As exercise professionals ranging from clinicians to personal trainers to researchers, we know that most adults in the United States are not getting enough moderate-to-vigorous intensity aerobic physical activity (MVPA). It is important for us to understand who may be at especially high risk of physical inactivity.

Prior studies have shown that there may be differences in MVPA participation by race and ethnicity. Yet, many studies tend to use very broad groupings of race/ethnicity, often “Black,” "White,” “Hispanic” and “Other.” Although these socially constructed categories may be useful for understanding some aspects of health, it is important to recognize that there is vast diversity within these subgroups. We believed it would be helpful to be able to understand the differences in MVPA participation in more specific subgroups.

The American Cancer Society has built a large cohort of over 303,000 participants from across the United States and Puerto Rico called the). (CPS-3). This dataset includes information on self-reported MVPA, race, ethnicity, and nativity (also known as country of birth, which is another important aspect of culture that may be related to physical activity behaviors). In our study, published in the July 2022 issue of Medicine & Science in Sports & Exercise_®, we used CPS-3 data to compare leisure-time MVPA participation in 18 different racial, ethnic and nativity groups.

We found that white participants born outside of the U.S. were the most physically active, and non-white (including Black, Indigenous and mixed race) Latinos born outside of the U.S. were the least physically active of all the subgroups we examined. The difference in leisure-time MVPA between white participants born abroad and non-white Latino participants born abroad was about 6 MET-hours per week, which is the equivalent of about 2 hours of brisk walking, or 1 hour of jogging, per week.

We were also able to look at differences in MVPA within the Latino subgroup. Latinos born in Puerto Rico were considerably less active (by about 7 MET-hours/week) than Latinos born in the U.S., Mexico or all other countries combined.

It is important to point out that many existing physical activity surveys were developed for and tested on predominately white participants. Therefore, results may be affected if these surveys are used in a more diverse study, like CPS-3. In prior work within CPS-3, we compared responses to our MVPA survey with accelerometer data in Black, Latino and white participants. We found that participants in these three racial/ethnic groups had similar agreement between survey-measured MVPA and accelerometer-measured MVPA. This work supports confidence in the current survey-based findings.

As exercise professionals, we should seek to understand why there is inequity in MVPA accumulation. With that information, we can work to find solutions to increase MVPA in all population subgroups. We can educate ourselves on cultural-specific barriers to MVPA; test culturally tailored interventions and messages; and provide thoughtful, appropriate, and inclusive physical activity programming to communities. We can also lobby for safe and free physical activity opportunities. 

Erika Rees-Punia, Ph.D., MPH, is a senior principal scientist at the American Cancer Society. Dr. Rees-Punia’s research focuses on the benefits of physical activity in those with a history of cancer, physical activity measurement, and the promotion of physical activity through digital interventions. She has been a member of ACSM since 2014.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

Anastasia “Stacy” Fischer, M.D., FACSM, was installed as president of ACSM during last month’s annual meeting in San Diego. SMB editor Lenny Kaminsky, Ph.D., FACSM, asked Dr. Fischer several questions that may be of interest to ACSM members. We appreciate Dr. Fischer taking the time to provide the following answers.

Q: What can you say about ACSM’s annual meeting, the first in-person gathering of members since 2019?

A: The energy at the annual meeting was exhilarating! More than 4,000 friends and colleagues from around the world gathered in the lovely San Diego bayfront to enjoy premier science and discovery in the field of exercise science and medicine. The meeting ran smoothly and efficiently, the speakers were fantastic, and members enjoyed introductions and reunions alike. We were also able to provide a virtual meeting for those not able to attend, which has recently launched.

A: What particular challenges do you see ahead during your year as president of ACSM?

Q: ACSM continues to promote learning and member engagement during this post-COVID-19 era. We have members around the United States and world who are unable to travel for educational opportunities, so we continue to improve our website and online educational activities to meet their needs.

Q: What is your vision of what you hope to accomplish as president of ACSM? If this has changed in any way from the statement you expressed as a candidate for the position, explain why.

