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 demo 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.

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For people focused on healthy eating in the new year, advice from certified (and, problematically, non-specialists) can be hard to decipher, never mind follow. But one diet in particular has withstood the test of time and been repeatedly heralded by doctors and researchers as promoting vitality and longevity.

The Mediterranean diet, identified in the 1950s through a global study of men's heart health, is a pattern of eating based on the habits of Italians, Greeks, and others who live in the region. The regimen favors healthy fats such as those found in olive oil and nuts and sets limits on consumption of animal products.

Walter Willett, a professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health, has spent more than three decades studying links between food and health, with special attention to the Mediterranean diet, around which, he says, "there are a lot of misconceptions." In a conversation with the Gazette, edited for clarity and length, he cleared some of them up.

Q&A: Walter Willett

GAZETTE: How strict are the rules of the diet?

WILLETT: Well, there's quite a bit of flexibility—that's probably one of the reasons people can stay with it for the long run.

A general rule of thumb is to think about having two servings of animal-sourced foods per day, which would be about one serving of dairy a day and about one serving of another animal-sourced protein. This could mean having red meat about once a week, fish a couple of times a week, poultry a couple of times a week, and eggs a couple of times a week. That's a pretty good goal. If someone would like to further reduce animal-sourced foods or be a strict vegan, that can also work, but taking an inexpensive multivitamin/multimineral supplement is desirable to ensure adequate micronutrient intake.

While this would be an appreciable shift for many Americans, it's not difficult because most of the ingredients are foods that are already familiar. Although I should say that 25 years ago, many people were not very familiar with whole grains. And most people were not familiar with good olive oil. I remember growing up in Michigan, my mom had this little bottle of olive oil up on the top shelf that had been sitting there for years; it was rancid and tasted terrible. Adopting the Mediterranean dietary pattern is likely to mean some adjustments and new flavors, but in general, they're things that most people can find enjoyable.

In terms of the percentage of calories from fat, this can vary but will usually be about 30% to 40% of calories, as long as they're mostly healthy fats from plant sources such as olive oil.

Importantly, we've also learned enough about the components of the Mediterranean diet so that those components can be put together in other eating cultures—Asian, Latin American, African—to produce what might be called a Mediterranean-type diet based on different flavors and different foods.

For example, you could swap out olive oil for many other types of plant oils. In Asian diets soybean oil has traditionally been one of the dominant oils, used for preparing stir-fried dishes with lots of vegetables and nuts. The available fruits may also be different, and tofu is a widely consumed plant-protein source.

About two years ago, we published a paper examining olive oil consumption here in the U.S. in relation to risk of heart disease and total mortality. In our large cohort studies, there were inverse relationships—in other words, better health with higher amounts of olive oil in the diet, but we also observed similar inverse relationships with other plant oils, like soybean and canola oil.

GAZETTE:What if I follow the diet most but not all of the time?

WILLETT: Of course, this depends what you do on those other days. If half the time you eat the average American diet—which is lots of refined starch, sugar, meat, and dairy foods—you'll get about half the benefit of the Mediterranean diet. If you really wanted to get the full benefit, it would be eating a healthy dietary pattern most of the time. Looked at another way, there is benefit with each step in the right direction.

This pattern is related to lower risk of cardiovascular disease, diabetes, multiple cancers, neurologic diseases, dementia—the list just goes on and on.

Some of us who have become accustomed to a Mediterranean-type pattern find the thought of returning to our Midwestern pattern—with large servings of meat, mountains of potatoes, lakes of butter, and slabs of cheese—a bit repulsive. But again, if someone really wants to have a sizable piece of red meat, like people in the Mediterranean region do a few times a year on special occasions, that's OK, too.

GAZETTE: What are some of the biggest misconceptions about the diet?

WILLETT: The big one was that all fat is bad and therefore the Mediterranean diet should be avoided. This was conventional wisdom in the nutrition community in the 1980s and 1990s, and it was embedded in dietary guidelines. The nutrition community has moved on to focus on the types of fat, which is supported by layers of evidence, but there are still lingering strains of this idea.

GAZETTE: The Mediterranean diet is far from the only area of study related to food and health. What else have we learned lately?

WILLETT: Until recently, we have had little information on diet during childhood and adolescence in relation to long-term health. We are now able to look at the effects of diet at different points in life. So far, diet during adolescence appears to be particularly important for cancer risk later in life, and sometimes even more important than what we're eating in midlife.

Another major part of our current work is the impact of our diets on environmental sustainability and climate change, which is an existential issue. In this respect, the Mediterranean diet is quite good, because it is primarily plant-based.

We're also digging down to look in more detail at specific fruits and vegetables. We have typically lumped them all together, but what does a carrot have in common with, say, a head of lettuce? It's not very much, and we are seeing that they may have different health effects. Some appear to be particularly important for breast cancer prevention.

