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 6^th 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 6^th April 2012: Make a difference to every consultation: include exercise advice, every patient!

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Ann Gates BPharm(Hons)  MRPharmS

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

Founder of Exercise Works!

@exerciseworks

email: ann@exercise-works.org

Guest blog by @JosephLightfoot

The State Of Our Health

Britain is facing a health crisis and the statistics paint a bleak picture for the future.

Why Is This Happening?

Humans are evolved to be highly active and to consume natural, unrefined food. However, our lifestyles have changed radically. As a population, we are now largely sedentary and consume more refined food. Our lives are out of step with our genetic heritage resulting in obesity and chronic disease.

Healthcare professionals do an incredible job in challenging conditions. However, our training lacks emphasis on how to use lifestyle advice to empower people to live healthy lives.

My Personal Experience

If I had to sum up my time at medical school in one sentence, I’d do so like this:

I have learnt about disease, but I haven’t learnt about health.

Whilst there are many contributing factors to the current state of our nation’s health, I think the lack of education for healthcare professionals on lifestyle advice is a particularly important area.

The lack of education and training has resulted in many professionals who are unable to effectively help their patients stay healthy, and a healthcare system, which focuses almost entirely on reactive measures and only steps in when patients are already ill.

I don’t think this is good enough.

The Future

My vision for healthcare can be summed up by this fantastic quote from Thomas Edison.

“The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.”

The Move Eat Treat Campaign

In order to achieve this vision, I founded a campaign called Move. Eat. Treat. Along with the rest of the campaign team, I am working to promote the importance of preventative medicine with the aim of eventually developing a healthcare system, which doesn’t wait until patients become ill before it acts, but works to keep the population healthy – a true health service that is proactive rather than reactive.

We believe that the best way to achieve this is to educate healthcare professionals on how to deliver effective lifestyle advice. We hope that this will lead to a sea-change in culture within the healthcare system to one that assertively seeks prevention instead of cure. Then this will be followed by policy and organisational changes to prioritise prevention via promotion of healthy lifestyles.

Lifestyle should be a core theme of healthcare education, alongside other key pillars such as anatomy, physiology, and pathology. This campaign wants to pave the way for updated curriculums and provide education to both undergraduates and current healthcare professionals.

We Need Your Help

However, we need your help. The most successful campaigns have all had significant public backing. The first goal of the Move Eat Treat campaign is to gain 100 000 signatures on our petition.

With support, we have a voice and we can lobby the people and organisations that can bring about the changes in the healthcare and education systems that are so desperately needed.

You can sign that petition HERE .

We hope you’ll also consider sharing the campaign with friends and colleagues via email and social media. The infographics used above which illustrate the problems we face can be freely downloaded HERE.

A Final Word

The Move. Eat. Treat. vision is a lofty one, but with your help we believe we can make a positive change to healthcare philosophy and help keep people healthy.

Move. Eat. Treat isn’t the same old drone from your doctor about losing weight. It’s about creating innovative solutions, tools and guidance to really equip people to be, and more importantly, stay healthy.

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Joseph Lightfoot BSc(Hons) is a final year medical student at the University of Manchester.  He is also currently the strength and conditioning coach to England Under 19 Lacrosse team. Along with the other members of the Move Eat Treat team he is campaigning for a proactive healthcare system.

For more information about the campaign and our goals visit www.moveeattreat.org

Photo by Serge Melki, Flickr CC

Exercise  during pregnancy provides many benefits to the mother and baby. Fortunately, clinicians and mothers have moved well beyond the view that women should be confined, or cannot initiate activity and be active at any stage of pregnancy. Here are 10 ‘take home messages’ for both clinicians and mums from a recent BMJ podcast with Dr. Browyn Bell.

1. Consider type, frequency and duration; a combination of different types of exercise is important to:

• Reap the different rewards of different types of exercise (pre, during, and post-partum)
• Prepare women for the physical demands of pregnancy and motherhood
• Maintain a healthy bodyweight which decreases likelihood of pregnancy complications

2. There are multiple benefits to exercise during pregnancy such as:

• Prevention of Gestational Diabetes
• Reduction of stress and fatigue

3. Keep core body temperature below 38.5 degrees Celsius (especially in the first trimester)

4. Avoid contact sports, scuba diving, and supine exercises during later pregnancy (listen to the podcast for specifics/details)

5. Consider pre-existing health conditions that may become more pronounced during pregnancy

6. For sedentary pregnant woman who want to start exercising, guidelines are the same as for non-pregnant women (gradual increase in activity)

7. One way to ensure a safe exercise intensity is by maintaining a conversation during exercise

8. Women are encouraged to continue exercise during all stages of pregnancy (even if performance ability is reduced)

9. As always, make healthy food choices

10. Everyone has different (pre-existing and unique) health and physical needs. Common sense activities such as walking are always a good idea. Consult a physician or physiotherapist to develop an individualized approach to exercise.

