Exercise and associated features with low-level exercise among doctors

Highlights • Exercise, one of the most crucial and beneficial health habits, is not a common practice among the general population.• Data on exercise were mainly from trainees, with few from professional doctors.• Nearly half of the 1187 doctors in the study had low-level exercise with young age, female, hard work, poor diet, and irregular health surveillance as risk factors.


Introduction
The World Health Organization (WHO) has recommended daily physical activity for everyone of any age. 1 Health benefits from physical activity are well recognized that the activity can reduce the risks of several Non-Communicable Diseases (NCD), including cardiovascular disease, hypertension, cancers, diabetes mellitus, prevention of falls, and reduction of anxiety and depression/stress. 1 Despite a large body of evidence about the benefits of physical activity, more than a quarter of the world's adult population was insufficiently active. 1 Physical inactivity was responsible for more than 10% of NCDs and 9% of premature death. 2 Health promotion and prevention of illnesses are the frontline services of medical personnel, including doctors, nurses, and other public health practitioners.Health promotion includes, but is not limited to a healthy diet, adequate physical activity, exercise, and maintaining a good mental state or well-being.A doctor who generally serves as a team leader certainly positively impacts the behavior of other team members and their patients.−5 The healthcare providers who were physically active or had positive attitudes towards physical activity were more likely to counsel better and promote physical activity to their patients compared to those who were not active themselves.An individual's physical activity depends on many factors, such as his or her basic health and attitude as well as the lifestyles of the family members, peers, associates at work, availability, type of work and responsibility, residence, and social environment, etc. Focusing on availability and responsibility, a doctor has specific tasks that are different from other medical personnel.Compared to the number of populations, the adequacy of doctors is a significant issue in determining their availability.The WHO has reported that the ratio of doctors per 1000 population was 3.53 globally. 6Conversely, the National Statistical Office of Thailand reported an unproportionable ratio of one doctor per 1680 population. 7Undoubtedly, this would impact not only the population's health but the health of the doctors as well.
−11 The patterns of physical activity among professional doctors may vary due to differences in lifestyles, work schedules, and responsibilities compared to other medical professions and doctors in training.However, there have been no studies that specifically addressed the physical activity levels of professional doctors or explored the reasons behind their lack of exercise.This study aimed to assess the physical activity of Thai doctors, focusing on exercise frequency, and clinical features or risk factors associated with low-level exercise.

Materials and methods
This study was conducted in parallel to the hospital's Corporate Social Responsibility (CSR) project Save Doctors' Heart, which was conducted between February 14, 2022, to October 31, 2022.The research was approved by the Institutional Review Board (COA-MPIRB 003/ 2022).T a g g e d A P T A R A P The project participants were Thai doctors aged between 35-75 years without any congenital heart diseases.In brief, the project's medical services comprised physical examination of weight, height, blood pressure, and cardiovascular system examination.Basic laboratory testing and selected cardiac testing were performed according to the risk features, abnormal basic testing, and at the discretion of the examining cardiologist.The details of clinical testing were presented in our main cardiovascular report.
The individuals who joined our CSR project were invited to the study.Data of the doctors, who had read an information sheet about the study and verbally consented to participate by voluntarily giving information, were collected from electronic medical charts and a one-page questionnaire about personal, work and health habits, which were selfanswered upon entering the study.Only the doctors who had answers to physical activity (exercise in particular) were included in this study.
Data collected included age, gender, marital status, monthly family income, number of workplace, primary (major) workplace, weekly work hours, which was summed from total working hours per week, health coverage, history of health checkup, health habits of alcohol & caffeine consumption, the relative quantity of fiber diet (minimal, low, moderate, high), smoking, exercise (open-end question), stress (none, mild, moderate, severe), history of illness, and personal characteristics for well-being (generosity, positive outlook to life, attention or mindfulness for problem-solving, and resilient to life difficulty; each was scored one as least to 4 as most).The Body Mass Index (BMI) was also collected.
Each characteristic feature was grouped as the following: monthly family income as more or less than 200,000 Baht (5730 USD); primary workplace as private or public; weekly work hours as ≤ 40 hours or more; history of health checkup as regular annually or irregular (when there were symptoms or at convenience); dietary fiber consumption as good (moderate/high) or fair (minimal/low); stress as none/mild or moderate/severe.The frequency of exercise was categorized as none, 1-2 days/week, and ≥ 3 days per week and grouped as low-level (≤ 2 days/week) or high-level (≥ 3 days/week).The well-being scores were summed up and grouped as good (higher score than median) or fair.The BMI was categorized as underweight (< 19 kg/m 2 ), normal (19-26 kg/m 2 ), overweight (> 26-30 kg/m 2 ), or obese (> 30 kg/m 2 ) before grouping into non-obese or obese.
Statistical analyses were performed using IBM SPSS Statistics 22.0 was used (IBM Corp., Armonk, NY, USA).Continuous variables were presented as mean ± Standard Deviation (SD) for normally distributed data or as median and ranges.Categorical variables were presented as frequency and percentage.A univariate analysis, by Chi-Square or Fisher exact test as appropriate, was performed to identify clinical features, including BMI, which may be associated with exercise.Significant factors found from univariate analysis were included in the multivariate logistic regression analysis to explore independent factors associated with exercise.Data on risk factors of low-level exercise were presented as Odds Ratio (OR) with a 95% Confidence Interval (95% CI).A p< 0.05 was considered statistically significant.

