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

By Dr. Andrew Murray

Increasing Physical Activity is the biggest public health challenge of the 21st century.  Steven Blair’s message is so powerful that it is worth taking to the ends of the earth. I’m currently working for our CMO Harry Burns in the Scottish Government, promoting physical activity for health as part of their Sport and Physical Activity policy team.  Sir Harry is a fantastic advocate for this important form of medicine and enjoys running himself.

In March I received a late call up to take part in the North Pole Marathon. The race itself takes place at the Geographical Pole.  I’d be helping provide medical cover whilst competitors readied themselves and went husky racing etc. in Spitsbergen – 79 degrees North.  The North Pole is only “inhabited” for 3 weeks of the year, as for the rest of the year it is either permanently dark or the ice starts to break up.  Russians sky-dive in and set up an ice runway each year.  The video footage of tractors floating down on parachutes over the pole is bizarre.  The base doctors take care of competitors during the race itself, with a full medical kit that included a gun. Race director Richard Donovan explained that if a polar bear did turn up that it would be disqualified for failure to enter the race and could be discouraged from hanging around by firing a few shots in the air.

The old medical idiom that “prevention is better than cure” holds true in the Arctic, and of frostbite and hypothermia in particular. We advised competitors on clothing strategy (basically to cover every inch of the body), and when to seek medical attention. The risk assessment ensured that a lapped course kept competitors visible to staff, and avoided any leads/breaks in the ice. A warm tent was available to stock food and water for runners and to ward off any impending hypothermia.  Warm areas had been assigned for self-treat i.e. blisters, as well as for minors and majors.

The race itself is like no other, run not on land but on the frozen Arctic Ocean. Some competitors wear snowshoes with their Gore-Tex trainers to traverse the white world of this beautiful natural freezer.  The 9th of April brought perfect conditions of -26 Celsius and light winds.  The full medical kits were cross checked and the race began.

Amazingly all 41 competitors, from 18 different countries finished with the event even featuring a marriage proposal. Spectator numbers were low, although a seal did pop up occasionally.  I ran round in 4hrs 17 mins, whilst the final competitor took over 11 hours.  There were only a few relatively minor cases of frostbite (much to the disappointment of the documentary makers), in addition to the common expected musculoskeletal injuries.  Anterior knee pain was especially common probably due to the wide gait adopted to chew through the deep snow by most runners, whilst other injuries seen included Achilles tendinopathy, ankle dorsiflexor tendinopathy, and a hip flexor injury. I helped patch runners up once I had finished, and advised the few that were injured on appropriate treatment, including what to tell their doctor in Mauritius who presumably doesn’t see much frostbite.

I think we all have the opportunity to promote physical activity for health.  Steven Blair, Karim Khan, Mike Evans, Richard Weiler and others have done much to produce data, and frame it imaginatively. 23 and a half hours is a must share resource, and sticky messages like “Smokadiabesity” seem to resonate with the public and policy makers.   Additionally, sporting events like the North Pole Marathon offer the chance to put forward a health message.

On a personal level, I’m looking forward to running seven ultra-marathons on seven continents in seven days in November this year, with the sole aim of promoting physical activity as the single best thing that we can do for our health.

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Follow Andrew on twitter at @docandrewmurray

Andrew Murray is a Sport and Exercise Medicine Registrar in Scotland.  His book is called “Running Beyond Limits” Mountain Media.  He failed to mention in his blog that he won the North Pole Marathon 2012!

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

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!!

On Monday the Guardian published It’s not obesity that’s killing us – it’s the lack of exercise. Inspired by research presented at UKSEM (see also Blair Physical inactivity: the biggest public health problem of the 21st century, and BJSM Warmup 2011; 45), the Guardian exhorted us to focus less on obesity and more on physical activity. With 191 comments, 1000 Facebook likes, and 71 tweets (in 48 hours) it doesn’t take a social media expert to figure that this topic is hot.

A critical question is whether exercise is THE primary tool for weight loss (rather than just as part of a healthy lifestyle).

Does exercise promote weight loss?

King, Horner et. al’s have a great article – Exercise, appetite and weight management…in BJSM Online first.

Professor Timothy Noakes (and @GaryTaubes) add these insights to the discussion in this guest blog:

Photo courtesy of Gavin Clarke, Flickr cc

What astonishes me is the continuing failure of so many people, my medical colleagues included, to realize that the solution to personal obesity is so simple. The cause for most people is exactly as Gary Taubes described it – a diet too low in fat and protein and too high in carbohydrate especially sugar. If you are over forty, overweight, personally motivated, and not eating a high fat/high protein/low carbohydrate diet, then you are missing out – your life is passing you by.

The second key is also as Taubes describes it – obesity begets inactivity whereas leanness promotes activity. Trying to get lean by exercising whilst continuing to eat the “healthy” high carbohydrate diet will be unhelpful for most with an elevated BMI (and who are are therefore by definition, carbohydrate intolerant/resistant). You need first to lose the weight by changing to a high fat/high protein/low carbohydrate diet. As the weight falls of (as it does very dramatically at rates that most will not believe), the desire to exercise becomes increasingly overwhelming. In time the desire to exercise becomes addictive.

