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Behavior changes

New York Times and Huffington Post broadcast BJSM’s focus area of ‘urban planning’/ ‘built environment’/ parks for physical activity and health

30 Mar, 13 | by Karim Khan


BJSM’s mandate is to promote better health through (i) injury prevention, (ii) excellence in treatment of injuries and medical problems, as well as (iii) encouraging exercise prescription as appropriate at both the primary prevention and secondary/tertiary prevention level.

This blog focuses on this Easter weekend’s attention to the role of green space for mental health. Professor Peter Aspinall from  the School of Built Environment, Heriot-Watt University, Edinburgh examined how the brain responded to outdoor physical activity. The Huffington Post did a nice job of summarising the study and you can read that here.

Earlier, Gretchen Reynolds @GretchenReynold  – a preeminent exercise medicine journalist and author – had run the story in the New York Times wellness blog.

Why do the BJSM editors (including Deputy Editors Babette Pluim @DocPluim and Jill Cook @ProfJillCook) give a high rating to a submission like this? Because the socioecological model of behaviour change (Prof Dan Stokols, among others) indicates that physical activity must be heavily influenced by external influences; the key not ‘individual motivation’ alone.

Thus, in keeping with the very important ‘7 investments’ document – transit options and urban design are two crucial elements for an active community. See this link for the free PDF of the ‘7 investments’ document. And all BJSM readers already know that physical inactivity is the biggest public health problem in the world. (Ranked 4th by the WHO but they are forgiven. (over 100 citations in Web of Science for this Blair paper)).

Other BJSM papers relevant to the Built Environment include:

Development of a Walkability Index (how to quantify urban environments for research)

Time to Walk the Talk (editorial on why this area is important)

Changing the Street Environment for Older Adults – DIY Streets Intervention (one of the very few intervention studies to date in this field

Validation of Walk Score (a methods study relating to the Google “walk score”)

Other key contributors in this field include Professors Billie Giles-Corti, Fiona Bull and the indefatiguable and immensely prolific James Sallis.

Personalised dose, prescription and administration of exercise using the MedExercise device: a pilot study

28 Nov, 12 | by Karim Khan

By Drs. Vadim N. Dedov and Irina V. Dedova


Background/Aim – Beneficial health effects of regular physical activity and exercise are well established. However, a variety of exercise types and modes complicates quantification of physical activity. Introduction of a single parameter for the objective measurement of exercise amounts might facilitate exercise prescription in primary care practice.

Methods – A novel exercise device with a friction resistance mechanism was equipped with a temperature sensor to measure heat production during the exercise. Heart rates were monitored with a fingertip pulse oximeter. Four healthy volunteers participated in this study.

Results – Heat production in the device during an exercise bout was used as a measure of exercise amount. An individual amount of device usage was determined in the respective fitness test and prescribed according to the current recommendations for daily physical activity. Automatic daily recordings showed significant variations in exercise intensity and duration in unsupervised conditions, but the prescribed amount of exercise has been exceeded on most days and weeks, indicating a full adherence to the exercise prescription. Upon completion of a three-month exercise prescription daily exercise amount was adjusted according to a new fitness test.

Conclusion – This study demonstrated for the first time that amount of physical activity can be calculated as a single parameter of exercise device usage. The results suggest that a personal amount of exercise can be determined and prescribed, and that adherence can be objectively monitored on regular basis.


Medical research has demonstrated that regular physical activity has a significant preventive and therapeutic effect.1 Nevertheless, the implementation of exercise recommendations and guidelines is not effective, especially in general practice.2 It was shown that ‘considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis’.3 It might be argued that in order to improve efficiency of exercise prescription it should be: (i) personalised and hence based on the assessment of patients’ fitness level,4 (ii) expressed in well-defined doses and (iii) followed by objective monitoring of compliance.

However, current methods for quantification of individual fitness levels and exercise amounts might be too complex for routine application. For example, the maximal oxygen consumption (VO2max) is considered a gold standard for assessing cardiorespiratory fitness, but respective VO2max protocols are not always feasible for many reasons, including limited time and staff, participant burden, possible medical oversight, costly equipment, and difficulty obtaining a maximal effort.5 Quantification of physical activity is also challenging because it takes many forms and varies in type, intensity, duration and frequency.6 It is a common practice to base the assessment of physical activity on self-reporting, which is prone to measurement error and can lead to incorrect inferences about physical activity behaviours.7 It was shown that healthy adults overestimated energy expenditure during exercise by 3-4 folds.8  Exercise-induced energy expenditure can be measured objectively, but it requires sophisticated equipment and complex technologies.9

Here, we report the development of a feasible approach for personalized exercise prescription, which might be suitable for wide implementation in primary care practice and for use in medical research.


A novel resistance exercise device MedExercise® ST (MDXD Pty Ltd, Australia) was used in this study (Figure 1A). Changes of temperature in the resistance unit were measured with a temperature sensor connected to the industrial multimeter IP57 (Digitech, Australia). Data was collected using respective software Multimeter V1.0 from Digitech and then converted into Excel databases (Microsoft, U.S.A.) for analysis. The average exercise-induced rise in temperature was calculated after subtraction of ambient temperature values. A fingertip pulse-oximeter CMS-50E (Contec, China) and corresponding SpO2 Review software were used for the continuous measurement of heart rates during the exercise. Overall, four healthy volunteers, aged between 36 and 49 years, participated in this study. Respective informed consents were obtained. Statistical analysis was performed using the Student’s t-test.


