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MOOCs: Marvellous or Moot for Exercise Medicine and Physical Activity?

8 Nov, 16 | by BJSM

By Chris Oliver @CyclingSurgeon, Mairi Buchan, and Jo Hilton

Massive Open Online Courses (MOOCs) have become increasingly popular over the past few years. Especially after successful early MOOCs such as “Circuits and Electronics” by American Universities, Harvard and MIT [1]. In their simplest form MOOCs are vehicles for delivering information on a topic to an enormous number of people at any one time. Recent additions to the MOOC portfolio include MOOCs that offer education in Exercise Medicine and Physical Activity. For example, McGill University’s MOOC “Exercise is Medicine” was “created to provide the public with a reliable source of information and exposure to experts in the field” [2]. Whilst there are many positive aspects of these programmes, there are important considerations related to the benefits, challenges, and implications that these innovative e-learning programmes have for the sports and exercise medicine community, and the world at large. In this blog, we introduce some key themes of this debate.


Image courtesy of Chris Oliver

MOOCs: The positive story

An ancient Chinese proverb states “if you are planning for a year, sow rice; if you are planning for a decade, plant trees; if you are planning for a lifetime, educate people”[3]. Free access to education is a hot topic and in modern-day society. As we are increasingly aware of inequalities in all aspects of our lives, we want to allow everyone, regardless of background, access to this basic human right [4]. Some MOOCs have been created in order to bridge the access gap for populations from more socioeconomically deprived regions [5]. There are a plethora of positives surrounding MOOCs, particularly the focus on the appeal to human curiosity and a more relaxed approach to learning. Individual choice in study topic over a given timeframe is key in developing and maintaining an intrinsic motivation to learn. Many education critics believe intrinsic motivation is often lacking in formal educational settings [6].

What are the educational themes and why are these important?

Despite advantages of MOOCs, the accompanying educational themes are worthy of further investigation. Firstly, yes, the whole idea behind these projects is that they provide equal access opportunity to education by breaking down financial and infrastructural barriers; however, in general, the evidence so far is that people accessing these courses tend not to be from more socioeconomically deprived demographics [7]. Many of the MOOC participants are university-educated with a desire to further their knowledge and advance in their current careers [8].

Another inherent glitch is catering to the huge number of students. Some courses have had many tens of thousands of participants. In a formal education setting, physical or online, hundreds of tutors are required to cater to each student’s needs. The number of tutors involved in MOOCs is often very small and may struggle to match the personalised educational experience, expected in formal education [8]. In addition, the lack of funding to employ a greater number of tutors to support participants and to develop educational materials provides yet another challenge to the success of MOOCs [9].   The long-term economic sustainability of MOOCs will rely on a clear business case. The impact of use of intellectual property by MOOCs has still to be widely debated.

Whilst many people enjoy the experience of engaging in a MOOC, there are challenges for participants. Embarking upon a MOOC can be intimidating for those new to this style of learning [6]. Lists of recommended reading, participation in discussion groups and completion of weekly assignments may cause information overload issues. Some participants may not know where to begin or how to manage their time accordingly. The student may also be left to rely on guidance from connecting with other MOOC participants and gaining advice from their previous experiences. There is an assumption that students will be proactive and enthusiastic learners. However, if no-one contributes to discussions on a regular basis, the onus is on the individual to find their own way around the MOOC [6].

Future implications of MOOCs for modern-day higher education

Access to educational materials produced by highly-rated universities, can contribute to facilitating the economic, political, and social growth of developing countries. It would appear that MOOCs combine local access to e-learning that can be applied to practice in the field of sports and exercise medicine. Nevertheless, despite the access ideals behind MOOCs, it seems that one group may be benefiting more than the other from these courses: the developed world. This is likely in direct relation to evidence that suggests there is an early uptake effect of MOOCs by those who already have already experienced higher education.

Although initial subscription to and enthusiasm towards MOOCs is often high, the attrition rate is higher than that of conventional higher education settings [10]. The impact of low staff-to-student ratios, the relatively low personal investment and the high intrinsic motivation necessary to learn may all contribute to a high drop-out rate.