A: As chair of the program committee for the 2022 annual meeting, I was already able to accomplish some of my goals of celebrating Title IX and shining a spotlight on early childhood physical activity and wellness. Dr. Mary Lloyd Ireland gave an incredible D.B. Dill Historical Lecture at our annual meeting entitled “50 Years of Title IX: View through the Eyes of Athlete Turned Orthopaedic Surgeon,” where we learned how Title IX impacted Dr. Ireland and created the environment that many of us grew up in athletically and professionally. Dr. Karin Pfeiffer delivered the Joseph B. Wolffe Memorial Lecture entitled “The ABCs of Movement in Early Childhood: Building Blocks for Lifetime Physical Activity,” a fantastic lecture teaching us the importance of encouraging physical activity and play in our children, and how it helps to set them up for wellness for life.

I plan to continue to use my year to encourage all members to learn, research and provide good care to the youngest in our communities — and of course, spend the rest of 2022 celebrating Title IX!

Q: Is there anything else that you would like to share with your fellow ACSM members?

A: A sincere thank-you to all of our members who were able to make this year’s annual meeting a huge success both in person and virtually. Your continued engagement makes the college a great place to learn, grow, discover and make friends for life.

ACSM President Anastasia Fischer, M.D., FACSM, is a member of the Division of Sports Medicine in the Section of Ambulatory Pediatrics at Nationwide Children’s Hospital and a clinical associate professor of pediatrics at The Ohio State University College of Medicine. Dr. Fischer obtained a master’s degree in exercise physiology at the University of Georgia before attending medical school at The Ohio State University College of Medicine. She then completed a family practice residency at University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania, and a primary care sports medicine fellowship at Maine Medical Center in Portland, Maine.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

The influence of cardiopulmonary rehabilitation (CR) participation on desirable patient outcomes is well established. Moreover, the role clinical exercise physiologists (CEP) and exercise physiologists serve in such programs is becoming better understood and desirable in many health care settings. Less understood, and perhaps more vital for substantiating the CEP’s role in health care, are the unseen benefits these professionals guarantee through high-quality CR services.

The purpose of CR can at times be oversimplified in an attempt to educate administrators and stakeholders. The goal of improving an individual’s fitness and quality of life often takes center stage. While this is a crucial component of optimal patient outcomes, it represents only a small window of the patient’s overall well-being and prognosis. For this reason, event-free survival should be the hallmark of CR and the driving design of the CEP’s services. Decreasing length of stay (LOS) and the elimination of 30-day readmissions should be front of mind to support patients in achieving event-free survival, improved physical conditioning and overall quality of life.

The operational impacts of decreased LOS and reduction of 30-day readmissions are often overlooked because these can be difficult to quantify. Despite the challenges, positive impacts in these categories can provide substantial cost-savings opportunities for health care systems. It should be said that the difficulty in such cost analyses are often only a matter of expertise and access to information. Generally, operational finance teams take the lead when determining the costs associated with prolonged LOS and 30-day readmission events.

For many organizations, LOS and 30-day readmissions are measures that drive reimbursement contracts. Poor performance in these areas can lead to penalties or reduced reimbursement. Therefore, the quantification of these variables is instrumental in preserving operational stability. Diagnosis related groups (DRGs) are the key component in determining the cost burden of both prolonged LOS and readmissions. DRGs represent the average expected bundled cost of a particular medical event. Insurance companies use DRGs to benchmark reimbursement and contract negotiations. If individual treatment codes are like groceries, DRGs would represent the final cost once the groceries have been bagged and given to the customer.

There are two LOS types that are important in deriving costs for a particular DRG. The first is facilities’ average length of stay (ALOS), and the second is a nationalized LOS average known as the geometric mean length of stay (GMLOS). The GMLOS is an important benchmark as it is the performance measure by which reimbursement is distributed to organizations.

Consider the six-month cost analysis of LOS and readmission events for a coronary artery bypass graft (CABG) performed at Generic General Hospital under DRG 233: Generic General performed 35 cases of DRG 233 with a reported ALOS of 12.1 days for a gross total of ~420 patient days (12.1 x 35). Finance declares direct costs for this DRG case load as $1,230,480 — or $2,930/day. 

The national GMLOS for DRG 233 is 11.4 days, 0.7 days lower than Generic General’s current performance. If Generic General were to decrease their ALOS to the GMLOS standard, the organization would save $82,040 = (0.7 x $2,930 x 35) for the six-month period. The annualized amount of $164,080 is a meaningful savings for any organization. This figure is even more substantial when combined with other applicable CABG DRGs.

Readmission cost analysis is calculated in a similar way. In this case, common readmission DRGs must be identified rather than treatment event DRGs. In this way, direct costs can be calculated and applied in the same manner of LOS where the associated readmission DRG cost multiplied by the average LOS for a particular readmission event yields direct and annualized costs for an organization.

