Applying The ACSM Preparticipation Screening Algorithm To U.S. Adults

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Published ahead of Print
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Applying the ACSM Preparticipation Screening Algorithm to U.S. Adults:
NHANES 200104
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Geoffrey P Whitfield1, Deborah Riebe2, Meir Magal3, and Gary Liguori2
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Centers for Disease Control and Prevention, Atlanta, GA
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University of Rhode Island, Kingston, RI
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North Carolina Wesleyan College, Rocky Mount, NC
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Accepted for Publication: 18 May 2017
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Medicine & Science in Sports & Exercise Published ahead of Print contains articles in unedited
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Please note that during the production process errors may be discovered that could affect the content.
Copyright 2017 American College of Sports Medicine

Medicine & Science in Sports & Exercise, Publish Ahead of Print
DOI: 10.1249/MSS.0000000000001331
Applying the ACSM Preparticipation Screening Algorithm to U.S. Adults:
NHANES 200104
Geoffrey P Whitfield1, Deborah Riebe2, Meir Magal3, and Gary Liguori2
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Centers for Disease Control and Prevention, Atlanta, GA
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University of Rhode Island, Kingston, RI
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North Carolina Wesleyan College, Rocky Mount, NC
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Running title: Preparticipation screening algorithm
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Corresponding Author: Geoffrey P Whitfield
Centers for Disease Control and Prevention

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4770 Buford Highway, MS F-77
Atlanta, GA 30341
770-488-3976 (v); 770-488-4820 (f)
Copyright 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
No outside funds were used for this study. The results of the study are presented clearly,
honestly, and without fabrication, falsification, or inappropriate data manipulation. The findings
and conclusions in this report are those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and Prevention, nor do they constitute
endorsement by ACSM. The authors have participated in development of the ACSM
preparticipation screening algorithm and the Guidelines for Exercise Testing and Prescription.
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Other than travel compensation, no financial support was received.
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Abstract
PURPOSE: For most people, the benefits of physical activity far outweigh the risks. Research
has suggested exercise preparticipation questionnaires might refer an unwarranted number of
adults for medical evaluation before exercise initiation, creating a potential barrier to adoption.
The new American College of Sports Medicine (ACSM) prescreening algorithm relies on current
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exercise participation; history and symptoms of cardiovascular, metabolic or renal disease; and
desired exercise intensity to determine referral status. Our purpose was to compare the referral
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proportion of the ACSM algorithm to that of previous screening tools using a representative
sample of US adults. METHODS: Based on responses to health questionnaires from the 2001-
2004 National Health and Nutrition Examination Survey, we calculated the proportion of adults
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aged 40 years or older who would be referred for medical clearance before exercise participation
based on the ACSM algorithm. Results were stratified by age and sex and compared to previous
results for the ACSM/American Heart Association Preparticipation Questionnaire and the
Physical Activity Readiness Questionnaire. RESULTS: Based on the ACSM algorithm, 2.6% of
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adults would be referred only before beginning vigorous exercise and 54.2% of respondents
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would be referred before beginning any exercise. Men were more frequently referred before
vigorous exercise and women were more frequently referred before any exercise. Referral was
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more common with increasing age. The ACSM algorithm referred a smaller proportion of adults
for preparticipation medical clearance than the previously examined questionnaires.
CONCLUSIONS: Although additional validation is needed to determine if the algorithm
correctly identifies those at risk for cardiovascular complications, the revised ACSM algorithm
referred fewer respondents than other screening tools. A lower referral proportion may mitigate
an important barrier of medical clearance from exercise participation.
Key Words
Population, Exercise safety, Cardiovascular screening, physician exam
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Introduction
The benefits of regular participation in physical activity are well-established and consistently
outweigh the risks of participation (10). Musculoskeletal injuries are the most common adverse
event associated with physical activity participation, and are seldom severe (10). An individual
bout of activity also carries an elevated risk of acute myocardial infarction (AMI) or sudden
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cardiac death (SCD). While severe, these events are rare and most commonly occur among
habitually inactive people performing vigorous-intensity activity (3, 8, 10); the risk of AMI or
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SCD during activity is sharply attenuated by progressive, regular physical activity participation
(10). Among adults, occlusive coronary artery disease is usually the underlying cause of activity-
associated AMI and SCD (7). Because of this, attempts to identify adults at risk for activity
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associated AMI or SCD have often included cardiovascular disease (CVD) risk factor assessment
(1).
The American College of Sports Medicine (ACSM) recently released an updated exercise
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preparticipation screening algorithm (henceforth: ACSM algorithm) that focuses on 1) the
respondents current exercise participation 2) the presence of signs/symptoms or known history

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of cardiovascular diseases and 3) the desired exercise intensity, and in contrast to previous
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screening tools, does not assess cardiovascular risk factors (11). These changes came about in
part because of indications that CVD risk factor-based screening may be overly conservative and
unnecessarily refer adults for medical clearance before exercise participation (15). Using data
from the 2001-2004 National Health and Nutrition Examination Survey (NHANES), the
ACSM/American Heart Association Preparticipation Questionnaire (AAPQ) could potentially
refer 95% of all US adults aged 40 years or older to a medical provider before beginning an
exercise program (15), and 68% of US adults aged 40 years or older could be referred using the
Physical Activity Readiness Questionnaire (PAR-Q) (15).
Additionally, The AAPQ and PAR-Q predate the 2008 Physical Activity Guidelines for
Americans, which, like the ACSM algorithm, focus not on CVD risk factors, but on history of
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chronic diseases, the symptoms thereof, and current activity levels to inform the need for medical
involvement (13). To date, referral estimates for the new ACSM algorithm are not available, so
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its performance relative to the AAPQ and PAR-Q is unknown. Therefore, the purpose of this
research was to estimate the proportion of US adults aged 40 years or older that would be
referred for preparticipation medical clearance using the ACSM algorithm in order to place this
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tool in context with previous findings.
Methods
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Data Source
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To ensure comparability across the three screening measures, a dataset from previous work was
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used that included health history interview responses from US adults aged 40 years or older from
the 2001-2004 NHANES (15). Accordingly, the number of respondents and demographic
characteristics of the samples are identical with the previous report (15). This dataset was limited
to adults aged 40 years and older because of 1) the importance of underlying CVD as a causative
factor for exercise-associated SCD and MI in adults and 2) age restrictions in many of the CVD
questionnaire items in the data source. Complete information regarding NHANES methods are
publically available from the Centers for Disease Control and Prevention (9) and are only
summarized here. NHANES is an ongoing public health surveillance system that uses
multistaged, stratified, probability sampling methods to achieve a representative sample of the
US, non-institutionalized population. Among all individuals screened to participate, 84% in
2001-2002 and 79% in 2003-2004 completed questionnaires (9). Data are continuously collected
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and are prepared for release every two years. All NHANES data collection activities are
approved by the research ethics review board of the National Center for Health Statistics and
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include informed consent for all participants.
Referral for medical clearance