MOOCs are still valuable despite their limitations. However, they should not be viewed as the sole solution, or as a replacement for other initiatives that seek to increase access to quality education in developing countries. MOOCs may be best viewed as complementary to rather than competing with the traditional education setting, physical or online.

The inherent issues of financial and time resource constraints as well as the challenges MOOC participants face, need to be held in mind by all stakeholders with an interest in quality, low-barrier education opportunities.

In the field of exercise and physical activity, MOOCs appear to be here to stay. A next-step to collectively consider is the challenge of measuring their social, educational and financial impact long-term.


  1. Breslow L, Pritchard DE, DeBoer J, Stump GS, Ho AD, Seaton DT. Studying Learning in the Worldwide Classroom: Research into edX’s First MOOC. Res Prac Ass. 2013; 8: 13-25. Available from: [Accessed 10 October 2016].
  2. Griffin S, Shrier I. University of McGill massive open online course: pioneering sport and exercise medicine education. Br J Sports Med 2016;50:1101-1102. [Accessed 30 October 2016]
  3. Chinese Proverbs [Accessed 10 October 2016].
  4. The Universal Declaration of Human Rights. United Nations. [Accessed 10th October 2016].
  5. Kay J, Reimann P, Diebold E, Kummerfeld B. MOOCs: So many learners, so much potential. 2013; 52(1):49-67.
  6. Kop R. The challenges to connectivist learning on open online networks: Learning experiences during a massive open online course. The International Review of Research. In Open and Distributed Learning. 2011 Jan 13; 12(3):19-38.
  7. Christensen G, Steinmetz A, Alcorn B, Bennett A, Woods D, Emanuel EJ. The MOOC phenomenon: who takes massive open online courses and why? 2013. [Accessed 10 October 2016].
  8. Laurillard D. Five myths about MOOCs. Times Higher Education. 2014 [Accessed 10 October 2016].
  9. Hollands F, Tirtahli D. Resource requirements and costs of developing and delivering MOOCs. The International Review of Research in Open and Distributed Learning. 2014 5 October; 15(5). [Accessed 10 October 2010]

Sit Less, Get Active! First MOOC to deliver and evaluate physical activity promotion, call to action: sign-up or share

22 Jun, 16 | by BJSM

By Adam Bleakley (Foundation Doctor, NHS Lothian) and Evan Jenkins (Medical Student, University of Edinburgh)

Physical activity is regarded as a global public health priority (Kohl, 2012), and physical inactivity the biggest public health problem of the 21st century (Blair, 2009).

Physical inactivity and sedentariness, “silent killers”, are associated with increased morbidity and reduced life expectancy (Lee et al. 2012, Levine 2015). Despite this, about one third of the global population are inactive (Hallal et al. 2012). In 2012, almost half of England and Scotland’s population did not meet the physical activity guidelines, and physical activity further decreases with age (British Heart Foundation, 2015).

It is imperative to further promote benefits of physical activity, work on strategies that will increase population levels of physical activity and make it an important part of people’s everyday lives.

bike moocSit Less, Get Active MOOC

Here, at the University of Edinburgh (Usher Institute for Population Health Sciences and Informatics, Physical Activity for Health Research Centre, Sports and Exercise and School of Informatics), we are the first to offer a “Sit Less, Get Active” Massive Open Online Course (MOOC), on June 30th, 2016. This new, interactive MOOC promotes and evaluates physical activity.

For those thinking, “what’s a MOOC??”: MOOCs are online courses that can be taken by anyone from any part of the world in their own time as long as you have access to the Internet.

Sign up here (it’s that easy):

Join us on a journey to learn how to sit less and become more active. Use this free course to learn how to monitor your own activity, set physical activity goals and make physical activity a habit- or share it with networks that you think it will benefit. We will present various examples on how to sit less and be more active in various settings such as your neighbourhood, home, work or educational environment, to help you incorporate the ones that fit the best to your lifestyle.

The MOOC is 3 weeks long with a commitment of not more than one hour per week. This course also offers you a unique opportunity to receive weekly physical activity health messages and monthly video reminders for 6 months after the initial 3 week-course as nudges to help you sit less and stay more active.

And if you are a health professional, use knowledge gain through this course to empower your patients to be more physically active. However, if time is the constraint, you can simply “prescribe” the course to your patients.

