches are able to take on and manage much larger numbers of clients than ever before, scaling their businesses – and their earnings – far more rapidly. In turn, this should enable them to lower their charges, ensuring that personal coaching becomes much more widely available – Mittal believes coaches using the platform should be able to offer their services at around a fifth of the cost of traditional training.

“We’re using technology to democratise health and fitness coaching,” says Mittal. “We want to help coaches grow their businesses and deliver more people access to help that can be life-changing.” She points to research suggesting that while people striving for health and fitness targets on their own are largely disappointed, more than 70% of those who engage a personal coach achieve their objectives.

It's early days for FitBudd, which only launched a year ago, but progress so far is encouraging. The platform has already signed up more than 1,000 coaches in around 20 countries around the world, and revenues are 10 times’ up on the initial months of trading. The aim is to hit $5 million of recurring revenues within the next 18 months.

Today’s seed round should help the business achieve that goal. FitBudd has raised $3.4 million from Accel India, Beenext, Sequoia Capital India and Waveform Ventures, with the cash earmarked for further product development and customer acquisition.

“There is a clear shift in the fitness and wellness industry of ‘solopreneurs’ breaking away from institutions and building their own digital and hybrid businesses,” says Manasi Shah, a vice president at Accel. “FitBudd is accelerating the success of these solopreneurs while providing personalisation at scale for end users.”

Mittal is eager to add to the platform’s feature set soon. She hopes to launch multi-person connectivity so that coaches can offer group classes. And FitBudd is also looking at contextual automation technologies that will help coaches manage their clients more effectively – monitoring client activity and notifying the coach if someone is falling behind, for example, in order to trigger a contact.

“Our most important objective of all is to make a dent in the deteriorating health trends we see in so many countries worldwide,” adds Mittal. “We know health and wellness coaches can make all the difference in helping people to reverse those trends, so it’s critical that more people have access to them.”