We hypothesised that the amount of exercise device usage achieved by the participant at particular intensity and duration would reflect participant’s level of fitness and could be used as the personalised amount of daily physical activity. MedExercise device was chosen for this study because it allowed continuous monitoring the intensity of usage through the measurement of exercise-induced rise of temperature in the friction resistance mechanism. During exercise the user repeatedly extended and flexed legs by moving foot platforms against graded resistance to their movement (Fig. 1A). Friction between the rails and foot platforms caused fast rise of temperature in the resistance mechanism, whereas stopping of exercise results in drop of temperature to pre-exercise level (Fig. 1B). Conversely, a total amount of device usage during the exercise bout correlated with the amount of heat produced in the resistance mechanism. The latter was reflected by an area under the curve and calculated by multiplication of an average exercise-induced rise in temperature and duration of recording in seconds.

For quantification of daily exercise amounts we used the current physical activity guidelines, which stated that: ‘all healthy adults aged 18 to 65 years need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week’.10 The definition of exercise intensity in literature varies considerably,11 but a heart rate of 100 beats per minute (bpm) might be assumed as an indicator of moderate physical activity for most healthy adults, whereas 120 bpm usually indicates a vigorous level of exercise. Therefore, usage of exercise device by the participant at 100 bpm for 30 minutes or at 120 bpm for 20 minutes would represent a recommended daily exercise amount according to the physical activity guidelines.10

Figures 1B represent a typical recording of temperature in the MedExercise device during moderate (trace 1) and vigorous (trace 2) exercise bouts, as monitored by respective heart rates (Fig. 1C), where a higher intensity of exercise caused temperature rise to the higher level (Fig. 1B). The respective amounts of device usage were calculated and expressed in kilo C⁰ (kC⁰). The amount of exercise at vigorous intensity was higher than during moderate physical activity: 139.5+16.4 kC⁰ and 113.8+7.9 kC⁰ (n=3, P<0.05), respectively. However, since the moderate intensity of exercise was better tolerated, the personal amount of 113.8 kC⁰ daily exercise was selected for the prescription. Therefore, according to the current physical activity guidelines,10 a personalised exercise prescription for this participant was: a minimum of 113.8 kC⁰ x 5 days per week = 569 kC⁰ weekly for three months of MedExercise device use.

Figure 1D exemplifies the patterns of device usage in unsupervised conditions during the exercise prescription. It was shown that the intensity and duration of usage varied to a great extent and included breaks (dents in the curve). Figure 1E and 1F shows daily and weekly amounts of device usage, respectively, for the full period of exercise prescription. The device was used for 4.9+1.2 days a week. An average amount of usage was 217.1+56.1 kC⁰ per day and 1067+251 kC⁰ per week. These results indicated that exercise prescription has been administered in full because the usage of device exceeded the prescribed amount. After completion of the three-month exercise prescription, a fitness level of the participant was retested and resulted at 132.7+15.1 kC⁰ (n=3). Accordingly, the next personalised exercise prescription was adjusted to a minimum of 132.7 kC⁰ x 5 days per week = 663.5 kC⁰ weekly of MedExercise device use for the next 6 months.


In contrast to prescription of conventional drugs, which are given in the specific doses and regimes, physical activity takes many forms and varieties, making it difficult to standardise.6 We have hypothesised that the amount of exercise device usage could serve as an objective and practical measure of exercise amounts. MedExercise device allowed direct measurement of heat production during the exercise through detection of temperature rise in its friction resistance mechanism. Conversely, the amount of heat produced in the device corresponded to the amount of exercise that participant performed with the device. A total amount of heat production during an each exercise bout depended on the intensity and duration of device usage, and could be calculated as an average rise in temperature multiplied by the durations of exercise. Therefore, a single parameter of heat production incorporated all variability of device usage such as resistance, frequency, duration and presence of breaks.

As a test for validity of our approach, we have determined a daily amount of exercise according to the most commonly used physical activity guidelines10 and selected the amount of device usage at a tolerable moderate intensity for three-month prescription. This exercise prescription was personalised because it was based on individual exercise capacity of the participant. Daily monitoring of device usage provided an objective insight into patterns and amounts of physical activity during exercise prescription. It is an important advantage because commonly used self-reporting is biased and prone to errors.7, 8 It was observed that the patterns of unsupervised exercise varied to a great extent due to fluctuations of intensity, different durations and presence of breaks. However, the amount of device usage consistently exceeded the prescribed daily and/or weekly amounts for the whole period of prescription that indicated a full adherence to exercise prescription and regular physical activity. After completion of previous exercise prescription the fitness test was repeated in order to adjust the dose for the next period of exercise prescription.

The limitation of this study is a small number of healthy participants that necessitates further clinical studies. The strength of our approach includes the measurement of exercise amounts as a single parameter, simplified assessment of fitness levels, personalised exercise prescription and objective monitoring of adherence. It is important that exercise prescription sets only a minimum amount of exercise so that other types of physical activity should be encouraged for better health effects.


1.    Lucini D, Pagani M. Exercise: Should it matter to internal medicine? Eur. J. Intern. Med. 2011;22:363-70.

2.    Weiler R, Feldschreiber P, Stamatakis E. Medicolegal neglect? The case for physical activity promotion and exercise medicine. Br J Sports Med 2012;46:228-32.

3.    Pavey TG, Taylor AH, Fox KR, et al. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ 2011;343:d6462.

4.    Buford TW, Pahor M. Making preventive medicine more personalized: Implications for exercise-related research. Prev Med 2012.

5.    Mitros M, Gabriel KP, Ainsworth B, et al. Comprehensive evaluation of a single-stage submaximal treadmill walking protocol in healthy, middle-aged women. Eur J Appl Physiol 2011;111:47-56.