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The ACSM algorithm (Figure 1) first classifies respondents as active or inactive based on the
presence or absence of exercise in the past 3 months, with exercise defined as planned, structured
physical activity at least 30 min at moderate intensity on at least 3 days per week. Next,
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respondents are classified based on presence or absence of known cardiovascular, metabolic, or

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renal disease and presence or absence of signs or symptoms of these conditions (Figure 1,
footnote). Recommendations for medical clearance are then made based on the desired intensity
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of exercise:
Among those not currently exercising:
o Asymptomatic respondents with no history of the specified diseases are
recommended to begin light to moderate intensity physical exercise without
clearance, and gradually progress per ACSM guidelines
o Asymptomatic respondents with a positive history of the specified diseases are
recommended to seek medical clearance before beginning exercise of any intensity
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o Symptomatic respondents, regardless of history, are recommended to seek medical
clearance before beginning exercise of any intensity
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Among those currently exercising:
o Asymptomatic respondents with no history of the specified diseases are encouraged
to continue moderate or vigorous intensity exercise without clearance, and gradually

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progress per ACSM guidelines
o Asymptomatic respondents with a positive history of the specified diseases are
encouraged to continue light to moderate intensity exercise without clearance, but
should have medical clearance before progressing to vigorous intensity exercise

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o Symptomatic respondents, regardless of history, are recommended to seek medical

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clearance before continuing exercise of any intensity

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Linking NHANES to the ACSM Algorithm, AAPQ, and PAR-Q
The health questionnaires from NHANES 2001-2004 provide much of the information needed to
complete the ACSM algorithm. A matrix of algorithm components and their corresponding
NHANES items is presented in Table 1. To determine current exercise participation (based on
the algorithms definition noted previously), the weekly frequency of each selected leisure
activity (bouts per week) was estimated by dividing reported monthly frequency by 4.286. The
weekly frequency was then multiplied by the reported duration (minutes per bout) and
NHANES-assigned metabolic equivalent value (METs), which is a measure of exercise intensity.
This provided estimated weekly exercise volume in MET*minutes/week. A value of 270
MET*minutes/week was classified as current regular exercise (30 minutes * 3 times per week *
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3 METs). Several items in the ACSM algorithm were not available in NHANES. Regarding
CVD history, we were unable to determine if respondents had a previous diagnosis of peripheral
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vascular disease, but patients could report pain in the lower legs when walking, which may
capture intermittent claudication. Regarding signs and symptoms of CVD, we were unable to
ascertain presence of orthopnea or paroxysmal nocturnal dyspnea (PND), ankle edema,

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palpitations or tachycardia, murmur, or unusual fatigue. Sensitivity analyses suggested that signs
and symptoms we were able to assess tended to occur jointly (few reported only one symptom).
For example, of the 816 respondents that reported chest pain, fully 88% reported 1 additional
assessed symptom; of the 2,478 that reported breathlessness, 60% reported 1 additional
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symptom. Three of five omitted symptoms relate to heart failure (orthopnea and PND, ankle
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edema, and unusual fatigue) and often cluster together (14), which would lessen the impact of
each symptoms omission.

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For each participant, binary variables for each component of the ACSM algorithm were created.
The value of this variable was determined by the value of the corresponding NHANES item(s)
(Table 1). These binary variables were used to classify respondents into the six possible groups
in the algorithm. Next, the referral status based on algorithm classification was assigned: 1) no
clearance needed, 2) clearance needed before vigorous-intensity exercise only, and 3) clearance
needed before any exercise. As noted previously (15), this method of algorithm completion and
scoring operates under the assumption that respondents will answer a preparticipation
questionnaire in the same manner that they answer the health history items in NHANES.
A similar process was used to complete the AAPQ and PAR-Q based on NHANES responses.
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These methods have been previously published (15) and are only summarized here. Following
the AAPQ instructions, a participant was classified as referred if he or she responded yes to any
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of the history and symptoms of CVD items or other health issues items, or responded yes to
two or more CVD Risk factor items (see Table, Supplemental Digital Content 1, Items from the
AAPQ and their corresponding items from NHANES 2001-2004,

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http://links.lww.com/MSS/A958). Following the PAR-Q instructions, a respondent was
classified as referred if he or she were aged >69 years and reported less than the equivalent of 10
minutes per day of combined transportation, household/occupational, or leisure time physical
activity of at least moderate intensity, or responded yes to any of the PAR-Q items for which
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NHANES corollaries were available (see Table, Supplemental Digital Content 2, PAR-Q items
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and their corresponding items from NHANES 2001-2004, http://links.lww.com/MSS/A959).

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Statistical Analyses
Referral proportions with 95% confidence intervals were calculated for the sample as a whole,
and stratified by sex and age group. A cross-tabulation of referral status comparing the ACSM
algorithm to the AAPQ and PAR-Q was also conducted. Differences in referral proportions were
assessed with Wald tests with a Bonferroni correction for multiple comparisons; =0.5.
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Post-hoc analyses were done to investigate the prevalence of reported symptoms of CVD. A
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Monte Carlo simulation was conducted to determine the sensitivity of the algorithm to the most
prevalent symptom. In 500 replications, 10% of those reporting no for the most prevalent
symptom were randomly reassigned to yes and the referral criteria were applied to the resulting
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dataset. This process was also used to change 10% of those originally reporting yes for the
most prevalent symptom to no. The average of the 500 referral proportions under each
condition (10% higher and 10% lower prevalence) was then compared to the original referral
proportions. All analyses used sampling and analytic weights supplied by NHANES. Variance
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estimation was by Taylor series linearization. Survey commands within Stata version 13.1 were
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used for all analyses.