Follow this link to listen to the complete podcast

Related Articles

Artal, R and O’Toole, M. 2003. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med 2003;37:6-12 . (FREE ONLINE!)

Ruben Barakat, R, Cordero Y, and CoteronJ et al. 2011. Exercise during pregnancy improves maternal glucose screen at 24–28 weeks: a randomised controlled trial. Br J Sports Med Published Online First: 26 September 2011.

Three exciting updates from the frontlines of health promotion through physical activity.

Illustration by Liisa Sorsa, 23.5 hours video

First, congratulations to Professor Steven Blair for winning the Bloomberg Manulife Prize for the Promotion of Active Health. This international competition celebrates a researcher whose work promises to broaden understanding of how physical activity, nutrition or psychosocial factors influence personal health and well-being.

Professor Blair has tirelessly raised awareness of the burden of low fitness. His dedicated data gathering and adroit analysis has allowed him to deduce that physical inactivity is the biggest public health problem of the 21st century. His 2009 editorial in BJSM shares this title and has been downloaded more than 20,000 times (available free online).

To read more about the award, follow this link to the Globe and Mail.

Secondly, after garnering global attention, Mike Evan’s videos 23.1/2 hours is being translated into multiple languages. Sports Medicine colleagues will ensure the video can be enjoyed by speakers of Arabic, Spanish, Chinese, and Italian. And there will likely be more offers to come.

This will further enable the first physical activity ‘YouTube sensation’ – 23 1/2  - to promote behaviour change, while recognizing the physical activity challenges in a wide range of countries.

While 1.6 million hits demonstrates 23.1/2’s current success, translation into multiple languages may take this video to the ‘next level’ with a goal of 10 million views!

The video has already gained international traction as shown by the breakdown of views per country: US 844, 664, Canada 320, 000, UK 61, 345, Australia 49, 100, India 32,000, Netherlands 14, 977, Singapore 13,761, Germany 13, 345, Malaysia 11, 986, Sweden 11,589, Israel 11, 387, Saudi Arabia 10, 786, Mexico 10, 607…and the list goes on.

If you haven’t watched the video yet, check it out here (and note Steve Blair’s fun cameo at around 2 minutes 50).

And a third exciting sign of progess was Scotland appointing a physician to head their campaign against physical inactivity.

Doctor Andrew Murray (@docAndrewMurray) – who clearly has to differentiate himself from his colleague “Andy Murray” (@andy_murray).

The more important of the two, although seemingly not by # of Twitter followers, Doctor Murray, makes the point that “having a low level of fitness is equivalent in risk to having diabetes, smoking, and being obese combined”. BJSM likes that emphasis – amazing but true. All the best in the job DocAndy – we look forward to interviewing you for a BJSM podcast (with subtitles).

For more information on this check out the BBC article: GP runner Andrew Murray given sports education role

So – things are moving in the right direction – let’s all take up the cudgels and promote, promote, promote. Remember that Kotter said transformational changes takes 10 times as much communication as you expect it will need (plus 7 other things: see BJSM article on Kotter’s eight-step programme for transformational change).

Related BJSM publications

Rhodes RE and Dickau L. 2011. Moderators of the intention-behaviour relationship in the physical activity domain: a systematic review . BJSM. Published Online First: 25 Jan, 2012.

Burton NW, Khan A, and Brown WJ. How, where and with whom? Physical activity context preferences of three adult groups at risk of inactivity. BJSM. Published Online First: 20 Jan, 2012.

Bauman A, Titze S, Rissel Cand Oja P. 2011. Changing gears: bicycling as the panacea for physical inactivity? BJSM 45:761-762. (Free online!)

Khan, KM. 2009. Mid-year review: physical inactivity universally accepted as the biggest public health problem of the 21st century, shoulder exam challenges, and progress against the scourges of anterior knee pain and ACL injuries. BJSM, 43:469-470. (Free online!)