6.    Slade SC, Keating JL. Exercise prescription: a case for standardised reporting. Br J Sports Med 2011.

7.    Ainsworth BE, Caspersen CJ, Matthews CE, et al. Recommendations to improve the accuracy of estimates of physical activity derived from self report. J Phys Act Health 2012;9 Suppl 1:S76-84.

8.    Willbond SM, Laviolette MA, Duval K, et al. Normal weight men and women overestimate exercise energy expenditure. J Sports Med Phys Fitness 2010;50:377-84.

9.    Levine JA. Measurement of energy expenditure. Public Health Nutr 2005;8:1123-32.

10.  Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med. Sci. Sports. Exerc. 2007;39:1423-34.

11.  Norton K, Norton L, Sadgrove D. Position statement on physical activity and exercise intensity terminology. J Sci Med Sport 2010;13:496-502.

Figure legend

Figure 1. (A) Position of the participant in the chair, while using MedExercise® device. (B, C) Typical changes of temperature in resistance mechanism of the device (B) and participant’s heart rate (C) recorded simultaneously during the moderate intensity (trace 1) and vigorous (trace 2) exercise bouts. Double headed arrows indicate duration of actual exercise. (D) Patterns of temperature traces during of unsupervised device use. Dents in the curves represent breaks in device usage. Double headed arrows indicate duration of recording. Background room temperatures were subtracted (all temperature curves). (E) Daily amounts of device usage during the three-month exercise prescription. (F) Weekly amounts of device usage during the three-month exercise prescription. Horizontal dotted lines indicate a single and double prescribed amount of device usage.

Competing interests

Dr Vadim Dedov has a stake in MDXD Pty Ltd, which designed and produced the equipment used in this study.


Vadim N. Dedov, M.D., Ph.D., MDXD Pty Ltd, NSW, Australia

Irina V. Dedova, M.D., Ph.D., School of Medical Sciences, University of New South Wales, NSW, Australia


Physical activity effectively promoted to Arabic speaking countries through translation and social media dissemination of viral video ‘23½ hours’

21 Nov, 12 | by Karim Khan

By Ann Gates (@exerciseworks), Dr Mike Evans (@docmikeevans) and

Dr SalihAlAnsari (@SaudiHPC)

The World Health Organisation describes physical activity promotion to mass populations as one of its top 5 ‘Best Buys’. We collaborated to develop an Arabic version of the viral social media success 23 ½ hours to promote the importance of regular exercise to Arab countries. Particularly, those countries at high risk of inactivity associated with the non-communicable diseases epidemic of obesity, diabetes, cancer and heart disease. The Co-operation Council for Arab States (CCG) has identified that non communicable diseases (NCDs) cause more than 60% of all deaths in the region. In addition to video development, we conducted a ‘best buy’ research study to evaluate its effectiveness in reaching this audience. Our aims were to:

  • Monitor and analyse the uptake of the video via Twitter, Facebook and YouTube
  • Compare the success of the original English video with the Arabic version
  • Understand the different viewing patterns of men and women in the English and Arabic speaking countries

The results were amazing!

There are 1.6 million views of the Arabic version to date (viewing statistics represented 92% coverage of the Arab States). This video was the fifth most viewed YouTube video (covering ALL YouTube video releases) during the second week of the launch.

Other study highlights include:

  • Significant viewing differences in sex and age range by country (available by country on request); overall, 76% of the viewers were male and 24% female
  • The viral spread of the Arabic version was significantly faster over 6 months than the English version
  • The relative audience retention data (when compared to YouTube’s average statistical data) showed slightly below average for the full 9.21 minutes.
  • The release of the Arabic version caused a significant spike in viewing figures for the English version.
  • 64% of viewers shared the link via Facebook compared with 88% for the English version.

Our results show that health professionals are able to successfully promote key health messages using social media. The translated 23.5 hrs communicated the benefit of simply walking for 30 minutes each day, to a large audience (in a short timeframe) in a region where greater physical activity promotion is of key importance.

This clearly demonstrates how social media may be used as a powerful tool for targeted messaging about regular exercise and physical activity interventions to communities at risk of NCDs.

A sum of take home messages are:

  • The viral social media spread of important health messages can reach specific ‘at-risk’ populations
  • Specific targeted viral media campaigns need further study and evaluation. A simple ‘thumbs up’ vote system at the end of the video saying ‘has this video changed your views and behaviour on regular exercise’ may suffice.
  • Creative dissemination strategies, and the use of multiple web based platforms, may be more effective to reach large audiences and thus, combat public health problems, than traditional methods.
  • YouTube, Facebook and Twitter may revolutionise the way we deliver and implement key health messages around the world on physical activity. The 23 ½ hours video translations (covering 5 languages and including the Arabic version) has been viewed by 4.8 MILLION people. This represents a significant ‘best buy’ initiative in terms of audience access through social media and extensive international reach. For the Arabic translation to reach the fifth most viewed video on YouTube demonstrates that targeted health messages can compete effectively with audience interest, and may be in fact be as interesting to the general public as cat videos!


Ann Gates BPharm(Hons) MRPharmS, Founder of Exercise Works!

Dr Mike Evans Family physician at St. Michael’s Hospital and an Associate Professor of Family Medicine and Public Health at the University of Toronto and My Favourite Medicine

Dr Salih AlAnsari Saudi Health Promotion Centre, Riyadh, Saudi Arabia.

Exercise Medicine: Inspiring the next generation, an interview with Dr. Mike Loosemore (Part 1 of 2)

14 Nov, 12 | by Karim Khan

By Liam West (@Liam_West) & Dr. Mike Loosemore

Undergraduate perspective on Sports & Exercise Medicine (a BJSM blog series)

The field of Sport & Exercise Medicine has two distinct areas. Namely, Exercise Medicine and Sports Medicine. To gain insights and get tips for students looking to follow in their footsteps, I interviewed two influential figures pushing the boundaries of each field.