MOOC_TeamThe core MOOC team includes (in alphabetical order): Dr Graham Baker, Dr Danijela Gasevic, Professor Dragan Gasevic, Dr Andrew Murray, Professor Nanette Mutrie, Professor Chris Oliver, and Helen Ryall. We are grateful to all volunteers and partners who have advised us, endorsed us or worked with us in many capacities such as The Scottish Government, NHS Health Scotland, NHS Health Lothian, Sustrans Scotland, Edinburgh Leisure, SPORTA, Cycling UK, and Queen Margaret University.

How to sign up and share

The course starts on June 30, 2016, and it will run three to four times per year. You can sign up to Sit Less, Get Active MOOC by registering online via link:

Follow us on Twitter @GetActiveMOOC for a daily dose of physical activity promotion. If you have any questions, please contact the Team Lead Dr Danijela Gasevic at And don’t forget, Sit Less and Get more active for your health and happiness!



Blair, SN. Physical inactivity: the biggest public health problem of the 21st century. BJSM 2009: 43:1-2. OPEN ACCESS HERE

British Heart Foundation. Physical Activity Statistics 2015. Accessed at on June 18 2016

Hallal PC, Andersen LB, Guthold R, Haskell W for the Lancet Physical Activity Series Working Group. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012;380(9838):247-257.

Kohl HW, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G, Kahlmeier S. The pandemic of physical inactivity: global action for public healthThe Lancet, 2012;380(9838):294-305.

Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzy PT for the Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012, 380(9838):219-229.

Levine JA. Sick of sitting. Diabetologia 2015, 58(8):1751-1758

Worin bestehen die Vorzüge körperlichen Trainings hinsichtlich Gedächtnis und kognitiver Funktion?

16 Jun, 16 | by BJSM

To read in english go HERE

Antwort auf eine Frage im Rahmen eines Online Kurses der McGill Universität, Kanada („MOOC“ *): „Auf den Körper kommt es an“

von Dr. Julia Alleyne

Dr. Alleyne (Twitter account: @JKAlleyne) ist Fachärztin für Sportmedizin zu deren Erfahrungsschatz u. a. ihre Funktion als leitende Medizinerin für Kanada bei diversen olympischen Spielen, sowie bei den Pan-Pazifischen Spielen 2015 gehört. Sie hat zahlreiche führende Positionen in der kanadischen Akademie für Sport- und Bewegungsmedizin (Canadian Academy of Sport & Exercises Medicine “CASEM”), eine der Mitgliedsgesellschaften des BJSM (Anm.: British Journal of Sports Medicine), innegehabt. Ihre akademische Arbeit an der Universitiy of Toronto verbindet sie mit der Tätigkeit als Ärztin bei „Toronto Rehabilitation“.

German translation by Isi Schneider @isi69schneider

German translation by Isi Schneider @isi69schneider

 Weltweit sind geschätzt 44 Millionen Menschen von Demenz und verwandten kognitiven Störungen unmittelbar betroffen (CDC 2014). Der Nutzen eines körperlichen Trainings für Menschen mit einer Demenzerkrankung überwiegt bei Weitem die Risiken, trotz der kognitiven Einschränkungen der betroffenen Personen. Die optimale Art der Betätigung um die kognitive Verarbeitung erfolgreich zu verbessern liegt entweder in einem Ausdauer- oder Krafttraining, oder einem beständigen aktiven Lebenswandel.

Die am meisten verbreitete Ursache von Demenz ist der Altersprozess in Verbindung mit Erkrankungen der Gefäße. Aus diesem Grund, nachdem körperliches Training bekannter Weise in der Lage ist das Vorkommen von Bluthochdruck, koronarer Herzkrankheit und Schlaganfällen zu mindern, wird durch Training auch das Altern der Blutgefäße im Gehirn verlangsamt.