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Results
The descriptive characteristics for this sample have been previously described (15) and are
summarized here. Complete questionnaire responses were available for 3459 women (97.9% of
total) and 3326 men (98.5% of total), accordingly, the demographic characteristics were quite
similar to the general adult population over 40 years of age in the US from this time period.
Based on the algorithm definition above, 47.1% reported enough leisure time activity to be
classified as current exercisers.
The distribution of the population across the six categories of the 2015 ACSM algorithm and the
total referral proportions are presented in Table 2. Among those reporting no current exercise,
18.0% reported no history or current symptoms, 3.0% reported a positive history but no current
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symptoms, and 32.0% reported current symptoms. Among those currently exercising, 25.1%
reported no history or current symptoms, 2.6% reported a positive history but no current
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symptoms, and 19.3% reported current symptoms. With this distribution across categories,
43.1% of the population would receive no referral for medical clearance before beginning or
continuing exercise, 2.6% would be referred for medical clearance before engaging in vigorous
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intensity exercise, and 54.2% would be referred for medical clearance before beginning or
continuing any exercise.
The referral proportions stratified by sex and age group are presented in Table 3. Across four of
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the seven age groups and for the sample as a whole, women would be referred for medical
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clearance before any exercise more frequently than men (all p<0.05). The differences between
men and women across age groups was less clear for referral before vigorous intensity exercise,
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but no group exceeded a 7% referral proportion for this outcome.
Combined results from the ACSM algorithm, the AAPQ, and the PAR-Q are presented in Figure
2, stratified by age group. Across all age groups, the AAPQ would refer more respondents
(94.5%) than either the PAR-Q (68.4%) or the ACSM algorithm, including those referred only
before vigorous exercise (2.6%) and those referred before any exercise (54.2%). When
considering those referred before any exercise, the ACSM algorithm and the PAR-Q performed
similarly in the 40-44 year age group (42.9% and 48.8% referred, respectively), then the referral
proportions diverged with increasing age. For those aged 70 years or older, the ACSM algorithm
would refer 70.9% before any exercise and the PAR-Q would refer 93.2%.
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According to the cross-tabulation presented in Table 4, 37.7% of respondents were referred by
the AAPQ but were not referred by the ACSM algorithm. Only one respondent (<0.1% of the
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weighted total) was not referred based on the AAPQ but was referred before vigorous-intensity
exercise based on the ACSM algorithm. Further, 19.0% of respondents were referred based on
the PAR-Q but were not referred based on the ACSM algorithm. Only 7.4% of respondents were
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not referred based on the PAR-Q but were referred based on the ACSM algorithm (0.5% before
vigorous-intensity exercise only, 6.9% before any exercise).
The proportion that reported any current symptoms was higher than expected (54.2%) and
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further investigated. Shortness of breath was the most commonly reported symptom: 72.0% of
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those with any symptom reported shortness of breath. It is likely that many reported cases of
shortness of breath are due to benign causes other than worsening CVD. Monte Carlo-based
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sensitivity analyses suggested shortness of breath was an important referral trigger. When the
prevalence of shortness of breath was randomly increased 10% in the sample, the proportion
referred for clearance before any exercise increased 9% (five percentage points) from 54% to
59%. When the prevalence was decreased by 10%, the proportion referred before any exercise
decreased 2% (one percentage point) to 53% (not shown).
Discussion
Using the same methods and assumptions as a previous evaluation (15), the ACSM algorithm
would refer fewer US adults aged 40 years or older for medical clearance than either the AAPQ
or the PAR-Q. Previous research suggested that 95% of this demographic group would be
referred for a physician visit under the AAPQ scoring criteria. While additional validation is
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needed, this analysis suggests 37.7% of adults in this age range that would be referred based on
the AAPQ would not be referred based on the ACSM algorithm. This reduction in referrals may
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mitigate a potentially important barrier to exercise adoption.
The lower referral proportion in the ACSM algorithm is likely attributable to the removal of
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CVD risk factors from the prescreening criteria. Because of the widespread prevalence of CVD
risk factors (4) and the rarity of exercise-associated CVD events (12), CVD risk factor
assessment is likely a poor predictor of these events. For example, the CDC estimates that 70
million American adults have high blood pressure, compared to 600,000 who die of CVD each
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year (0.9% of 70 million) (5, 6), and only a small percent of these CVD deaths occur during
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exercise (12). Assessment of CVD risk factors therefore may overestimate the proportion of
people at risk for exercise-associated CVD complications. The removal of CVD risk factors also
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aligns the ACSM algorithm with the 2008 Physical Activity Guidelines for Americans, which
place focus on diagnosed chronic diseases and symptoms thereof:
People without diagnosed chronic conditions (such as diabetes, heart disease, or
osteoarthritis) and who do not have symptoms (such as chest pain or pressure, dizziness,
or joint pain) do not need to consult a health-care provider about physical activity. (13)
As with the ACSM algorithm, the Guidelines also consider a persons initial level of activity,
progression of activity, and development of symptoms when considering medical involvement:
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Inactive people who gradually progress over time to relatively moderate-intensity
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activity have no known risk of sudden cardiac events, and very low risk of bone, muscle,
or joint injuries. A person who is habitually active with moderate-intensity activity can
gradually increase to vigorous intensity without needing to consult a health-care provider.