The first of this two part interview series is with Dr. Mike Loosemore (ML) who is leading the “Exercise Is Medicine” initiative in the UK.

LW: Hi Dr. Loosemore. Could you describe to the undergraduate readers what Exercise Medicine entails?

ML: Exercise Medicine, or ‘Exercise Is Medicine’ as it’s promoted by the American College of Sports Medicine (ACSM), is the idea that exercise is important in preventing chronic non-communicable diseases (NCD) such as Type 2 diabetes mellitus, heart disease & cancer. Exercise can also be prescribed as a treatment for a NCD allowing the patient to simultaneously reap the additional benefits of regular moderate activity such as reducing co-morbidities and improving the patient’s sense of well being.

LW: So essentially undergraduates can view exercise as a more powerful treatment than handing out a single pill in many circumstances?

ML: Yes. Medical school essentially teaches students how to poison patients as that’s what you do by giving small doses of drugs; although obviously if you give them too much of the drug you poison them properly! It’s completely different with exercise. Using exercise we re-establish a natural process which allows the body to heal itself, returning it to the homeostatic state & often improving health considerable. Humans are exercising monkeys, we need to be active and if you don’t exercise enough important functions of your body start to degenerate!

LW: Powerful stuff! Would you be able to share with the readers some of the data surrounding exercise as a treatment for various NCDs?

ML: Here are some basic facts and figures for the undergraduates from the ACSM website. Regular physical activity reduces the;

  • Risk of heart disease by 40%
  • Incidence of diabetes by roughly 50%
  • Risk of developing Alzheimer’s disease by 30%
  • Incidence of high blood pressure by nearly 50%
  • Risk of stroke by 27%
  • Recurrence of breast cancer by almost 50%
  • Risk of colon cancer by approximately 60%
  • Depression as effectively as Prozac or Behavioural therapy

A pretty impressive intervention that has no medical equivalent that can do one of those things, never mind all of them! If you consider that medical inflation is going up significantly quicker than normal inflation and the population is ageing, we are reaching the edge of a financial cliff as far as healthcare costs are concerned. Currently the vast proportion of the NHS budget is spent on treating disease. Instead we should concentrate on preventing disease occurring in the first place which is relatively cheap! We cannot continue to be a disease service. It is called the National HEALTH Service not the National Disease Service!!!

LW: Hopefully that is a quote that will stick in the mind of many undergraduates! You have briefly touched upon some of the research, but are there any other resources students could use to find out about exercise medicine?

ML: I suggest they go to the ‘Exercise Is Medicine’ website where they can access lots of relevant resources & facts from evidence based research, read the BJSM blog and attend Sport & Exercise Medicine conferences, such as the Cardiff SEMS Olympic Conference 2012 on 15th December which is aimed primarily at undergraduates.

LW: Finally, if there was only one thing that we could do during our undergraduate career to spread the message of Exercise Medicine what would it be?

ML: Include it in your history paradigm. Every time you take history from a patient, ask about exercise. Two reasons for that;

  1. You will find out their individual activities levels and then can encourage them to do more. Any increase in exercise, no matter how small, will start to reduce the risks of chronic NCDs.
  2. A doctor asking about exercise sends a very powerful message to the patient and they clearly see that exercise is important.

LW: Thanks Dr. Loosemore for your expert opinion on Exercise Medicine and how undergraduate students can get involved.


Dr. Mike Loosemore MBBS DCH MRCGP MSc FFSEM(UK) is a Consultant in Sport & Exercise Medicine at the Institute of Sport, Exercise and Health, University College London. He is the lead Sports Physician (South of England) for the English Institute of Sport and currently the doctor to British Boxing. He is currently president of the Sports and Exercise Medicine section at the Royal Society of Medicine and leads the ‘Exercise is Medicine’ task force in the UK.

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

‘Run the World’ to change health behaviours – are you ready to practise what you preach?

8 Nov, 12 | by Karim Khan

By Liam West (@Liam_West)

We all know regular physical activity is good for our health. So good in fact that it is often regarded as the equivalent of medicine’s ‘wonder drug.’  Exercise prescription is steadily increasing in practice and there might even be medico-legal implications if we don’t encourage patients to get physically active to reduce their risk factors for morbidity. But how can you enthuse patients to get off the sofa and get moving?

A possible answer – lead by example and propose a challenge!

The www.5× campaign is an effort to raise awareness of the benefits of exercise & physical activity. I am currently helping to promote this campaign across the UK, especially in Wales, so that the message spreads – regular physical activity helps keep you healthy; it helps keep you free of disease; it is effective.

Physical Inactivity kills 9% of the world’s population.

The next stage of the campaign is the ‘Run the World’ challenge. It asks people to walk, cycle or run 5kms (3.1 miles) a day for a week from 23rd November, and involve friends, family, and patients as a taster to get fit. Challenge yourself and your community to be active and share in the experience of the benefits of physical activity. Sign up now!

Andrew Murray wins 2012 North Pole Marathon

Dr. Andrew Murray is making a documentary film about his commitment to the challenge . He is personally going to complete an ice marathon in Antarctica followed by 50kms on 7 different continents in 7 days. We applaud Dr. Murray’s commitment to both being physically activite and promoting its importance!

In comparison to this, 5kms a day from you is a drop in the ocean. But, nonetheless, it is an important drop.