Nachweis des Trainingseffekts

Um die Anatomie des Gehirns begutachten zu können, haben Colombe et al. (PNAS 2004) Kernspintomographien älterer Erwachsener unter die Lupe genommen, die sechs Monate lang dreimal pro Woche spazieren gegangen sind, und fanden dabei signifikante Verbesserungen im Volumen der grauen und weißen Substanz. Teresa Liu-Ambrose, verantwortliche BJSM Redakteurin, benutzte funktionelle MRT-Verfahren, um die Gehirnfunktion älterer Erwachsener zu untersuchen, die zweimal pro Woche an einem Krafttraining teilnahmen (Arch Int Med 2010). Sie entdeckte dabei signifikante Verbesserungen in der Hirnfunktion, die auch nach Beendigung des Trainings noch über 12 Monate hinweg anhielten. Diese Veränderungen bestanden u. a. in einem verbesserten Erinnerungsvermögen, der Dauer der Zeitspanne bis zu einer kognitiven Rückmeldung sowie der Fähigkeit, Anweisungen korrekt umzusetzen.

Aber was ist mit den Persönlichkeitsveränderungen und den Stimmungsschwankungen, die mit dem kognitiven Verfall einhergehen? Behrman et al. (Practitioner 2014) haben mit einem ähnlichen Ansatz die bekannten Vorzüge von Training auf depressive Symptome extrapoliert und Trainingseffekte auf ältere Erwachsene unterschiedlicher Jahrgänge näher untersucht. Dabei fanden sie bei Patienten mit milden bis moderaten depressiven Symptomen und damit einhergehender Demenz positive Zusammenhänge zwischen zunehmender Aktivität, wie z.B. Spazierengehen oder Tanzen, und Verbesserungen von Stimmung und Selbstwertgefühl, während andererseits negative und verwirrende Gedanken weniger wurden. Beim Vergleich mit einer Arzneimittelbehandlung stellten sie fest, dass Training genauso effektiv und in der Regel in der Lage ist, den Bedarf nach Medikamenten mit möglichen Nebenwirkungen herabzusetzen.

In einer 2010 von Sofi et al. (J Int Med 2011) durchgeführten Meta-Analyse überprüften die Autoren Studien, in denen Erwachsene ohne Demenzsymptome rekrutiert wurden und in deren Verlauf die kognitive Funktion der Probanden gegenüber möglichen Zusammenhängen mit dem anatomischen Vorhandensein einer Erkrankung überwacht wurde, um feststellen zu können, ob sich das Risiko des kognitiven Verfalls bei sportlich aktiven Erwachsenen verändert.
Es wurden fünfzehn prospektive Studien mit Erwachsenen mittleren Alters gefunden, die einem regelmäßigen aktiven Lebenswandel nachgingen. Die gesamte Analyse folgte mehr als 30.000 Probanden über den Verlauf von 1-12 Jahren und ergab, dass das Risiko des kognitiven Verfalls bei Probanden mit einem hohen Aktivitätsniveau um 38% herabgesetzt war, sowie um 35% bei Menschen mit niedriger bis mittlerer Aktivität, verglichen mit sitzenden Versuchspersonen.

Wie sieht es mit nachteiligen Ergebnissen aus?

In meinem Bemühen eine ausgewogene Forschungslage zu präsentieren, habe ich eine Literatursuche zu möglichen nachteiligen Ergebnissen bezüglich kognitiver Funktion bei aktiven älteren Erwachsenen durchgeführt. Das Resultat ergab lediglich ein paar nachvollziehbare Warnhinweise… ruhig anfangen und langsam aufbauen, um eine Überlastung des Bewegungsapparates zu vermeiden, den nötigen Energiebedarf decken und sicherstellen, dass neue Trainingstechniken unter Anleitung und entsprechender Aufsicht erfolgen. Das Hauptergebnis war jedoch, dass sich die kognitive Leistung durch Training nicht verschlechtert; dies ist die entscheidende Kernaussage!

Zusammengefasst lässt sich sagen, dass zwischen den schützenden Effekten körperlicher Aktivität auf die kognitive Leistungsfähigkeit und dem Erhalt einer adäquaten zerebrovaskulären Versorgung des Gehirns mit Blut und Sauerstoff sowie durch unmittelbare endokrine Mechanismen ein enger Zusammenhang besteht. Durch die positiven Effekte von Training auf die Reduktion kardiovaskulärer Risiken wird das Vorkommen damit assoziierter zerebrovaskulärer Ereignisse in Folge von Diabetes, Bluthochdruck, Adipositas und Störungen des Fettstoffwechsels ebenfalls herabgesetzt – und damit auch der krankheitsinduzierte kognitive Verfall. Ein aktiver Lebenswandel schützt darüber hinaus mit einer hohen Wahrscheinlichkeit das Gehirn durch die Stimulation von Neurotrophinen die, wie ihr Name bereits nahelegt, das Wachstum und Überleben von Nervenfasern sichern. Zu guter Letzt lassen aktuelle Forschungsergebnisse vermuten, dass körperliches Training in der Lage ist, stressbedingte Kortisolwerte zu senken, wodurch ebenfalls die kognitive Funktion langfristig erhalten bleibt.