Trying to encourage overweight people to exercise without first changing their habitual eating patterns (not diet, please note) will never produce the same outcome as will one in which the initial focus is on changing to a high fat/high protein/low carbohydrate diet.

As Gary Taubes describes, this has been known since 1861 but was written out of the medical and popular literature after 1970 when Dr Ancel Keys essentially single handedly developed the global fear of fatty foods that mislead the world and led directly to the epidemic of obesity and diabetes that began to engulf especially people in the developed world especially after about 1977.

Until we rid ourselves of the ridiculous idea that carbohydrate foods are somehow “healthy” (for all) and fatty foods are unhealthy, and as long as we allow our eating patterns to be dictated by industries that aim remorselessly to increase global consumption of sugar and refined carbohydrates, then we cannot solve the global problem of obesity and diabetes.

But at an individual level we can take control by realizing that obesity is a genetic/nutritional disorder caused by excessive carbohydrate consumption in those who are carbohydrate-resistant (and who are therefore unable to metabolize carbohydrates especially fructose, appropriately but who will store the excess calories in fat, rather than expend them in physical endeavor).

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.

Guest blog by Sean Carmody

“Where are all of the other students?”

This was the question posed by opening speaker Dr. John Moroney at the official launch of The Hull York Medical School (HYMS) Society for Sport and Exercise Medicine last year. He was referring to the fact that there were only fifty or so students in the lecture hall, which is a relatively small proportion of the student population of HYMS, and a number which indicates the uphill battle that this society faces in trying to convince our peers that Exercise Medicine has an increasingly significant place on the health agenda.

As we prepare to celebrate our one year anniversary, we must acknowledge that the HYMS Society for Sport and Exercise Medicine faces a different set of challenges from those which we encountered twelve months ago. While before we were preoccupied with expanding our Facebook following and ensuring we had the most attractive logo, now we must delve deeper and ask ourselves challenging questions about the fundamental purpose of our Society:

• Do we still believe in spreading the word of Sports Medicine?
• Is there a credible place for our society amongst the likes of SurgSoc and The Ethics Society?

Bearing in mind that birthdays can be retrospective occasions, now seems a particularly appropriate time to address these questions.

The short answer to the these questions is yes. It must be. By now the global obesity pandemic, and its associated complications, has received widespread media coverage. A recurring theme in the newspaper columns and TV programmes dedicated to this pandemic is that exercise, coupled with nutrition, is the safest and most practical solution to the crisis. So, in exposing our colleagues to experts in the field of Sport and Exercise Medicine, we are enhancing their awareness of its importance, while defeating the myth that Sports Medicine is limited to the glamour of providing for professional sports teams. (see Blair, SN. 2009. Physical inactivity: the biggest public health problem of the 21st century, BJSM).

The highlight in our brief history so far has, undoubtedly, been the official launch event. It was particularly fitting that Dr. John Moroney, a General Practicioner in the local community and Chief Medical Officer at York City FC, would commence proceedings. He provided us with a valuable insight into the challenges of balancing life as a GP and lower league team doctor. We were also provided with the unique opportunity of hearing from a ‘patient’ as such, as Matt Murray, a former professional footballer with Wolverhampton Wanderers, detailed his experience of medical professionals throughout his career-long battle with injury.

During this academic year, we are hoping to build on what we achieved last time round, and the impending London 2012 Olympics provides an excellent platform from which to do so. With membership swelling, and the hosting of a national student conference in the pipeline for Spring 2012, there are encouraging signs for the HYMS Society for Sport and Exercise Medicine. Nevertheless, the question posed by Dr. Moroney on opening night, and its implication, still resonate with us. But it has challenged us, and driven us forward too.

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Sean Carmody is a third year medical student at the Hull York Medical School, and a co-founder of the HYMS Society for Sport and Exercise Medicine.

The Hull York Medical School (HYMS) Society for Sport and Exercise Medicine is a student-led initiative which acts as a formal outlet for HYMS students to explore the possibility of taking up a career in Sports Medicine. It was founded in Autumn, 2010.

Blair. 2009. BJSM, (43) pp1-2

Smoking, diabetes and obesity are  major public health concerns.  At the same time there is little attention given to the health consequences of missing a day (or a lifetime) of physical activity.
Yet low physical fitness kills more Americans than does either smoking, diabetes, or obesity (see Blair). And, when one looks at it carefully, low fitness kills more Americans than smoking, diabetes and obesity in COMBINATION!! (apologies for red but it deserved it!)

As a nation, an unfit America (that’s where these data exist) dies more from low fitness than from ‘smokadiabesity.’ And low fitness is readily curable.  Do personal, and policy, priorities reflect the real killer?

Comment below or send guest comments to karim.khan@ubc.ca

Does our health system reflect this order of importance?

This graph (redrawn from Blair SN, BJSM 2009, pp. 1-2)  compares the population attributable fraction of death for men (left, coloured bar in each set) and women (right, open bar in each set). The low fitness column reflects a greater PAF for deaths than the combined smokadiabesity column.

See also Supercourse for Professor Blair`s 40-slide lecture on this topic

And click here to listen to Professor Blair`s BJSM podcast