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People who develop new symptoms when increasing their levels of activity should
consult a health-care provider. (13)
While designed primarily for fitness professionals, the ACSM algorithm is more aligned with the
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public health recommendations set forth in the Physical Activity Guidelines than previous
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screening tools.
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The ACSM algorithm differentiates referrals based on the desired exercise intensity of the
respondent, and the proportion that would be referred before any exercise was much higher than
the proportion that would be referred only before vigorous intensity exercise. This is likely
attributed to two factors. First, a recommendation for clearance only before vigorous exercise is
given to one highly specific group in the algorithm: those who have previously had
cardiovascular, metabolic, or renal disease, but have recovered or stabilized to the point that they
now perform regular exercise and are free of symptoms. They warrant referral under the
algorithm only before increasing to vigorous intensity. Second, in contrast to the very specific
group previously mentioned, three of the six categories in the algorithm receive a
recommendation for clearance before any exercise. These include any respondents that report a
current symptom (both physically active and inactive) and those that are currently inactive and
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have a history of cardiovascular, metabolic, or renal disease. Among adults aged 40 years and
older, this includes a considerable proportion of the population. Samples with more diverse age
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ranges would likely exhibit different referral proportions.
Using the present methods, the referral proportion of the ACSM algorithm was more similar to
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the PAR-Q than the AAPQ, which was likely because of the similarity of these two instruments.
For example, both the ACSM algorithm and PAR-Q place emphasis on a history of CVD,
current chest pain, and dizziness or lack of balance. Further, the ACSM algorithm does not
consider age and the PAR-Q only considers age as important if the person is currently inactive.
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The 19.0% of respondents that were referred based on the PAR-Q but not referred based on the
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ACSM algorithm is likely due to the inclusion of bone and joint issues and medication use for
hypertension in the PAR-Q, neither of which are considered in the ACSM algorithm.
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This report has several strengths. First, the exact methods and dataset from a previous evaluation
of the AAPQ and PAR-Q were used, allowing comparison of referral proportions under identical
assumptions (15). Second, the NHANES dataset is representative of the non-institutionalized US
population over 40 years of age; this study provides information about referral performance in
the general public. Finally, this method allows for rapid comparison of screening tools at low
cost. Several limitations should also be noted. First, several symptoms on the ACSM algorithm
could not be assessed, but analyses suggested that assessed symptoms tended to cluster together,
which could limit the impact of unassessed symptoms. Nevertheless, omission of symptoms
could cause an underestimation of referral proportion. Second, we were unable to assess referral
proportions in adults under 40 years of age. Third, as with the previous report (15), this method
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assumes that people will answer a pre-screening questionnaire the same way they answered
comprehensive health interview questions, and the validity of this assumption is unknown.
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Finally, the criteria for participating in regular exercise in the ACSM algorithm is different from
the 2008 Physical Activity Guidelines (13), but a post-hoc analysis that defined regular exercise
as 150 minutes per week of at least moderate intensity leisure-time activity instead of 90 minutes
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per week suggested little impact on referral status (43.1% not referred [43.1% originally], 2.3%
referred before vigorous exercise [2.6% originally], and 54.6% referred before any exercise
[54.2% originally]).
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In conclusion, the revised ACSM algorithm referred fewer NHANES respondents for medical
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clearance compared to the AAPQ. Definitive confirmation of this finding would require
comparison of referral proportions in actual practice in exercise facilities. While additional

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validation is needed to determine how well the algorithm identifies those at risk for CVD
complications during exercise, a lower referral proportion may mitigate an important barrier to
exercise adoption, especially among those who undergo a preparticipation screening program
based on ACSM recommendations. Considering that 73% of ACSM-certified Health Fitness
Specialists report performing some type of preparticipation screening (2), the potential use of this
new algorithm is considerable.
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Acknowledgements
No outside funds were used for this study. The results of the study are presented clearly,
honestly, and without fabrication, falsification, or inappropriate data manipulation.
Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily
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represent the official position of the Centers for Disease Control and Prevention, nor do they
constitute endorsement by ACSM.
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Conflict of Interest
The authors have participated in development of the ACSM preparticipation screening algorithm
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and the Guidelines for Exercise Testing and Prescription. Other than travel compensation, no
financial support was received.

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References
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10. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory
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11. Riebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, Pescatello LS.
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Sports Exerc. 2015;47(11):2473-9.
12. Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events
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13. United States Department of Health and Human Services. Physical Activity Guidelines for
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Americans, Chapter 6: Safe and Active. Washington, DC: U.S. Department of Health and Human
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https://health.gov/paguidelines/guidelines/chapter6.aspx. [Cited 20 December 2016].
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11 May 2017]. Available from: http://www.heart.org/HEARTORG/Conditions/HeartFailure/
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15. Whitfield GP, Pettee Gabriel KK, Rahbar MH, Kohl HW 3rd. Application of the American
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Heart Association/American College of Sports Medicine Adult Preparticipation Screening
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Figure Captions
Figure 1: 2015 ACSM Preparticipation Screening Algorithm, reproduced with permission from
Riebe, et al (11)
Figure 1 footnotes:
Exercise Performing planned, structured physical activity at least 30 min at
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Participation moderate intensity on at least 3 dwk-1 for at least the last 3 months.
*Light Intensity 30% to <40% HRR or VO2R, 2 to <3 METs, 9-11 RPE, an intensity that
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Exercise: causes slight increases in HR and breathing
**Moderate 40% to <60% HRR or VO2R, 3 to <6 METs, 12-13 RPE, an intensity that
Intensity Exercise causes noticeable increases in HR and breathing

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***Vigorous 60% HRR or VO2R, 6 METs, 14 RPE, an intensity that causes
Intensity Exercise substantial increases in HR and breathing
Cardiovascular Cardiac, peripheral vascular, or cerebrovascular disease.
(CV) Disease
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Metabolic Disease Type 1 and 2 diabetes mellitus.
Signs and At rest or during activity; includes pain, discomfort in the chest, neck,
Symptoms jaw, arms, or other areas that may result from ischemia; shortness of
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breath at rest or with mild exertion; dizziness or syncope; orthopnea or
paroxysmal nocturnal dyspnea; ankle edema; palpitations or tachycardia;
intermittent claudication; known heart murmur; or unusual fatigue or
shortness of breath with usual activities.
Medical Approval from a healthcare professional to engage in exercise.
Clearance
ACSM Guidelines See ACSMs Guidelines for Exercise Testing and Prescription, 9th
edition, 2014
Figure 2: Comparison of predicted referral proportions for the 2015 ACSM algorithm, AAPQ,
and PAR-Q
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Figure 2 footnotes:
Results for the AAPQ and PAR-Q have been previously published (15)
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Abbreviations: ACSM: American College of Sports Medicine; AAPQ: ACSM/American Heart
Association Preparticipation Questionnaire; PAR-Q: Physical Activity Readiness Questionnaire;
PA: Physical Activity