Guest blog by Dr Jonathan Hanson FFSEM

Like many doctors in sport for years I have relied upon the goodwill of colleagues and employers in the remote corner of Scotland I call home.  Last year I felt the time had come to give something back to the local sport in my region, rather than consistently abusing the goodwill to work with sports many miles away in the cities. Not that there is an extensive choice of sports for a physician to become involved in.

The reality of living and working in the North-West Highlands is that most sport is not of the organised variety – climbers, hill walkers and kayakers are the largest proportion and we already play in role  – albeit in an emergency, critical injury and primary care sports medicine role for these visiting “athletes”.

Of the organised sport out here, the extreme weather dictates that summer is outside and winter is inside. In contrast to the rest of the UK, football is a summer sport in the Hebrides and it supports a very competitive local league. A league that the winners of end up in national cup competitions. Despite being the most popular sport in Scotland by a mile, in the Highlands football remains the little brother of the real Daddy – shinty.

Describing shinty to anyone is a bit like trying to explain Cricket to Americans – until you strip in down to the most basic analogy –“imagine full contact golf”.

Shinty is a sport deeply engrained in Gaelic culture and a distant relative of the Irish sport of hurling. A bit like Aussie Rules and Gaelic football, the international version of the sport is a combined rules shinty- hurling affair between the Scots and the Irish that is played home and away each autumn.

The major cup finals (of which the Camanachd cup is the premier event) are televised on the BBC and simultaneously broadcast on national radio. A handful of seasoned campaigners have reluctantly acquired local celebrity status – but all of whom then go back to work on the croft (smallholding) or fishing boats etc.

The sports governing body – the Camanachd association, has a structure not unlike many other sports with development officers, coaching courses and an active junior section. The local papers are filled each week with photos and match reports and it is discussed passionately down the pub, just like its more widely known relations. Despite some modernisation – the sport remains the archetypal “man’s game” with traditional values which the clubs fight fervently to protect.

Injury Prevention –  medical point of view

KYLES V NEWTONMORE

From a medical point of view, living in the islands, we don’t need a comprehensive injury reporting system to note the injury prevention issues of the sport.  As a Doctor in the communities it’s hard not to be aware of club stalwarts with visual problems incurred playing the sport. Working in the emergency department, Saturday afternoons bring a steady procession of wounds around the face caused by the stick (or caman), hand fractures and the occasional hyphema or actual globe injury. Just like any other sportsman, the primary concern of the athlete is “When can I play again?”

So it was with this in mind that I thought about approaching the Camanachd association to see if I could help them in an advisory capacity. From the perspective of the organisation, the response was positive. A meeting was arranged with the lead development officer and we discussed what I thought I could offer them and what they thought they needed.

Not surprisingly the issue in the Celtic stick sports remains that of helmets and facial protection. Having seen many facial injuries, I have also learned a bit about the coaching of the sport and attitude to injury. Essentially, the good players get close enough to the attacker so that they are within his swing circle and avoid being hit. Being hit is looked down upon as something that lesser players do.

At junior level (age 14) helmets with a faceguard are compulsory and the helmets recommended are the brand specific to their hurling counterparts – so it is essentially fit for purpose. However beyond age 14 there is no compulsory regulation and given the image of the sport as a tough working mans game, very few players continue with any protection at all. Recent high profile players such as Ronald Ross have begun wearing one, but as yet this has not spread across a sport where the goalkeeper is often selected by size (and often adiposity) and chooses protection more useful against the cold (a woolly jumper) rather than against a small high velocity projectile.

I had hoped to set up an injury reporting system and look at coaching and injury prevention as well as establishing a minimum standard of first aid. A senior figure of our local club is the patron of a charity that places defibrillators (having himself had an out of hospital cardiac arrest) so the links between shinty and immediate care are strong (www.lucky2bhere.com). However, such is the suspicion around medical involvement and the perceived desire to take away traditional values of the sport by mandating helmets, that every enquiry to clubs about medical support and training, let alone collecting an injury database were either flatly ignored, or returned with aggressive questions about my motives.

Fortunately the Camanachd association have been more supportive. They are fully aware of the challenges of building medical bridges to the clubs and the value of what we were trying to do. They have taken on the F-MARC FIFA 11+ as an injury prevention strategy and introduced it to the coach education sessions. Whether or not it will make any difference to preventing injury I may never be able to measure. They are also trying to use their contacts with coaches to improve the club / medical relationship and start to quantify some of the perceived problems in the sport. Fingers crossed it continues.