Scotland’s Chief Medical Officer Harry Burns, their NHS executive team & Sports Minister Shona Robison have all signed up to www.5× Here in Wales both Cardiff & Swansea medical schools, Cardiff City Football Club, the Welsh Rugby Union doctor and some players have signed up along with Public Health Wales – If they can do it, so can you! We all need to be in this together!

We really want UK / world wide doctors, lecturers & students involved as a priority. However, we also want to engage the broader public, so that everyone thinks about how they might become more physically active. We need your help to make a difference:

  • Join the challenge and become a physical activity ambassador;
  •  Encourage all your friends, families or patients to get more active;
  •  Use http://5× to do so.

‘Run the World’ starts soon (November 23rd); sign up now and share with your networks!


Liam West

Founder and President of Cardiff Sports & Exercise Medicine Society (CSEMS); Organiser of the Cardiff SEM Conference 2012; BJSM Associate Editor; Coordinator of the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM; Student Representative for the Council of Sport Medicine for the Royal Society of Medicine; Founder of Undergraduate Sports & Exercise Medicine Society (USEMS)

 Dr. Andrew Murray

Scottish Government Physical Activity Champion; @docandrewmurray – Twitter; ; General Practitioner, Sport & Exercise Medicine Registrar; Author – Running Beyond Limits

Depression, exercise and the impact of research

26 Sep, 12 | by Karim Khan

Guest blog by Dr Joseph Lightfoot and Mr Charlie Fry

The recent BMJ publication Facilitated physical activity as a treatment for depressed adults: randomised controlled trial stirred the medical world and the media with the claim that exercise has no impact on depression. This supposedly myth-busting paper was shared, tweeted, commented upon and even appeared in a 10-minute slot on BBC Radio 4.

However, it also received a large degree of backlash. Many doctors, physiotherapists, psychiatrists and other healthcare professionals critiqued the paper, and disagreed with the authors’ (Chalder et al.) claims. These critiques are among the comments on this rapid response section of the BMJ website HERE.

A Critique

A letter recently published in the British Medical Journal summarises these critiques – which you can view HERE.

In summary, the research paper had several major flaws including validity of the exercise intervention and rate of follow-up. The only conclusion that can be drawn from the paper is that the exercise intervention they employed had no effect on depression – not exercise as a whole. Yet via a press release from Bristol University and as aired on BBC Radio 4, the overriding, propagated message is that exercise does not appear to be effective in treating depression”.

As Dr Mike Loosemore, Sports and Exercise Medicine Consultant added:

“The paper doesn’t show anything of the sort. There is a mismatch between the results and what the authors are concluding and as such what the media is spreading to the population.”

Photo courtesy of Janey Kay (Flickr CC)

What Does Other Research Say?

There is a wealth of research from the last three decades that provides contrary evidence: that exercise is effective in treating depression. For example, a paper published in the BMJ in 1985, reported that moderate aerobic activity was sufficient to produce an antidepressant effect at a six and nine week follow-up (1).  This is supported by another study undertaken between 1998 and 2001 that also found exercise to be effective in treating mild to moderate depression (2). Finally, a paper looking at exercise as an intervention in severe depression, positively associated exercise with significant therapeutic benefit (3).

We also must not forget exercise is a “polypill” and has a beneficial effect on other co-morbidities and quality of life, which the authors of the recent depression paper also conclude.

The Impact Of Research

Outside of the debate about exercise and its effectiveness in treating disease, this recent paper and resulting media attention illustrates an important point. In making certain claims we have to understand the impact these widely broadcast messages may have on individuals, including the lay public.

The 10-minute broadcast on Radio 4, which you can listen to HERE, reached an estimated seven million people. It contained a very clearly delivered the message that exercise is not good for treating people with depression.

No comment was made on the validity of the study design, nor was their mention of the previous research that demonstrates exercise’s benefits for helping patients with depression.

According to NHS clinical knowledge summaries, each year 6% of adults will suffer an episode of depressive symptoms. Out of the seven million listeners therefore, 420 000 individuals may have suffered in the past 12 months or indeed be currently suffering depressive symptoms.

Suppose we assume only 25% of listeners take the advice and adapt their exercise habits, then that’s 105 000 people who have altered their behaviour. This is a conservative estimate and doesn’t take into account further propagation of this information by individuals to others who might have or be currently suffering from depression.

In drawing conclusions and then relaying them to the media, and thus to the general public, we need to consider the consequences of our messaging – whatever the topic.


The researchers’ conclusions are heavily questionable, but what is more concerning is the way that bold claims extrapolated from the research were distributed so widely throughout national media.

We welcome new research that goes against the grain, and offers evidence to refute commonly held beliefs, but to do so the research needs to be detailed and any conclusions drawn need to have sufficient support from the evidence.

The larger issue here is the lack of training about the benefits of exercise (for all conditions, not just depression), and just as importantly advice on implementation.

To illustrate this with a crude example, if we, the authors, were to perform neurosurgery for a year, and you audited our results, you could conclude that neurosurgery was a poor intervention, when in fact the correct answer is that we have not been trained to perform that intervention effectively.

In order for exercise to be utilised as a successful intervention, healthcare professionals require more training.

Final Words

Many healthcare professionals have been campaigning for the increased use of exercise as a treatment modality, and there is ample research that proves its effectiveness not only for depression but also for many other diseases as common as diabetes, and as specific as glioma.

The damage this paper has done for the movement to improve people’s activity level is hard to predict. Rather than reducing the number of those undertaking exercise, we hope its inaccuracy provides a springboard from which further education of both the medical establishment and the general population, ultimately leading to a happier, healthier nation.