The CEPs professional efforts will accelerate when health care administrators, legislators and insurance representatives grasp the financial implications of preventing the downstream cost burden associated with prolonged LOS and readmissions. Until the associated cost burdens are demonstrated, CEPs will continue to be professionally misunderstood and their scope of practice overlooked. The business case of the CEP’s worth may just be the prospect we have been awaiting.

Cardiorespiratory fitness reflects integration of several body systems, including the cardiovascular, respiratory and musculoskeletal systems. It helps optimize heart health and is an important predictor of adverse health outcomes, including premature death, heart attack and heart disease. Indeed, the American Heart Association suggests that cardiorespiratory fitness should be measured as a vital sign during a doctor’s visit. Yet, cardiorespiratory fitness declines with age, which is thought to result from changes to heart structure and function that are further influenced by factors we can (e.g., physical activity) and cannot (e.g., heredity) change.

Interestingly, much of what we know about changes in cardiorespiratory fitness with increasing age comes from cross-sectional studies. While cross-sectional studies provide important preliminary evidence to support further research, they cannot tell us how cardiorespiratory fitness changes in the same person over time, or if the rate of decline increases as we get older. While a handful of longitudinal studies have been conducted, few young adults and people of color were included.

Understanding changes in cardiorespiratory fitness from early adulthood to midlife may be particularly important. Young adults experience several important life events, such as starting a career and/or family that might temporarily or permanently change behaviors that influence cardiorespiratory fitness. Young adults may discount the long-term benefits of regular physical activity to optimize cardiorespiratory fitness in exchange for immediate rewards, like extra time in the day. Also, there is a lack of cardiorespiratory fitness data in population-based samples that include early adults. This may be due to prioritizing study questions that specifically examine the importance of cardiorespiratory fitness to reduce risk of adverse events, which typically occur later in life.

Our study, published in the July 2022 issue of Medicine & Science in Sports & Exercise_®, sought to address this important research gap using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study. In addition to describing age-related changes in cardiorespiratory fitness from early adulthood to midlife, we also examined if there were differences in these changes by factors present in early adulthood. The CARDIA cohort, which began in 1985, includes 5,114 Black and white men and women aged 18-30 years recruited at baseline from four clinical centers in the U.S. The cohort has been re-examined every 2-5 years and a symptom-limited maximal graded exercise test protocol was included at baseline as well as the year 7 and year 20 follow-up exams. Data collection for the year 35 follow-up exam is ongoing and includes a fourth symptom-limited maximal graded exercise test.

The most important takeaway from this study was that declines in cardiorespiratory fitness occurred within the first few years of early adulthood. The rate of decline through midlife was more accelerated than previously reported in the Baltimore Longitudinal Study of Aging, ranging from 4.6% from ages 20-25 to about 10% every 5 years from ages 30 to 50. Also, these declines varied based on sex, race and other factors present in early adulthood. For example, physically active participants and those who consumed alcohol but never smoked had higher cardiorespiratory fitness in early adulthood and less of a decline in fitness through midlife. In contrast, participants who experienced overweight/obesity or reported fair or poor reported health status had lower cardiorespiratory fitness during early adulthood which persisted through midlife.

Together, these findings suggest that early adulthood is a critical life-course stage to intervene in unhealthy behaviors to optimize cardiorespiratory fitness. We simply cannot put off maintaining a healthy lifestyle for later in life. With routine follow-up of adverse events, CARDIA is well-positioned to add to what we know regarding the importance of optimizing cardiorespiratory fitness across adulthood.

Kelley Pettee Gabriel, Ph.D., M.S., FACSM, FAHA, is a professor of epidemiology at the University of Birmingham at Alabama with undergraduate and graduate training in exercise science, clinical exercise physiology and epidemiology. Dr. Gabriel actively collaborates with several large observational studies, including CARDIA, to examine the timing of physical activity and cardiorespiratory fitness on subsequent risk of disability and disease using a life-course framework. She currently serves as a principal investigator on four National Institutes of Health-funded studies.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

Public health is having a moment right now, and the fitness industry must rise to the occasion. The truth is, the fitness industry is uniquely positioned to improve many public health outcomes through promotion of regular physical activity. Positioning physical activity as part of the health care continuum — as an accessible, integral part of a healthy lifestyle for all people — is a big part of the path forward. And, we need high-performing fitness professionals to lead the way!

