1

JEMonline

ASEP’s Exercise Medicine Perspective for Better Public Healthcare

Tommy Boone

Member of the Board of Directors, American Society of Exercise Physiologists, USA

ABSTRACT

Boone T. ASEP’s Exercise Medicine Perspective for Better Public Healthcare. JEMonline 2016;1(6):1-7. The purpose of this paper is to further the emphasis on exercise medicine and the role of the primary care physician and the Board Certified Exercise Physiologist working together to safely individualize the prescriptive dimensions of regular exercise. After all, the pandemic of physical inactivity is the greatest public health threat of the 21st century, which is linked to staggering productivity losses due to disability and early death. The ASEP leaders created a credible certification for exercise physiologists as healthcare professionals who are responsible for prescribing exercise medicine (i.e., Board Certified Exercise Physiologists). Unfortunately, the medical community is more often than not predisposed to medical training that addresses treatment rather than prevention. The ASEP leaders believe it is imperative that physicians find the time to talk about promoting physical activity with their patients, particularly since even moderate levels of physical exercise (e.g., 150 min·wk-1) are linked to a dramatic reduction in mortality. When done professionally, exercise medicine (such as walking 30 min·d-1, 5 d·wk-1) not only prevents and helps to manage heart disease, blood pressure, stroke, and diabetes, it helps to control body weight, improves the strength, endurance, and flexibility, delays cognitive impairment, decreases the risk of falls, raises the red blood cell count, improves sleep quality, reduces migraine suffering, decreases the risk of osteoporosis, improves the muscles’ use of fat during exercise, improves agility and co-ordination, and reduces death from any cause by 14%. By working together, physicians and exercise physiologists can provide the patients the individualized attention that is necessary to achieve important behavioral changes in the patients’ lifestyle.

Key Words: Board Certified Exercise Physiologists Exercise Medicine, Exercise Prescription, Primary Care Physicians

The decrease in the physical demands of everyday life and the increase in caloric consumption is a lethal combination that is responsible for the increase in non-communicable diseases. In fact, the World Health Organization (WHO) ranks physical inactivity, in particular, as the fourth leading risk factor for overall morbidity and mortality worldwide (1). The reason for this conclusion is that the majority of adults do not meet the 150 min·wk-1 of physical activity (2), which is an important contributor to negative clinical outcomes such as obesity, increased blood pressure, as well as the increase in the risk of depression and decreased cognitive function in older adults with dementia and Alzheimer’s disease (3,4).

Physical inactivity is “the” public health threat of the 21st century (5,6) that is linked to not only the staggering healthcare costs and productivity losses, but also early death and disability. This point gives rise to two important factors in the analysis of major non-communicable diseases. First, if qualified healthcare professionals were to prescribe and supervise exercise medicine programs, such programs would help cut the costs, deaths, and disabilities that result from chronic diseases. Second, if society deems it important to embrace regular exercise as an “exercise medicine” to improve its health and well-being, then, the physical inactivity related mortality and disability would decrease.

With regard to the first point, one vitally important step that can no longer be ignored is the work of ASEP to produce credible healthcare professionals responsible for prescribing exercise medicine. The healthcare professionals are referred to as Board Certified Exercise Physiologists (7). As college-prepared exercise physiologists (who understand the client’s time constraints due to work and family matters, the lack of motivation, the lack of training or education of individuals with an interest in promoting physical activity, and the complex problems that associate with a range of chronic diseases and early deaths), they are committed to providing a comprehensive exercise medicine strategy to improving clients’ health and well-being. They understand the work of Ding et al. (8) that speaks to physical inactivity related productivity losses, the economic burden of physical inactivity, and related deaths and disabilities from coronary heart disease, stroke, type 2 diabetes, osteoporosis, and certain cancers.

Unfortunately, the primary care physicians’ job from a healthcare perspective is all about the treatment of chronic diseases and disabilities. This appears to result from a twofold problem. First, the medical community is predisposed by their medical training to “treatment vs. prevention”. Second, medical treatment with drug prescriptions is quicker than the implementation of prevention strategies to deal with tobacco use, poor diets, and the lack of regular exercise. Therefore, very little time is spent in the doctor’s office discussing the patient’s unhealthy lifestyle and causes of chronic diseases. Even with the ever-increasing list of publications that speak to exercise medicine and prevention, there has been little change in healthcare during the past 8 years (i.e., since the former ACSM President Robert Sallis, MD, spearheaded the initiative, Exercise Is Medicine). Why is this case? On average, how many primary care physicians ask their patients during the brief visit, “Do you engage in regular exercise?” or “How many minutes a day do you walk or exercise?” Not many, and essentially a very small percent of primary care physicians evaluate their patients’ physiological capacity via an exercise ergometer and heart rate and/or oxygen consumption monitor or use the well-recognized regression equations before providing a written prescription with weekly exercise and lifestyle goals.