Related BJSM articles

McIntosh AS, Andersen TE, and Bahr, R et al. 2011. Sports helmets now and in the future. BJSM. 45:1258-1265.

McIntosh AS, McCrory P, Finch CF, and Wolfe R. 2010. Head, face and neck injury in youth rugby: incidence and risk factors. BJSM. 44:188-193. (Editor’s choice – full text online!)

Mishra A. 2010. Management of soft tissue injury of hand wrist and elbow in sports. BJSM. 44:i3.

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Dr Jonathan Hanson FFSEM is a Sport and Exercise Medicine Physician/Rural Practitioner. Broadford Hospital. Skye

Mike Evans circulated this to his hockey team of kids early in December 2011.  #1 educational video on YouTube. Remember that low fitness (<30 mins of physical activity daily) kills more Americans that smoking, diabetes, and obesity combined (smokadiabesity).

Click on this link. Watch it, share it. Do it yourself.

Encourage patients to watch it and start today! Great ‘sticky’ message capturing Steve Blair’s evidence that this treatment will save more American’s lives than a cure for smoking, diabetes and obesity put together. That’s a fact!

It passed 2 million views in February, 2012. Wow!!

I have been reading Gary Taubes‘ books on nutrition and health – Good Calories, Bad Calories and Why We Get Fat and What to Do About It.

It is clear to me now that carbohydrate intake is the factor driving the obesity/diabetes/ heart disease/ metabolic syndrome epidemic globally. Taubes explains how this was known up to 1970 and then was lost as the “fat causes heart disease/diabetes” message came out.

I have proved to myself that in my genetic pre-diabetic state my body fat mass is entirely regulated by my carbohydrate intake. I have lost 15kg of fat (looks like I have lost no muscle) by switching from a “healthy” high carbohydrate diet to an “unhealthy” one comprising 55-60% fat, 30% protein and 5-10% carbohydrate (about 80g CHO per day) diet.  Thus I have proved that my body fat mass is inversely related to the fat content of my diet – the less fat I eat, the fatter I become.

The explanation is that my fat cells are profoundly insulin sensitive and store fat (and according to the Taubes hypothesis cause hunger and reduced energy expenditure in voluntary exercise) whenever there is a trace of insulin around. Removing insulin removes the break, the fat cells release the stored fat and hunger disappears and the desire to be physically active increases – this is the Taubes hypothesis that was the standard theory between 1920 and 1970.

Taubes’ book suggests that the idea that dietary fat is bad for your health is another myth that is fueled by those who draw up the US Dietary Guidelines, aided and abetted by the carbohydrate industry who do not want the alternative truth to be realized.  There may also be little appetite for Big Pharma to allow it to be known that simply by reducing their carbohydrate intakes all those at risk of diabetes, heart disease and metabolic syndrome might be able to cure themselves without medication – a frightening thought for the industry.

You, Mr Editor, are lean whilst eating a high CHO diet because:

1. You have muscles that are not insulin resistant so that you store most of the CHO in muscle and;
2. Your fat cells do not respond to the insulin effect by storing fat. Probably you have a signalling defect on a genetic basis in your fat cells.

Your genetic abnormality allows you to eat as much CHO as you wish whereas my insulin intolerant muscles and hypersensitive fat cells causes the opposite effect.

I am also running faster than I have for 20 years and my body shape looks identical to pictures I have of myself when rowing for my University 40 years ago at age 22.  I am looking to break 50 minutes for 10km running in the next 3 months – an improvement of about 25 minutes on times I was running when eating the high carbohydrate diet that I (used to) and others still do advice for athletes.

Anyone who has unsuccessfully tried to lose weight in the past by cutting fat and calories and trying to eat less should know that that approach is utterly ineffective since, in a homeostatically regulated system, all this produces is hunger.  For those who are predisposed as am I, the key is to keep circulating insulin concentrations as low as possible.

If Taubes is correct, then the advice that we should reduce the fat in our diet and replace it with carbohydrate might just be the single greatest public health disaster of the past century (since it has led to the global obesity epidemic).

Rather than dismissing this blog as random mutterings may I suggest that readers either (i) read Taubes’ books or (ii) experiment on yourself or (iii) better still as I have done, do both.  You might just be astonished and angry that something considered to be so complex and inexplicable is actually really so very, very simple.

Dr. Timothy Noakes is a Sports Physician, Exercise Physiologist and Discovery Health Professor of Exercise and Sports Science at the University of Cape Town and Sports Science Institute of South Africa, Cape Town, South Africa

Professor Caroline Finch is a leading advocate for decreasing the divide between the science and practice of injury prevention through greater cross-fertilization in the fields of injury and sports medicine research.