Abgesehen jedoch von jeglicher Wissenschaft kann ich mich an eine öffentliche Kampagne der vergangenen Jahre erinnern, die selbstbewusst mit dem Slogan Be smart, exercise your heart („Sei schlau, trainiere Dein Herz“) geworben hat. Ich denke die zu Grunde liegende Botschaft lernt langsam laufen – kein Wortspiel beabsichtigt!

P.S.: Dr. Alleyne ist Mitglied der internationalen Expertengruppe, die Fragen von Studenten im Rahmen des MOOC beantwortet.

* Anm. d. Übers.: “MOOC” – “Massive Open Online Course” = Offenes Online Seminar

Der englischsprachige Originaltext ist im Blog des British Journal of Sports Medicine erschienen:

Übersetzt von

Isabel Schneider

M.A. Englisch als Fremdsprache

MA Sportwissenschaften

Dozent an der H:G Hochschule für Gesundheit und Sport, Technik und Kunst

Physio-Motion – Beratung und Dienstleistungen rund um Sport, Bewegung und Gesundheit




  1. Stanley J. Colcombe et al; Cardiovascular Fitness, Cortical Plasticity, and Aging Proceedings of the National Academy of Sciences of the United States of America. Vol. 101, No. 9 (Mar. 2, 2004), pp. 3316-3321.
  1. Liu-Ambrose T. et al; Resistance training and executive functions: a 12-month randomized controlled trial, Arch Intern Med. 2010 Jan 25;170(2):  (siehe auch
  1. Behrman S, Ebmeier KP.; Can exercise prevent cognitive decline? Practitioner. 2014 Jan;258(1767):17-21, 2-3.
  1. Sofi et al; Physical activity and risk of cognitive decline: a meta-analysis of prospective studies, Journal of Internal Medicine, Volume 269, Issue 1, pages 107–117, January 2011




Runners with red pee = red alert?…The answer to MOOC’s question of the week

4 Apr, 16 | by BJSM

Each week students in Professor Ian Shrier’s (@McGillU) Massive Open Online Course (MOOC) ask questions. We call on our ‘world expert panel’ for the answers, and profile select responses on the BJSM blog.  

This week’s question: What are the possible causes for first time gross hematuria in a female runner who experiences some abdominal pain during running?

The scenario presented occurs rarely, and most sports physicians would only see a few cases in their career. Haematuria is frightening for the athlete, so most present promptly for advice.

red runnerThe history, duration, frequency and type of exercise is important. Lots of downhill running provokes cell break down in the quadriceps due to eccentric loading, and this may result in myoglobinuria. Old shoes with poor cushioning have less shock absorption and can lead to foot strike haemolysis.
Anit-inflammatory medications can reduce renal blood flow, and studies on hyponatremia have found increased creatinine in the serum. However, we know these medications are commonly used by distance runners with relatively few suffering severe complications.

On physical examination, the athlete’s general condition is usually well unless there is a rare case of rhabdomyolysis. In collision sports, flank tenderness may be present. In the vast majority of cases, the diagnosis is Runners’ Haematuria, which was initially termed “10,000 metres haematuria” by the urologist Blacklock back in the 1970s. It is caused by abrasions of the bladder wall against the trigone, analogous to caecal slap in the gut. The only routine investigation necessary is a simple urinalysis to look for RBC and casts, plus protein.