While society’s lifestyle behavior is not the responsibility of just the medical profession, the traditional non-commitment to discussing health values inherent in regular exercise should be viewed as a major public health concern. The ASEP leaders believe it is imperative that physicians find the time to talk about promoting physical activity with their patients, particularly since Zhao et al. (9) pointed out that moderate levels of physical exercise (e.g., 150 min·wk-1) were associated with a dramatic reduction of 36% in mortality. In agreement, Thornton et al. (10) said “Effective counseling requires physicians to clearly explain to their patients what is meant by moderate-to-vigorous physical activity and offer advice on ways to limit sedentary behavior.” Note the words “effective”, “clearly explain”, and “advice” suggests more than saying to a patient, “Get some exercise.”

Is it any wonder why physical inactivity and obesity are increasing if the patients’ sedentary lifestyle is not clearly addressed and explained by the medical community? Elizabeth Joy (11), a medical doctor with an MPH degree, reported that “…it’s estimated that half of all adults in the U.S. will be obese by the year 2030 …, which would mean 7.8 million extra cases of diabetes, 6.8 million extra cases of coronary heart disease and stroke, and 539,000 extra cases of cancer … not to mention a $66 billion per year increase in health care costs….” And yet, according to Thornton et al. (10), “Fifteen minutes of moderate-to-vigorous physical activity per day (or 75 min·wk-1) is associated with ~15% relative mortality risk reduction, and benefits increase with the dose.”

Although generally healthy but inactive individuals with and without chronic disease can safely engage in low-to-moderate exercise while increasing exercise duration over time, the role of the Board Certified Exercise Physiologist is to ensure safe and progressive adaptation to individualized exercise medicine programs. When done professionally, exercise medicine (such as walking 30 min·d-1, 5 d·wk-1) not only prevents and helps to manage heart disease, blood pressure, stroke, and diabetes, it helps to control body weight, improves the musculoskeletal strength, endurance, and flexibility, delays cognitive impairment, decreases the risk of falls, raises the red blood cell count, improves sleep quality, reduces migraine suffering, decreases the risk of osteoporosis, improves the muscles’ use of fat during exercise, improves agility and co-ordination, and reduces death from any cause by 14% (12,13). These changes are critical to aging without major medical problems.

Physicians should be proactive in looking to Board Certified Exercise Physiologists to prioritize the patients’ exercise medicine. The winning strategy for individuals of sedentary lifestyles is the exercise prescription and not more scripts for medication. After all, it is clear that the self-care exercise medicine plan is cost-effective with the greatest influence on quality of life and life expectancy (14). Simply put, when clients and patients ignore their obesity or poor physical shape, the end result is sickness and premature death. Self-care improves mental and physical health and happiness by engaging in behaviors, such as regular exercise, progressive relaxation, focusing on the present, being happy, listening to music and dancing, reading a good book, laughing out loud, walking, jogging, and running, and stepping back from the phone and laptop (15).

Unfortunately, self-care is missing throughout the World, given that one in three people engage in little if any physical activity or exercise to burn calories, regardless of whether it is for work, play, or quality of health. Exercise medicine is physical activity that is planned, structured, and repetitive with the purpose to improve fitness, health, and mental well-being (16,17). It is about decreasing sedentary activities (e.g., watching television and using the computer) and staying active to increase total energy expenditure in combination with a low calorie eating plan (18). It is medicine in the form of exercise that offsets the changes of aging that become evident as early as the third decade of life. Hence, rather than experiencing a decrease in cardiorespiratory function (i.e., aerobic capacity), exercise medicine allows for plenty of energy and endurance. Life is much better with blood vessels that are not stiff, thus allowing for blood pressure to remain normal. The same is true with either a normal or slightly increased number of red blood cells coupled with the less viscous blood makes it is easier to pump to the active muscles and supply the necessary oxygen to the mitochondria to develop energy for muscle contraction. In fact, the deterioration in the muscular system brought on by the lack of regular exercise and aging doesn’t happen with adults who are regular exercisers. Moreover, the typical muscle weakness and disability (sarcopenia) coupled with the thinning of bones (osteoporosis) that set the stage for the likelihood of falling with an increase in the risk of fractures are not common among exercising adults.