(1) Martinsen EW, Medhus A, Sandvik L. 1985. Effects of aerobic exercise on depression: a controlled study. Br Med J (Clin Res Ed). July 13; 291(6488):109.

(2) Dunn Al, Trivedi NH, Kampart JB et al. 2005. Exercise treatment for depression: efficacy and dose response. Am J Prev Med. Jan:28(1):1-8.

(3) Babyak M, Blumenthal JA, Herman S et al. 2000. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Pyschosom Med. Sept-Oct:62(5):633-8.


Dr Joseph Lightfoot MBChB BSc(Hons) ( graduated medical school in 2012. He is currently working as a coach and researcher and has worked with a number of international teams, including the England under-19 lacrosse team. He is also the founder and a director of the Move Eat Treat campaign, which is campaigning for an increase in the use of lifestyle advice in medicine. For more information about the Move Eat treat campaign, visit

Mr Charlie Fry is a third year medical student at the University of Bristol, currently about to start his clinical placements. He has competed to regional level in hockey, athletics and squash and has undertaken work experience at sport injury clinics since 2010. He hopes after graduation to specialise in sports medicine.

Physical inactivity in Nigeria: A short analysis (part 2 of 2)

21 Sep, 12 | by Karim Khan

Guest blog by Damilola Alawode (@DAlawode)

 Read part 1 here

In Nigeria, government policies (e.g., policies that might influence health) can arise at three levels. There is the Federal Government, state governments, and local governments. Local governments tend to follow the policy laid down by state governments. Though there is a national health promotion draft policy, there is no legislation compelling the Federal Government to reduce or combat the scourge of NCDs through promotion of physical activity. Unfortunately, Nigeria does not have a goal of reducing physical inactivity by 10% as the government of Canada did for year 2003 or the Healthy People 2020 policy (a 10-year health agenda released by the US Department of Health and Human services in 2010), which identifies physical activity as a leading health indicator.

However, the FG through the National Sports Commission (NSC) set up a body known as the Nigeria Academicals Sports Committee (NASCOM) headed by a former Nigerian soccer star to collaborate with both state and local governments in promoting an initiative on physical activities in secondary schools (read more here). The initiative started with soccer, and it has been extended to 4 other sports (tennis, table tennis, basketball and swimming); athletics will start later in the year. The schools are required to train teams that would represent them in inter-school competitions from the local to the states up to the national level, thereby maintaining and promoting a culture of physical activity among the students. This is a good initiative that should be built upon by all levels of government as well as the private sector so as to sustain its impact.

The “Walk and Live” program

A state government in the southwest part of the country (The state of Osun) organizes what they call the “Walk and live” program. It is a once a month city walk similar to what takes place in the city of Mombasa, Kenya. It is an attempt to keep citizens of the state fit. Although this initiative can be improved, it has brought the importance of physical fitness to the forefront of more people. This should be applauded, but the message on the importance of having at least 30 minutes of physical activity everyday should be made known to all through different channels and utilising the best methods of public health education and support. This state has also made it mandatory for physical education to be taught in elementary schools, hoping it would make children enjoy the culture of daily participation in physical activities from an early age. This is a commendable policy which other states should look to implement.

The Medical and Dental Council of Nigeria regulates undergraduate medical education and, regrettably, physical activity does not feature within the undergraduate curriculum (in related news, stay tuned for the new BJSM undergraduate blog series). This is a fundamental flaw which should be rectified as patients deserve evidence based professional practice. However this is hampered in Nigeria due to the lack of training in physical activity promotion and behaviour change unlike countries such as USA, Canada and South Africa where sports and exercise medicine specialists use exercise and tailored physical activity to treat and prevent chronic diseases.

The ideal medical curriculum

This can be remedied if the Medical and Dental Council of Nigeria (MDCN) as the regulating authority for training doctors ensures that:

  1. A review of the medical curricular requirements to include emphasis and guidance for physical activity education.
  2. Refresher courses are offered on the significance and management of NCDs and reduction of physical inactivity

These two recommendations are crucial because a majority of the 32% of private facilities registered with the federal ministry of health are primary health care facilities; if we add this number to the public primary healthcare facilities and we have a very significant pool of healthcare facilities that are the first point of patient contact with probably being staffed by doctors who may not be up to date with managing physical inactivity induced illnesses.

We advocate for setting up a body (like the US National Society for Practitioners of Physical Activity and Public Health and the American College of Sports Medicine) to develop specialists in physical activity and public health. This will ensure that there is a practitioner workforce as well as academic trainers to ensure that in future, the medical curriculum includes physical activity promotion (more info here). This model is presently being used in the United States and may also be put in place in Nigeria. This involves training in competencies areas such as use of data and scientific information; planning and evaluation; intervention; organisational structure; and exercise science in public health.

Graduate training should also be created to guide the next generation of researchers in this field. Global capacity in exercise science, physical education, physical therapy, public health, architecture and planning, and environmental health should be increased. There is an urgent need for integration and comprehensive approaches to public health and physical activity.

Also more research into programmes that will increase physical activity and reduce physical inactivity are needed to help to build evidence base for our national policies and action plans.

Next steps – Olympic Legacy?

In conclusion, following the poor performance of Nigeria’s team at the 2012 London Olympics, the Federal Government has ordered a comprehensive re-organisation of the sports sector. I hope this will also have a positive effect on promotion of physical activity in the country and its people.

It will also be of immense national benefit if the appropriate authorities, private organisations and individuals take steps to implement a “Call to action” message. These key actions, namely reducing inactivity and sedentary behaviour, enabling patients and the public to access regular physical activity and exercise as part of an integral part of their daily lives, are necessary to advance global health through physical activities and is something that Nigeria can deliver.