In the June 24, 2011 edition of  BJSM’s sister journal Injury Prevention, Prof Finch offers a concise summary: Updating the international research agenda for sport injury prevention. She contextualizes and highlights key discussions from the IOC’s World Congress on Prevention of Injury and Illness in Sport (Monaco, April 2011) (See related BJSM Blog June 06, 2011  View Top Lectures Online: IOC World Congress of Prevention of Injury & Illness in Sport).

Prof Finch also comments on her own IOC Keynote address – the status of implementation and dissemination research in sports injury prevention. Turning research into action – a major BJSM theme for 2012. Read the article online now to learn more about how certain frameworks and strategies can dramatically improve uptake. See her Editor’s choice editorial in the current BJSM issue too (August 2011)!

In closing her Injury Prevention article, Prof Finch notifies readers that she will be making more guest contributions on both the Injury Prevention and BJSM Blogs…stay tuned!

The  health problems of office workers who ‘sit too much’ is getting increasing attention not only in medical journals but now also in popular media.

See:

Owen N, Baumen, AE, and Brown, W. 2009. Too much sitting: a novel and important predictor of chronic disease risk? BJSM;43:81-83.

Brown, WJ, Bauman, AE, and Owen N. Stand up, sit down, keep moving: turning circles in physical activity research? BJSM 2009; 43:86-88.

Carr, LJ, Walaska KA, and Marcus BH. 2011. Feasibility of a portable pedal exercise machine for reducing sedentary time in the workplace. BJSM, published online Feb 14, 2011.

Khazan, O. Love My Computer Lifestyle. Hate How It’s Killing Me. Forbeswoman, June 29, 2011.

One recent news article –   NJ court: Desk job, not bad health, led to death - raised the question:  is this a prelude for other hazards of physical inactivity related disorders or just a blip? Cardiac events, diabetes etc…

The trial lawyers have been saying when “smoking bullet” (cause-effect type mechanisms) is combined with lack of choice, its only a matter of time. We’ll see.

While it is clearly over-simplistic to say that ALL sitting is ‘bad,’ there is growing momentum for simple, effective strategies to counteract the health burden of sedentary office culture.

Marckowitz, E. Sitting Is Bad for You: What Can You Do About It at Work? Inc, May 4, 2001.

Don’t forget the short BJSM podcast, Sedentary behaviour and mortality, with Genevieve Healy, one of the pioneers in this field.

“Prevention is better than a cure, no matter what disease we look at…football is an ideal platform to promote a healthy lifestyle and prevent disease.”       – Professor Jiri Dvorak, FIFA’s Chief Medical Officer

This month’s BJSM Editor’s Choice (free online) highlights an innovative approach to health and exercise promotion in Africa. Authors Colin Fuller, Astrid Junge, Cadrivel Dorasami, Jeff DeCelles, and Jiri Dvorak investigated how FIFA’s 11 for Health programme (watch promo video) impacted 10 to 15 year old children’s health knowledge in Mauritius and Zimbabwe. They conclude that the collaborative implementation model was successful and that post-programme analyses showed significant increases in most of the participants’ health knowledge.

Photo courtesy of: StephenandMelanie, Flickr Creative Commons

As an outcome of these successful pilot projects and the 2011 nationwide implementation of the programme in Mauritius, over the last 2 months Dr Junge and Dr Fuller worked with Dr. Dvorak on a four-week programme expansion initiative. This involved ‘training the trainers’ in Nairobi (Kenya), and Windhoek (Namibia), and making presentations to Football Associations in Botswana and Malawi. (Read more about the nationwide implementation initiative here).

Dr. Dvorak also presented the results of successful nationwide implementation of the programme to the 61st FIFA Congress on June 1st, 2011 in Zurich. This congress received global media attention. Following the presentation, officials from many countries around the world approached FIFA’s medical team (F-MARC) to express their desire to partner in this initiative.

This project team exemplifies commitment to combining scientific rigour with social responsibility to create an exercise-based tool for health promotion. The potential for scaling up this programme means is has tremendous public health significance. BJSM will highlight ‘success stories’ from around the world as part of the journal’s promotion of ‘implementation’ as a key issue for sports medicine in the 2010s.

Would you like to share successful implementation stories?

Leave a comment below, or send an email: karim.khan@ubc.ca