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Figure 1
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Figure 2
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Table 1: Itemized components of the 2015 ACSM preparticipation screening algorithm and their corresponding items from the
National Health and Nutrition Examination Survey, 2001-2004.
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ACSM Algorithm National Health and Nutrition Examination Survey
Item
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Section Variable Prompt Classification Criteria
Regular Exercise PAQIAF PADACTIVE Over the past 30 days, what Reported exercise volume was
moderate/vigorous activities did you calculated as: (monthly
do? frequency/4.286)*duration in
PADLEVEL Reported intensity level of activity minutes)*(intensity in metabolic
equivalents [METs]).
PADTIMES How many times did you do this
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activity? Those reporting 270
PADDURAT On average, about how long did you MET*minutes/week were
do this activity each time? classified as currently exercising
(30 minutes * 3 times per week *
PADMETS Assigned MET score
3 METs).
Disease History
Cardiovascular
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disease
Cardiac MCQ MCQ160E Has a doctor or other health Those reporting yes to either
professional ever told you that you had question were classified as having
C
a heart attack (aka MI)? a history of cardiovascular disease
MCQ MCQ160C Has a doctor or other health
professional ever told you that you had
coronary heart disease?
A
Peripheral vascular n/a n/a n/a
Cerebrovascular MCQ MCQ160F Has a doctor or other health Those reporting yes were
professional ever told you that you had classified as having a history of
a stroke? cerebrovascular disease
Metabolic Disease
D
Type I / II DIQ DIQ010 (Other than during pregnancy) have Those reporting yes were
Diabetes you ever been told by a doctor or classified as having a history of
health professional that you have diabetes
diabetes or sugar diabetes?
TE
Renal Disease KIQ_U KIQ022 Have you ever been told by a doctor or Those reporting yes were
other health professional that you have classified as having a history of
weak or failing kidneys? Do not renal disease
include kidney stones, bladder
infections, or incontinence.
Signs/Symptoms
Pain/discomfort in CDQ CDQ001 Have you ever had any pain or Those reporting chest pain when
EP
chest, neck, jaw, arms, discomfort in your chest? walking uphill in a hurry or
or other areas walking at an ordinary pace on
(ischemia) level ground were classified as
CDQ002 Do you get it when you walk up hill or having pain that might be related to
in a hurry? (per 001) ischemia
CDQ003 Do you get it when you walk at an
ordinary pace on level ground? (per
C
001)
Shortness of breath at CDQ CDQ010 Have you had shortness of breath Those reporting yes were
rest or with mild either when hurrying on the level or classified as having shortness of
C
exertion walking up a slight hill? breath with mild exertion
Dizziness or syncope BAQ BAQ010 During the past 12 months, have you Those reporting yes were
had classified as having dizziness or
dizziness, difficulty with balance, or syncope
A
difficulty with falling?

Orthopnea or PND n/a n/a n/a
Ankle edema n/a n/a n/a
Palpitations or n/a n/a n/a
tachycardia
Intermittent DIQ DIQ140 Do you ever get pain in either leg Those reporting yes were
claudication while walking? classified as having intermittent
D
claudication
Heart murmur n/a n/a n/a
Unusual fatigue n/a n/a n/a
TE
Abbreviations: MET Metabolic equivalent; PND Paroxysmal nocturnal dyspnea
NHANES section abbreviations: PAQIAF Physical activity individual activities; MCQ Medical conditions; DIQ Diabetes;
KIQ_U Kidney conditions, urology; CDQ Cardiovascular health; BAQ - Balance
EP
C
C
A
Table 2: Percent of respondents aged 40 years that would be referred for medical clearance based on the 2015 ACSM
preparticipation screening algorithm, National Health and Nutrition Examination Survey, 2001-2004
D
No current exercise Yes current exercise
No Disease Yes Disease No Disease Yes Disease
Yes Yes
TE
History History History History
Symptoms Symptoms
No Symptoms No Symptoms No Symptoms No Symptoms
Referral
None Before Any Before Any None Before Vigorous Before Any
Status
Percent 18.0% 3.0% 32.0% 25.1% 2.6% 19.3%
(95% CI) (16.7-19.4) (2.5-3.5) (29.5-34.5) (22.7-27.7) (2.3-3.0) (18.0-20.7)
EP
Totals for Each Class of Referral Status
Not Referred Before Vigorous Before Any
43.1% 2.6% 54.2%
(40.6-45.7) (2.3-3.0) (51.6-56.8)
C
C
A
Table 3: Percent of respondents (with 95% confidence interval) aged 40 years that would be referred for medical clearance based on
the 2015 ACSM preparticipation screening algorithm, stratified by sex and age, National Health and Nutrition Examination Survey,
2001-2004
D
Age Categories (Years)
TE
40-44 45-49 50-54 55-59 60-64 65-69 70+ Overall
WOMEN n=447 n=394 n=370 n=268 n=420 n=348 n=1138 n=3385
Referred 1.2% 1.5% 2.1% 2.0% 3.2% 3.0% 1.8% 1.9%
Vigorous (0.4-3.4) (0.6-3.7) (0.9-4.7) (0.7-5.2) (1.7-5.7) (1.3-6.6) (1.1-2.9) (1.5-2.5)
Referred 49.8% 51.9% 56.1% 61.9% 57.9% 66.3% 74.6% 59.8%
Any (42.4-57.2) (45.9-58.0) (47.7-64.2) (55.1-68.2) (50.1-65.2) (59.8-72.2) (71.2-77.7) (56.3-63.2)
EP
MEN n=447 n=406 n=386 n=261 n=384 n=341 n=1051 n=3276
Referred 2.5% 2.2% 3.1% 2.0% 3.9% 7.0% 5.5% 3.4%
Vigorous (1.1-5.6) (1.3-3.6) (1.6-5.9) (0.7-5.4) (21.-7.2) (4.2-11.4) (3.9-7.7) (3.0-4.0)
Referred 36.1% 34.4% 50.8% 49.1% 57.0% 57.1% 65.7% 48.1%
Any (31.3-41.2) (30.8-38.3) (46.0-55.7) (42.4-55.9) (48.6-65.0) (48.6-65.1) (62.3-68.9) (45.7-50.5)
C
Values for women in bold are significantly different than the comparable value among men (Bonferroni-adjusted p<0.05)
C
A
Table 4: Cross-tabulation of the percent of respondents (with 95% confidence interval) aged 40
years that would be referred for medical clearance by three screening tools, National Health and
Nutrition Examination Survey, 2001-2004
AAPQ Referral Status PAR-Q Referral Status