Greater specificity is important. Because somebody could be eating a lot of fruits and vegetables but be missing out on some important parts of the overall basket of different foods. Also, almost everything has side effects, and we shouldn't assume that fruits and vegetables have none. One example where we can get into trouble is eating too much spinach, which has health benefits but can also cause kidney stones, presumably due to its high content of oxalate. In the U.S. diet, when we encourage consumption of green leafy vegetables, people think this overwhelmingly means spinach.

GAZETTE: For people interested in adopting the Mediterranean diet, what's a good first step?

WILLETT: It is important that we enjoy what we eat, or we probably won't stay with those foods. So I would suggest thinking about the components of the Mediterranean diet and starting with parts that are enjoyable, and building on this by adding more variety, especially for vegetables and the methods of preparing them. This can include grilling, roasting, and adding to salads. Healthy fats are important, and extra-virgin olive oil is a central core of the traditional Mediterranean diet. However, there are many varieties and flavors, so trying many to find some that fit your taste can be an adventure. As I mentioned, other liquid plant oils can also be healthy, and these can also be explored; you may want different ones for dressing salads versus sautéing your vegetables. We also see that nuts are particularly healthy, and there are many types with different flavors, so think about expanding their use, such as with breakfast, in salads, and as alternatives to meat in mixed dishes.

Those are some places to start—basically I would encourage being adventuresome.

This story is published courtesy of the Harvard Gazette, Harvard University's official newspaper. For additional university news, visit Harvard.edu.

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COPS have called in a specialist team of divers who have specialist sonar equipment to help search the river near where Nicola Bulley vanished.

The dog walker, 45, disappeared after dropping her children off at school in St Michael's on Wyre, Lancashire, on Friday January 27.

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Since then there has been no trace of the mum-of-two, leaving her family in agony.

Cops this week revealed their "main working hypothesis" was that Nicola had "sadly fallen" into the icy River Wyre.

And now a private specialist diving group revealed they are on the way to search the water.

Specialist Group International (SGI) offered to help Lancashire Police days ago but the force refused, they claim.

Now, cops announced the group WILL help in the hunt for Nicola.

A post on SGI's Facebook page read: “I have just had a long call with the Lancashire Police search adviser to discuss the search for Nicola. 

“We will work closely with the police search teams who are working long hours to find Nicola.

“The team are leaving shortly from our base in Dorking on route to Lancashire to start tomorrow morning.”

The team will be using a high-spec sonar "which can see every stick and stone lying on the riverbed".

CGI boss Mr Faulding said the company's £55,000 side-scan sonar has a high frequency of 1,800 kilohertz - meaning it will be able to examine every area.

Earlier this week, SGI claimed they contacted the police and offered to help, but their offer was denied.

SGI blasted at the time: “Unfortunately, Lancashire police have responded via the family declining my offer saying they will continue with their own river searches using their current resources.”

But in a statement last night, Lancashire Police announced a U-turn.

The force said: "SGI have reached out to the family and offered to assist in the search for Nicola. Lancashire Police have already liaised with them.

"They will deploy under the direction of Lancashire Police and will join an already large, multi-agency search operation involving a wide variety of search assets and resources.

"Their capability will overlay what has already been, and continues to be completed, in order to give extra search coverage along what is an extremely challenging environment to search."

Yesterday, Mr Faulding branded the Nicola probe "a mess" as crucial evidence may have been missed.

He also slammed the cops for not closing off the area where Nicola vanished, saying they were too quick to assume there were no suspicious circumstances.

It comes after the first CCTV images of missing mum Nicola Bulley on the day she vanished were released.

Snaps from Nicola's own Ring Doorbell show her loading her car outside her home just hours before she went missing on a riverside walk.

She is seen on security footage wearing a long dark coat, leggings and ankle boots with her hair tied in a ponytail.

She then hops into her Mercedes 4x4 before taking off on the school run to drop off her two daughters.

A friend of Nicola released the CCTV footage in a bid to find her.

It comes as another friend begged the public to keep their minds open about the cause of her disappearance.

Leanne Grace wrote on Facebook: “I’m about to watch the sunset on another day. 

“The hours are passing so slowly yet have somehow turned to days and now over week. Every day is getting harder for your friends and family and our hearts break a little more. 

“Trying to carry on with everyday life just doesn’t feel right.

"We will not give up on you Nicola. Please keep searching everyone.

“Despite the police hypothesis that Nicola may have fallen into the water, please be aware that there is no evidence to back this up. 

“There are still other avenues that have not yet been explored.

"If anyone has any information please contact the police immediately, no matter how small or insignificant you may think it is.

"Nikki has to be out there. Please help to get her home to her family. We love you Nik.”

On the day she went missing the mum-of-two was wearing an ankle-length black quilted gilet jacket, a black Engelbert Strauss waist-length coat which was worn underneath the gilet, tight-fitting black jeans, long green walking socks tucked into her jeans, ankle-length green Next wellies, a necklace and a pale blue Fitbit.

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