The role of exercise medicine in health and disease isn’t a new concept or practice. The harmful consequences of failing to exercise have been known for a long time, but society is made up of individuals who are not interested in exercising. They have become complacent with the taking of long-term medications to deal with chronic diseases and disabilities. If possible, given that they are conditioned to take pills, they would take an “exercise pill” in a second to deal with their energy metabolism issues and muscle and bone strength concerns. It is unrealistic to expect them to change their lifestyle, especially since many children and adults simply have never exercised and do not see themselves starting an exercise program (19). The bottom line is that, regardless of the Board Certified Exercise Physiologists’ desire to help clients and patients improve cardiovascular function to deliver oxygen-rich blood to the body’s tissues, the United States is a country of 300 million people who are apparently comfortable with the 15 million nuclear medicine scans, a 100 million CT and MRI scans, and almost 10 billion laboratory tests (20). Society has become very willing and accustomed to the medical overkill. After all, regular exercise (even 150 min·wk-1, i.e., 3, 50 min·d-1, such as MWF) is viewed as a distraction if not work.

Yet, if children and adults were to engage in regular exercise, they could expect a decrease in resting heart rate, blood vessel stiffness, blood viscosity, blood pressure, body fat, insulin levels, blood sugar, nerve conduction and reflexes, risk of depression and memory lapses, and an increase in quality of sleep, increase in HDL cholesterol, increase in metabolic rate, increase in muscle mass and strength, increase in calcium content and strength, and increase in maximum cardiac output. Each of the changes resulting from regular exercise helps to keep the body as young as possible for as long as possible (21) and yet, according to the Physical Activity Guidelines for Americans, school-age girls are at a greater risk than boys in meeting the 60 min of moderate-to-vigorous physical activity every day of the week (22). Overall, as adults, women and men continue to experience the ill effects of sedentary behavior, given that sitting and watching TV decreases years to life expectancy. In fact, according to an Australian study, the authors found that people who watched an average 6 hrs of TV a day lived an average 4.8 yrs fewer than those who didn’t watch any television (23). While getting up from the chair and walking around doesn’t produce the same physiological benefits as 50 min·d-1 of exercise medicine, it does help decrease the time sitting.

Exercise medicine is a drug (i.e., an “exercise” prescription) and, therefore, it is essentially the same as prescribing a drug! Hence, Board Certified Exercise Physiologists who prescribe exercise medicine or in effect prescribing a medicine in the form of exercise. In this case, it is an exercise prescriptive medication due to the pharmacological benefits of exercise that promotes significant health effects associated with longevity (24). This is true for both patients and healthy individuals, given that the strength of the scientific evidence for exercise medicine is strong for a risk reduction of 20 to 35% for death, coronary artery disease, and stroke, 35 to 50% for type 2 diabetes and colon cancer, 20% for breast cancer, and 20 to 30% for depression (25). The benefits are evident with moderate intensity exercise that occurs with brisk walking at 3.0 mph for 50 min 3 times·wk-1 or 30 min·d-1 5 times·wk-1 (to obtain 150 min·wk-1) (26). Also, it is evident that unfit clients and/or patients who are elderly, pregnant, overweight/obese, or have cardiovascular disease or type 2 diabetes can improve their fitness status and achieve a significant decrease in mortality with a low dose of intensity training (24,27,28).

These outcomes are primarily a function of the increase in mitochondriogenesis, the shift in muscle fiber distribution from glycolytic to oxidative steps in the development of adenosine triphosptate, enhanced muscle contraction, and the increase in fatty acid oxidation. Collectively, each outcome working together leads to the increase in aerobic capacity (VO2 max) and, ultimately, the increase in the expenditure of energy and loss of body fat (24). Exercise medicine also decreases systemic inflammation and blood coagulation while improving coronary blood flow to the myocardium (29), thus helping to enhance cardiac function and transport of oxygen to the peripheral tissues. There are also numerous physiological benefits of exercise medicine at the tissue and organ level that help to improve psychological well-being (30), which is especially important in the prevention and treatment of costly and debilitating chronic diseases.