ACSM Algorithm
Referral Status Not Referred Referred Not Referred Referred
5.5% 37.7% 24.1% 19.0%
D
Not Referred
(4.6-6.5) (35.3-40.1) (22.4-25.9) (17.5-20.7)
<0.1% 2.6% 0.5% 2.1%
Referred-Vigorous
(<0.1-0.1) (2.3-3.0) (0.4-0.8) (1.8-2.5)
TE
54.2% 6.9% 47.3%
Referred-Any 0%
(51.7-56.8) (6.2-7.8) (44.5-50.1)
ACSM: American College of Sports Medicine

EP
AAPQ: ACSM/American Heart Association Preparticipation Questionnaire
PAR-Q: Physical Activity Readiness Questionnaire

C
C
A
Supplemental Digital Content:
SDC 1: Table: Items from the AAPQ and their corresponding items from NHANES 2001-2004
SDC 2: Table: PAR-Q items and their corresponding items from NHANES 2001-2004
D
TE
EP
C
C
A
SDC 1 Table: Items from the AAPQ and their corresponding items from NHANES 2001-2004.
AAPQ ITEM
D
HISTORY (you have NHANES NHANES NHANES TEXT CLASSIFICATION CRITERIA
had:) SECTION VARIABLE
Heart attack MCQ MCQ160E Has a doctor or other health professional ever Those reporting yes were classified
told you that you had a heart attack (aka MI)? as having a history of heart attack
TE
Heart surgery MCQ MCQ160C Has a doctor or other health professional ever Those reporting yes were classified
Cardiac catheterization told you that you had coronary heart disease? as having a history of coronary heart
Coronary angioplasty disease
(PTCA)
Pacemaker/ICD/Rhyth n/a n/a Likely captured with meds (antiarrhythmics)
m disturbance
Heart valve disease n/a n/a Likely captured with meds (anticoagulants)
EP
Heart failure MCQ MCQ160B Has a doctor or other health professional ever Those reporting yes were classified
told you that you had congestive heart failure? as having a history of heart failure
Heart transplantation n/a n/a Likely captured under CHD, CHF, medication
use
Congenital heart n/a n/a Likely captured with meds
disease
Symptoms SECTION VARIABLE TEXT CLASSIFICATION CRITERIA

C
You experience chest CDQ CDQ0001 Ever had pain or discomfort in chest? Those reporting chest pain when
discomfort with walking uphill in a hurry or walking at
exertion CDQ0002 Do you get it (per 0001) when you walk uphill an ordinary pace on level ground were
or in a hurry? classified as having chest discomfort
C
CDQ0003 Do you get it (per0001) when you walk at an with exertion
ordinary pace on level ground?
You experience CDQ CDQ010 Have you had shortness of breath either when Those reporting yes were classified
unreasonable hurrying on the level or walking up a slight as having unreasonable breathlessness
A
breathlessness hill?
You experience BAQ BAQ010 During the past 12 months, have you had Those reporting yes were classified
dizziness, fainting, or dizziness, difficulty with balance, or difficulty as having dizziness, fainting, or
blackouts with falling? blackouts
You take heart RXQ_RX RXDDRGID Multum first level class 40 (CVD) or 81 Those reporting these classes were
medications (Coagulation modifiers) classified as taking heart medications
Other Health Issues SECTION VARIABLE TEXT CLASSIFICATION CRITERIA

You have diabetes DIQ DIQ010 (Other than during pregnancy) have you ever Those reporting yes were classified
D
been told by a doctor or health professional as having diabetes
that you have diabetes or sugar diabetes?
You have asthma or MCQ MCQ010 Has a doctor or other health professional ever Those reporting yes to any of these
other lung disease told you that you had asthma? were classified as having asthma or
TE
MCQ160G Has a doctor or other health professional ever other lung disease
told you that you had emphysema?
MCQ160K Has a doctor or other health professional ever
told you that you had chronic bronchitis
You have burning or DIQ DIQ140 Do you ever get pain in either leg while Those reporting yes were classified
cramping in lower legs walking? (>40y old) as having burning or cramping in legs
when walking short with walking
EP
distances
You have MCQ MCQ160A Has a doctor or other health professional ever Those reporting yes to either
musculoskeletal told you that you had arthritis? question were classified as having
problems that limit your OSQ OSQ060 Has a doctor ever told you that you had musculoskeletal problems
physical activity osteoporosis, sometimes called thin or brittle
bones
You have concerns n/a n/a Not assessed in NHANES
about the safety of
C
exercise
You take prescription RXQ RXD030 or In the past month, have you used or taken Those reporting yes were classified
medications RXDUSE medication for which a prescription is as taking prescription medications
needed?
C
You are pregnant RHQ RHQ140 Do you think that you are pregnant now? Those reporting yes to any of these
RHQ141 Do you think that you are pregnant now? were classified as pregnant (later
RHD143 Are you pregnant now? discarded)
A
Cardiovascular risk SECTION VARIABLE TEXT CLASSIFICATION CRITERIA