Results
Slightly over 1500 doctors had registered for the Save Doctors' Heart project.Due to many reasons, as detailed in another report that would be presented elsewhere (Work and health habits of Thai doctors), 1244 who had read the information sheet about the parallel research work agreed to participate in the study.However, only 1187 provided data on exercise and were included in this study.
Data on age and gender were available from all 1187 doctors.The median age was 45.0 years (range 35-73 years).Slightly more than half (52.4%) were between 35-45 years old, whereas nearly onethird (31.6%) were between 46-59 years, and the remaining (16.0%) were 60 years or over.Slightly more than half were female (55.4%).
The responses to the questions of personal and work habits varied.The personal and working data of the participating doctors are shown in Table 1.Approximately two-thirds (63.3%) were or had been married, and more than half (57.4%) had an average monthly family income of more than 200,000 Baht (5730 USD).The majority (85.5%) had only one primary (main) workplace, with approximately one-third being either in private or public hospitals (36.9% and 34.5%, respectively).The authors summed up the working hours of each participant each week.The median weekly work hours was 40.0 (range 1 to 168 hours), with less than half (44.7%) working > 40 hours per week.
Apart from the history of illness to which all 1187 participants responded, other questions were reported at different rates.The number and percentages of the doctors' health habits, health history, and health findings are shown in Table 2.No or low fiber diet was reported in 19.2%, alcohol or caffeine consumption in 10.7% and 68.6%, respectively, and almost all denied smoking habit.Focusing on exercise, 252 doctors (21.2%) reported no exercise.Among the other 935 doctors (78.8%) who reported that they have some exercises, the frequency was 1-2 days/week in 582 (49.0%) and ≥ 3 days/week in 353 (29.8%).In total, 834 (70.2%) were grouped as no or low-level exercise (≤ 2 days/week) and 353 (29.7%) as high-level (≥ 3 days/ week).
For health history and health findings, 71.0% reported regular health surveillance, and 44.1% did not have a history of any illnesses.Some degree of stress was reported in 82.2%: mild in 56.3%, moderate in 24.6%, and severe in only 1.3%.The median well-being score was 13, slightly over half categorized as good and 46.8% as fair.Slightly over one-fourth of the doctors in this study were overweight or obese (28.0%), whereas the remaining were normal or underweight.

Discussion
12][13][14][15] Only a few studies that focused on doctors' physical activity reported a prevalence ranging from 62% to 74%. 5,14,16,17The present study found that 78.7% of the Thai doctors had physical activity.This was slightly higher than previous reports.
The rate of physical activity in each study may vary depending on many factors such as the number and characteristics of the study population, the indicator and definition used, the method of study including the questions in the questionnaires, etc.For example, this study included Thai doctors in any healthcare unit (hospital, clinic and either private or public).Other studies conducted a survey study focusing on the physical activity of the doctors in various groups (medical students, residents, or doctors), in private practice or public primary health service., 3,9,13,[15][16][17][18] various ethnic groups. 16he WHO has recommended that adults aged 18-64 years should do a minimum of various durations: 150−300 minutes of moderate intensity, 75−150 minutes of vigorous-intensity, or an equivalent combination of them throughout the week. 1 For adults ≥ 65 years, multicomponent physical activity three or more days a week is recommended. 1These benchmarks are, at times, difficult to genuinely obtain in a clinical study.Few authors assessed the physical activity by frequency (duration per day or days per week), 16 whereas others were able to additionally assess the level of physical activity (moderate or strenuous).5,12-14,17 The present study used "exercise" to indicate physical activity.Data were collected from the hospital health assessment form, so the exercise was leveled by its frequency because the strenuousness or intensity was not available in detail.
The levels of exercise were categorized as either high-or low-level to assess their association with clinical features.The authors inferred that doctors who claimed to have no exercise should still engage in some physical activities through work and daily routines.Consequently, 21.3% of doctors who reported no exercise were combined with the 49% who exercised 1-2 days per week, resulting in a total of 70% classified a The median score of well-being was 13.0 (range 6-16).
as "low-level" exercise.The remaining 30% were categorized as "highlevel" exercise (> 3 days/week), which was notably lower compared to the 65% to 74% rates of moderate to vigorous or high-level physical exercise reported in other studies. 5,14The difference in findings could be attributed to the characteristics of the study population.Previous studies focused on primary care doctors.In contrast, the majority of our participants worked in hospitals, encompassing both private and public settings.3][14] For example, a large-scale study conducted in the US, involving nearly 2,000 doctors at different stages of their careers (566 attending doctors, 138 fellow doctors, 806 resident doctors, and 215 medical students), found that participants with normal BMI who engaged in vigorous physical activity felt more confident in counseling their patients on this issue. 13Of note, our study did not specifically focus on the impact of doctors' physical activity and their counseling practices.Instead, the authors aimed to explore various factors associated with low-level exercise among doctors.Upon evaluating multiple features, the authors found independent associated factors for low-level exercise included a fair fiber diet, irregular health surveillance, age ≤ 60 years, female gender, and working > 40 hours per week.
Few previous studies did not identify any association between physical activity and age, BMI, or smoking features. 12,19However, some of the significant associated factors with low-level exercise in our study were well recognized or had been reported in other previous studies.Different findings from each study might lie on characteristic features of the population, including gender distribution, 12 region and cultures of the study, 13 as well as the indicators and type of questionnaires used in each study. 5,12,13,16,17,19he doctors with long weekly work hours, which was associated with less exercise, were self-explanatory as these doctors may already be exhausted and had limited free time for physical activity.The poor health habits of a low-fiber diet and irregular health surveillance were also identified to have a higher chance of low-level exercise than other features.Some authors also reported that 25% of their doctors had irregular health checkups and found associated features of unhealthy food, beverages, and exercise habits. 20he authors also observed a higher prevalence of low-level exercise among female doctors.There were inconsistent data on the influence of

Table 1
Basic characteristics of participants.

Table 2
Health habits, health history and health findings of the doctors.

Table 3
Exercise level according to clinical features by uni-and multi-variate analyses.