Fitness professionals are the “boots on the ground,” translating decades of exercise science and sports medicine research into practice. In many ways, they are the heart of the field: They change lives every day, and sometimes every hour. They have the knowledge to help those new to exercise and the skill to train elite performers. They change behaviors and impact quality of life. So, what does it take to excel as a fitness professional? I’ve outlined five must-have qualities below.

1. Credibility 

To me, credibility is founded upon the trifecta of formal education, certification and practical experience. Earning an industry-leading certification helps you establish a strong foundation of key exercise science concepts while also requiring you to stay up to date by pursuing continuing education. Practical experience — or application of the knowledge you’ve gained through your education and credentialing — is critical for success. If you’re newer to the industry, seek out practical experience by programming for a friend or family member, or shadowing an experienced professional,

2. “Hungry-yet-Humble” Attitude

Recall your most influential teacher or coach. Chances are, their passion and hunger to improve your life is imprinted in your memory. Fitness professionals who have this same, genuine “it” factor can make a big splash. In a service profession, though, humility is key. Be confident in what you know; understand the limits of your knowledge; and be humble enough to seek guidance, take feedback or refer out to other professionals as needed.

3. A Zest for Learning

I’m a firm believer in intentional learning. Learning must not stop when you enter the job market — but, as your life gets busier with coaching clients and teaching group classes, you must be intentional with the time you set aside to learn. Maintaining your certification(s) through continuing education helps you prioritize study time, and I encourage you to try some of the following ideas too: If you’re into social media, follow accounts like ACSM to see what free, evidence-backed resources are available. Consider attending a virtual or in-person conference within the industry. And take workouts that differ in format and delivery style than the ones you coach — I guarantee you will learn something by putting on your “client hat” and remembering what it feels like to learn something new.

4. Skilled Communication

Effective communication helps in all aspects of life. But when you’re working 1:1 with clients or delivering a workout to a large group of people, communication takes center stage. Clear, confident delivery of instructions and education, with the ability to flex toward the communication and learning styles of the client(s) in front of you, can make or break the group exercise experience. Mastery of vocal inflection, and incorporation of nonverbal communication like gestures and body language, are also key to building trust and delivering a great product.

5. Empathy

Fitness journeys are personal and often emotional, so the ability to show empathy — or understand and share the feelings of another — is critical for success in the fitness industry. Purposeful development of skills like reflective listening, asking open-ended questions and motivational interviewing can help improve your ability to show empathy to your clients. Properly placed empathy can build trust, and that trust is often what keeps clients coming back for more.

Honorable mention goes out to “practicing what you preach,” or modeling the behavior you wish to inspire in others. After all, fitness professionals will be best equipped to serve their communities — and improve public health outcomes — if they have more energy, less fatigue, improved sleep quality, improved mood, more endurance and stronger hearts. And you know what helps with that? Exercise.

Additional Resources: 
Blog | A Day in the Life of a Group Exercise Instructor
Blog | How Being Dual Credentialed Can Improve Your Hiring and Salary Potential

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Don’t miss the second edition of ACSM’s Resources for the Group Exercise Instructor — available this summer! This updated edition is fully aligned with the eleventh edition of ACSM’s Guidelines for Exercise Testing and Prescription. It is an essential resource for undergraduate exercise science programs, students in pre-professional programs and those independently preparing for the ACSM Group Exercise Instructor (ACSM-GEI) certification. This new edition of ACSM’s Resources for the Group Exercise Instructor highlights the skills needed to effectively lead group exercise in gyms, studios, recreational facilities and clubs.

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Rachelle Reed has a B.A., M.S. and Ph.D. in exercise physiology, along with an ACSM-EP and NASM-CNC. She brings forth expertise in body composition, metabolism, physical activity measurement and behavior change, along with over a decade of group coaching experience. Dr. Reed aims to translate research about physical activity and behavior change into practice, bridging the gap between academia and the fitness industry through her work. She joined Orangetheory Fitness in 2019, where she is currently senior director of health science and research. Prior to joining Orangetheory, Rachelle was the kinesiologist for Pure Barre, a brand owned by Xponential Fitness. She lives in Watkinsville, Georgia, with her husband, Sam, their two kids (AJ, 4, and Madison, 5 months) and their dog, Roy.