factors
You are a man older DEMO RIDAGEYR Age in years Combined age/gender criteria
than 45 years RIAGENDR Gender
You are a woman older DEMO RIDAGEYR Age in years Any women aged greater than 55 years
than 55 years, have had RIAGENDR Gender who answered yes to the
a hysterectomy, or are RHQ RHD280 Have you had a hysterectomy including a hysterectomy question or indicated
postmenopausal partial hysterectomy, that is, surgery to menopause or hysterectomy in the
remove your uterus or womb? (F20-150y) subsequent questions was classified as
D
RHQ040 What is the reason you have not had regular having had a hysterectomy or being
periods in the past 12 months? (ans 5, going- postmenopausal
gone through menopause)
RHD042 What is the reason you have not had a period
TE
in the past 12 months? (ans 7:
menopause/hysterectomy)
You smoke, or quit SMQ SMQ020 Have you smoked at least 100 cigarettes in Those reporting currently smoking
smoking within the your entire life? cigarettes, pipes, or cigars were
previous 6 months SMQ040 Do you now smoke cigarettes? classified as current smokers.
SMQ050Q How long has it been since you stopped
smoking cigarettes? (+SMQ050U for unit) Those reporting quitting smoking
EP
SMQ120 Have you smoked a pipe at least 20 times in cigarettes within the past 6 months
your entire life? were classified as recent quitters.
SMQ140 Do you now smoke a pipe?
SMQ150 Have you smoked a cigar at least 20 times in These two classifications were
your entire life? combined in the checklist
SMQ170 Do you now smoke cigars?
Your blood pressure is BPQ BPQ020 Have you ever been told by a doctor or other Those reporting yes were classified
> 140/90 mm Hg health professional that you had hypertension, as having BP>140/90
C
also called high blood pressure?
You do not know your BPQ BPQ010 About how long has it been since you last had Those reporting never were classified
blood pressure your blood pressure taken by a doctor or other as not knowing their blood pressure
health professional?
C
You take blood BPQ BPQ040A Because of your hypertension/HBP, have you Those reporting current BP medication
pressure medication ever been told to take prescribed medicine? use were classified as currently taking
BP medications
BPQ BPQ050A Are you now taking BP medication?
A
RXQ_RX RXDDRGID Multum first level class ID 40 (CVD) and Regardless of BPQ questions, those
second class 41-44, 47-49, 52-56 reporting these classes of drugs were
classified as taking BP medications
Your blood cholesterol BPQ BPQ080 Have you ever been told by a doctor or other Those reporting yes were classified
is > 200mg/dL health professional that you blood cholesterol as having high cholesterol
was high?
You do not know your BPQ BPQ060 Ever had blood cholesterol checked? Those reporting never having a blood
cholesterol level BPQ070 About how long has it been since you last had cholesterol check, or not knowing
D
your blood cholesterol checked? when their last check was, were
classified as not knowing their
cholesterol level
You have a close blood MCQ MCQ250G Including living and deceased, were any of Those reporting yes were classified
TE
relative that had a heart your biological that is, blood relatives as meeting this criterion (note 50 years
attack or heart surgery including grandparents, parents, brothers, in NHANES is more conservative than
before age 55 (father or sisters ever told by a health professional that 55 years)
brother) or age 65 they had a heart attack or angina before the
(mother or sister) age of 50?
You are physically PAQ PAD020 Over the past 30 days, have you walked or Reported activity volume was
EP
inactive (i.e., you get bicycled as part of getting to and from work, calculated as: (monthly
<30minutes of physical or school, or to do errands? (plus time and frequency/4.286)*duration in
activity on at least 3 frequency follow-ups) minutes)*(intensity in metabolic
days per week) equivalents [METs])
PAQ100 Over the past 30 days, did you do any tasks in
or around your home or yard for at least 10
minutes that required moderate or greater
physical effort? (plus time and frequency Those reporting <270
C
follow-ups) MET*minutes/week were classified as
PAQIAF PADACTIV Over the past 30 days, what currently inactive per the AAPQ
E moderate/vigorous activities did you do? instructions (30 minutes * 3 times per
PADLEVEL Reported intensity level of activity week * 3 METs)
C
PADTIMES How many times did you do this activity?
PADDURAT On average, about how long did you do this
activity each time?
A
You are >20 lbs WHQ WHD010 How tall are you without shoes? Those reporting a weight at least 20 lbs
overweight WHD020 How much do you weigh without clothes or greater than the weight that results in a
shoes? BMI of 25 for their reported height
were classified as being 20 lbs
overweight
D
TE
EP
C
C
A
Supplemental Table 2: PAR-Q items and their corresponding items from NHANES 2001-2004
PARQ # and prompt NHANES NHANES NHANES TEXT CLASSIFICATION CRITERIA

SECTION VARIABLE
(Instructions) If you are over DEMO RIDAGEYR Age in years at screening Reported activity volume was
D
69 years of age and you are calculated as: (monthly
PAQ PAD020 Over the past 30 days, have you walked or
not used to being very frequency/4.286)*duration in
bicycled as part of getting to and from
active, check with your minutes)*(intensity in metabolic
work, or school, or to do errands? (plus
doctor equivalents [METs])
time and frequency follow-ups)
TE
PAQ100 Over the past 30 days, did you do any
tasks in or around your home or yard for at
Those reporting <210
least 10 minutes that required moderate or
MET*minutes/week were classified as
greater physical effort? (plus time and
currently inactive (<10 minutes of any
frequency follow-ups)
activity * daily * 3 METs)
PAQIAF PADACTIV Over the past 30 days, what
E moderate/vigorous activities did you do?
EP
Inactivity and a reported age of >69
PADLEVEL Reported intensity level of activity
years generated a referral based on the
PADTIMES How many times did you do this activity? PAR-Q instructions
PADDURAT On average, about how long did you do
this activity each time?
1. Has your doctor ever said MCQ MCQ160B Has a doctor or other health professional Those reporting yes to any of the
that you have a heart ever told you that you had congestive heart four questions were classified as ever
C
condition and failure? having a heart condition
MCQ160C Has a doctor or other health professional
ever told you that you had coronary heart
disease?
C
MCQ160E Has a doctor or other health professional
ever told you that you had a heart attack
(aka MI)?
MCQ160D Has a doctor or other health professional
A
ever told you that you had angina, also