Damilola  A. Alawode (MBChB ile-ife) is a Public Health resident in the Department of Community Medicine, Federal Medical Centre, Ido-Ekiti, Nigeria, a Msc Student (Sports and Exercise Medicine, University of Bath, United Kingdom), an advocate for the promotion of physical activities and a blog writer on Sports and Exercise medicine for

Twitter: @DAlawode  



Ann Gates (; A source of inspiration and motivation; and for sharing her resources.

Dr. Dayo Osholowu (IOC certified Sport Medicine Clinician and Director Sport Medicine Program, Lagoon Hospital Lagos state, Nigeria); for his advice and contribution to the piece.

Dr. Stathi Afroditi (Director of Sudies SEM, University of Bath United Kingdom); for her comments on an earlier draft of this report.


  1. Abubakari AR et al, Systemic review of the prevalence of diabetes, overweight/obesity and physical inactivity in Ghanaians and Nigerians. Public Health Journal, 2008 Feb;122(2):173-182
  2. Adegoke BO et al, Physical Inactivity in Nigerian young adults; Prevalence and socio-demographic correlates. Journal of Physical Activity and Health, 2011 Nov;8(8);11 35-42
  3. Canadian Fitness and Lifestyle Research Institute (CFLRI) reports 2001
  4. California Centre for Physical Activity (CCPA), California department of Health services; The economic costs of physical inactivity, overweight and obesity in Californian adults, 2005 report
  5. Cost of physical Inactivity, 2008 a publication of Physical and Health Education Canada
  6. Federal Ministry of Health, Nigeria Report 2010 Health promotion draft policy.
  7. Lancet Physical Activity series: Physical Activity 5; The pandemic of physical inactivity; global action for public health. Lancet 2012, 380: 294-305 Published online July 18, 2012
  8. National Society for Physical Activity Practitioners in Public Health. (accessed Jan 19, 2012)
  9. Nigeria demographic and Health Survey 2008 by National Population Commission, Federal Republic of Nigeria and DHSmeasure,2009
  10. Odegbami Segun, Mission to Addis Ababa, Segun Odegbami’s Official blog, 2012 Apr 30
  11. Odunaiya NA et al, Physical activity levels of Senior Secondary School Students in Ibadan, Western Nigeria. West Indian Medical Journal 2010 Oct;59(5):529-534
  12. Osun State Goverment report June 2012, Walk and Live.
  13.  Business day Newspaper August 15 2012, Poor Olympics outing: FG orders re-organization of sport sector.….
  14. Sallis RE, Exercise is medicine and physicians need to prescribe it. Br J Sports Med 2009 43: 3-4


  1. WHO Non-Communicable Diseases report, 2004
  2. WHO, A framework to monitor and evaluate the implementation: Global Strategy on Diet, Physical Activity and Health, 2008. (accessed Jan 19,2012)

We need to promote protective equipment differently

31 Jul, 12 | by Caroline Finch

Cross Fertilising Injury Prevention’ journal (IP) and BJSM                           



Protective sports equipment can prevent serious injury (McIntosh et al, BJSM, 2011). Why then doesn’t everyone use it?

Behaviour change theory tells us that, first, attitudes need to be right. But if people do not support protective equipment they will not use it.

A paper by Ruedl et al in the June 2012, Volume 18 (3) issue of Injury Prevention has categorized differences in why some people do and do not wear ski helmets. What differentiated the two groups most was a “subjective disadvantage” attitude in which users had much more positive opinions about helmet design factors such as their stylishness, ability to keep the head warm, non-restriction of vision, non-effect on hairstyles, cost and weight. In contrast, there was a negative association between helmet use and “safety awareness” attitudes, with the more safety conscious skiers being more likely to wear helmets.

As I read this paper, I was struck by the similarity of these ski helmet findings to those we found for protective eye-wear use in squash a decade ago (Eime et al, Sports Medicine, 2004). An additional observation from our work was that the non-users who were so critical of the design and wearability features of protective eye wear were also those who were more likely to have never tried it.  So preconceived opinions about protective equipment are a barrier to even trying it in the first place. By framing the issue within the socio-ecological framework for behavior change, we were able to successfully design and implement a promotion campaign aimed at addressing this particular belief, as well as others (Eime et al, BJSM, 2005).

Many sports have challenges towards maximising protective equipment use, especially (but not exclusively) when they do not introduce regulation mandating it.  We’d like more people to use it but that means convincing those with negative attitudes about it to change their behaviours.  In other words, we need to improve how we market protective equipment to those most likely to benefit from its use.

We argued in a very recent BJSM editorial, the way forward must be for injury prevention experts to learn from our social marketing colleagues (Newton et al, BJSM, 2012).  Imagine the power of a truly viral safety campaign that leads to demonstrably higher rates of appropriate protective equipment. What a dint that would make on injury rates!



Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specializes in both injury surveillance and implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

The challenges of health communication in a modern world of entertainment

22 Jun, 12 | by Karim Khan

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly series on the BJSM blog)

By Dr Wilby Williamson

Preaching about physical activity and demanding compliance with 150 minutes of activity per week, as I do with my friends and family, often falls on deaf ears.  Changing tack to discuss differences between London’s bus drivers and conductors in the 1950s and challenging my peers to a 2 minute wiggle at least allows me to stay for dinner!  Health communication is certainly a challenge, complicated by perceptions of risk and medical uncertainty.  But as professionals practicing evidence-based medicine, we have signed up to translate evidence and facilitate informed decision making.