called angina pectoris?
that you should only do n/a n/a n/a
physical activity
recommended by a doctor
2. Do you feel pain in your CDQ CDQ0001 Ever had pain or discomfort in chest? Those reporting chest pain when
D
chest when you do physical CDQ0002 Do you get it (per 0001) when you walk walking uphill in a hurry or walking at
activity? uphill or in a hurry? an ordinary pace on level ground were
CDQ0003 Do you get it (per0001) when you walk at classified as having chest pain with
an ordinary pace on level ground? activity
TE
3. In the past month, have CDQ CDQ0001 Ever had pain or discomfort in chest? Those reporting yes were classified
you had chest pain when as having chest pain. Note this is not
you were not doing physical temporally matched to the PAR-Q
activity? question
4. Do you lose your balance BAQ BAQ010 During the past 12 months, have you had Those reporting yes were classified
because of dizziness or do dizziness, difficulty with balance, or as losing balance because of dizziness
EP
you ever lose difficulty with falling? or losing consciousness
consciousness?
5. Do you have a bone or MCQ MCQ160A Has a doctor or other health professional Those reporting yes to either of the
joint problem (for example, ever told you that you had arthritis? questions were classified as having a
back, knee, or hip) that OSQ OSQ060 Has a doctor ever told you that you had bone or joint problem
could be made worse by a osteoporosis, sometimes called thin or
change in your physical brittle bones
activity?
C
6. Is your doctor currently RXQ_RX RXDDRGID Multum first level class 40 (CVD) or 81 Those reporting these classes of drugs
prescribing drugs (for (Coagulation modifiers) were classified as taking blood
example, water pills) for pressure or heart medication
your blood pressure or heart
C
condition?
7. Do you know of any other n/a n/a n/a
reason why you should not
do physical activity?
A

Applying The ACSM Preparticipation Screening Algorithm To U.S. Adults

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Applying The ACSM Preparticipation Screening Algorithm To U.S. Adults

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. . .

Published ahead of Print

Copyright 2017 American College of Sports Medicine

Applying the ACSM Preparticipation Screening Algorithm to U.S. Adults:

Geoffrey P Whitfield1, Deborah Riebe2, Meir Magal3, and Gary Liguori2

Corresponding Author: Geoffrey P Whitfield

Centers for Disease Control and Prevention

4770 Buford Highway, MS F-77

770-488-3976 (v); 770-488-4820 (f)

endorsement by ACSM. The authors have participated in development of the ACSM

has suggested exercise preparticipation questionnaires might refer an unwarranted number of

for preparticipation medical clearance than the previously examined questionnaires.

CONCLUSIONS: Although additional validation is needed to determine if the algorithm

an important barrier of medical clearance from exercise participation.

Population, Exercise safety, Cardiovascular screening, physician exam

preparticipation screening algorithm (henceforth: ACSM algorithm) that focuses on 1) the

respondents current exercise participation 2) the presence of signs/symptoms or known history

ACSM/American Heart Association Preparticipation Questionnaire (AAPQ) could potentially

Physical Activity Readiness Questionnaire (PAR-Q) (15).

multistaged, stratified, probability sampling methods to achieve a representative sample of the

US, non-institutionalized population. Among all individuals screened to participate, 84% in

Referral for medical clearance

respondents are classified based on presence or absence of known cardiovascular, metabolic, or

o Asymptomatic respondents with no history of the specified diseases are

recommended to begin light to moderate intensity physical exercise without

clearance, and gradually progress per ACSM guidelines

o Asymptomatic respondents with a positive history of the specified diseases are

recommended to seek medical clearance before beginning exercise of any intensity

clearance before beginning exercise of any intensity

o Asymptomatic respondents with no history of the specified diseases are encouraged

to continue moderate or vigorous intensity exercise without clearance, and gradually

o Asymptomatic respondents with a positive history of the specified diseases are

encouraged to continue light to moderate intensity exercise without clearance, but

should have medical clearance before progressing to vigorous intensity exercise

o Symptomatic respondents, regardless of history, are recommended to seek medical

clearance before continuing exercise of any intensity

Linking NHANES to the ACSM Algorithm, AAPQ, and PAR-Q

NHANES items is presented in Table 1. To determine current exercise participation (based on

NHANES-assigned metabolic equivalent value (METs), which is a measure of exercise intensity.

This provided estimated weekly exercise volume in MET*minutes/week. A value of 270

ascertain presence of orthopnea or paroxysmal nocturnal dyspnea (PND), ankle edema,

each symptoms omission.

AAPQ and their corresponding items from NHANES 2001-2004,

minutes per day of combined transportation, household/occupational, or leisure time physical

and their corresponding items from NHANES 2001-2004, http://links.lww.com/MSS/A959).

used for all analyses.

classified as current exercisers.

continuing any exercise.

but no group exceeded a 7% referral proportion for this outcome.

vigorous-intensity exercise only, 6.9% before any exercise).

decreased 2% (one percentage point) to 53% (not shown).

place focus on diagnosed chronic diseases and symptoms thereof:

progression of activity, and development of symptoms when considering medical involvement:

gradually increase to vigorous intensity without needing to consult a health-care provider.

consult a health-care provider. (13)

assumptions (15). Second, the NHANES dataset is representative of the non-institutionalized US

comparison of referral proportions in actual practice in exercise facilities. While additional

based on ACSM recommendations. Considering that 73% of ACSM-certified Health Fitness

new algorithm is considerable.

honestly, and without fabrication, falsification, or inappropriate data manipulation.

constitute endorsement by ACSM.

financial support was received.

1. American College of Sports Medicine. Preparticipation Health Screening. In: Pescatello LS