Dr Mike Evans (23 and ½ hours) has shown the world that scientific evidence can be the centre fold for our communication. He has set the physical activity public engagement ball rolling; now we need to keep the momentum going, pushing the understanding beyond the pages of our esteemed journals and the feverish eyes of our professional and academic circles.  In the UK there are approximately 40 million regular online users with 50 to 60 percent using YouTube or Facebook on a monthly basis1-3. Dr Evans’ work illuminates both the potential and some of the requirements for successfully engaging these users. Winning favour with our audience is not easy, we go online seeking specific information or to be entertained. As health communicators we may have as little as 15 seconds to hook the online user. The salience, affects, and messengers all being important determinants of gaining influence. See his discussion of what he learned in this exclusive BJSM paper – click here.

Communication campaigns have to acknowledge the distinctions and idiosyncrasies between different media platforms. Consumers may use multiple media sources at any one time and the lines between the offline and online environments are becoming increasingly blurred. 80 percent of twittering is via mobile devices and twitter is one of the fastest growing online platforms with 23% of the UK audience liking the occasional tweet1-4. Aspirations, in the modern world of communications are not only to go viral but to package material for the small screen and seek user generated content as a sign of success. Posts, tweets and uploads all providing measures of reach and engagement. BJSM has been customised for mobile platforms.

The skills required to launch a communications campaign go beyond the repertoire learned in the standard health communication class. Planning for an engagement project starts with getting the right multidisciplinary collaboration, with creativity and online experience being essential.

This summer, I am privileged to be working as one of the health professionals on a creative science and health communication project exploring strategies for public engagement.  Funded by the Wellcome Trust, the Fidget Project is bridging the offline and online worlds of communication. The collaboration is bringing together experience from artistic, online and health & science backgrounds to provide an explanation for the message that we sit too much and need to move more. With the summer of 2012 offering endless entertainment options, encouraging our nations to sit in front of their media devices, can we coax people to consider the benefits of being a ‘frequent breaker’ and embrace adding 22 minutes of (moderate) wiggling to their day? As we tread festival fields, pitch in city centres and navigate the social media world, feel free to join the tour and see how we trend.


  1. UK Online Measurement, UK Online Media Landscape 2011.  
  2. YouGov, Social Media ‘growing up’ in UK Feb 2012
  3. Ofcom, Social Networking : A quantitative and qualitative research report into attitudes, behaviours and use 2008  
  4. The Guardian, Twitter now has 10m users in UK May 2012 



Fidget  is a public engagement project funded via the Wellcome Trust’s Society Awards. The charity, London Arts in Health Forum is directing Fidget in collaboration with the installation artist Michael Pinsky and the online charity Youthnet.

Dr Wilby Williamson is a registrar in Sports and Exercise Medicine on an East of England rotation. He was a visiting researcher with the Physical Activity group at the Medical Research Council’s Diabetes and Obesity Epidemiology Unit. He is currently an associate in preventive medicine with London Arts in Health Forum.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” — a twice-monthly blog series

Call to action for World Physical Activity Day 6th April 2012: Help patients get active!

5 Apr, 12 | by Karim Khan

Guest blog by Ann Gates (@exerciseworks)



Call to action for ALL heath professionals:

Exercise direction to patients is emerging as an essential clinical skill in the prevention and treatment of both acute and chronic lifestyle diseases. Dr Bob Sallis MD has long advocated that regular exercise is a medical ‘vital sign’ in assessing and directing a patient with a lifestyle disease to enjoying exercise as a medicine. 

36 million people around the world die from preventable lifestyle diseases (non communicable diseases; NCDs) such as heart disease, cancer, obesity, diabetes and mental health problems. This means that 36 MILLION people would benefit from exercise advice and support in preventing and treating these diseases.

Just one in three doctors gives exercise advice as part of every consultation to their patients.

If EVERY doctor and EVERY health professional is able to ‘direct’ and ‘support’ patients to regular exercise, as part of every consultation, then the health and economic consequences of inactivity and sedentary behaviour could start to be addressed. Patients could then be supported, proactively, to better lifelong health. NCDs will cost health economies $47 trillion by 2030. This is an unsustainable approach to health care services.

When doctors and health professionals give advice as part of the consultation, patients don’t question that advice and direction. For example, a patient needing warfarin or aspirin in the treatment of atrial fibrillation doesn’t debate the clinical outcomes of that decision: they may discuss NNT’s and NNHs, but generally the patient will follow the doctor’s prescription.

If physiotherapists are giving advice to help a patient breathe easier, the patient will generally follow the advice to improve their symptoms.

In fact brief intervention of exercise advice as a therapeutic intervention has recently been shown to be more effective in sustaining regular exercise than exercise on prescription schemes.

This should come as no surprise to health professionals who use the ‘art of a medical direction’ in guiding and motivating patients to better health: this can be used to great success in primary care, secondary care, health clinics, communities, cities or nations. Follow this link for more information. 

What can we do?

World Physical Activity Day on the 6th April 2012 is an opportunity for sports and exercise professionals to lead the way on global exercise advice. Every health professional should give exercise advice to patients and the public. The medicine behind exercise as a critical public health intervention is now no longer debatable. Here is some evidence.

Adult patients should be advised to ‘enjoy’ stamina or endurance exercises for the minimum of 30 minutes, on at least five days of the week (ensuring they get slightly breathless).

Strength, flexibility and balance exercises should be advised twice a week. Age specific UK physical activity guidelines can be found here.

For World Physical Activity Day 6th April 2012: Make a difference to every consultation: include exercise advice, every patient!


Ann Gates BPharm(Hons)  MRPharmS

Personal Trainer, Chronic Disease Exercise Specialist, BACPR Exercise Instructor.

Founder of Exercise Works!





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