Although the vast majority of cases are Runner’s haematuria, physicians still need to ensure the less common possibilities from the differential diagnosis are ruled out based on history, physical and investigations:

  1. Renal or ureteric stone will cause pain. The condition is uncommon in young athletes, but the first episode can occur in youth. A detailed metabolic work up is required if this condition is diagnosed.
  2. Foot strike haemolysis with haemaglobin pigment causing red urine. This is common when old or worn shoes are used, and the running occurs on a concrete surface.
  3. Urinary tract infections classically presents with dysuria and frequency rather than severe abdominal  pain. Haematuria is uncommon in UTI.
  4. In a female athlete, the bleeding may actually be coming from the reproductive tract, i.e. uterus or cervix, but admixed with urine. Most women will be able to distinguish the two sources, but a pelvic examination may be required to clarify things in some circumstances.
  5. Myoglobinuria from damaged muscle can also change the colour of urine and appear similar to hematuria. This usually occurs after unaccustomed eccentric exercise and was originally termed the ‘squat jump syndrome’ within military settings. This condition can cause rhabdomyolysis and this would require an emergency work-up if suspected.
  6. Malignancy in the renal tract classically presents with painless haematuria. It is rare in young people, but should not be forgotten.
  7. In repeated cases of haematuria, a cystoscopy may help identify sites of bleeding, but these are usually just abrasions in the bladder wall opposite the trigone.

If the history and physical condition suggest any of the more serious differential diagnoses, further investigations are warranted. The only condition that needs urgent work up is rhabdomyolysis, which presents very differently from Runners Haematuria and needs hospital admission because an associated hyperkalemia can be life threatening, and an associated acute compartment syndrome can be limb threatening. If rhabdomyolysis is suspected, then the investigations should include a CBC, CRP, creatinine, electrolytes, plus ECG (to look for peaked T waves as a sign of hyperkalaemia). Thomas and Ibels summarised the recommendations for management of rhabdomyolysis in the 1980s and it has not been improved upon. They advocate:

  • A- aggressive fluid replacement 4-11 litres in the first 24 hrs
  • B-resonium ion exchange resins to correct  significant hyperkalaemia. Dialysis may be required in some circumstances
  • C-compartment pressure testing if there is suspicion of acute compartment syndrome, and decompressive surgery when required.

Management of Haematuria in a Runner

For a first episode where history and physical examination do not suggest any of the differential diagnoses, the physician should manage the patient as a case of runners’ haematuria ie bladder wall abrasions. Apart from the basic investigations mentioned above, the athlete should rest from exercise until the haematuria clears, and then resume exercise. Some authorities advise the athlete to exercise with the bladder partly full, with the idea that this will reduce the contact between the trigone and the opposing bladder wall. Practically, this can be difficult to achieve! Athletes should also be advised to minimise NSAID use prior to races and long training runs, particularly in the heat. When there are recurrent episodes of exercise related haematuria, the patient should be referred to a renal physician or urologist. The referral route will be determined by the clinical picture  and local or regional availability of services. Cystoscopy may be required to identify the source of bleeding

In summary, Runners’ Haematuria is uncommon, but sports physicians need to know how to deal with it. In most cases, the cause is relatively benign, but be aware of the occasional serious cause, and refer those people for prompt further management.

Other Readings:
Thomas MA, Ibels LS. Rhabdomyolysis and acute renal failure. Aust N Z J Med 1985;15(5):623-628.

Mercieri A. Exercise-induced hematuria. Up to date Oct 14 2015,
Siegel AJ, Hennekens CH, Solomon HS, Van Boeckel B.. Exercise-related hematuria. Findings in a group of marathon runners. JAMA 1979;241:391-392.


Dr Chris Milne is a Sports and Exercise Physician based in Hamilton New Zealand. He has particular interest in exercise related renal and GI issues. He has been Team Physician to several NZ Olympic Teams, and is Chair of the Medical Commission for Oceania National Olympic Committees.

This week’s answer to MOOC question: Professor Louise Burke on fitness, weight loss and abnormal menstrual periods

5 Mar, 16 | by Karim Khan


Each week students in Professor Ian Shrier’s (@McGillU) Massive Open Online Course (MOOC) ask questions. One questions is answered by our world expert panel on the BJSM blog. Here’s this week’s question.

Q: I have been working hard in gym over the last 6 months. I got cool muscles and I look very fit. I also like that instead of losing weight I gained 3 kg extra (muscles). I eat well. But what worries me is the absence of a menstrual period. I wonder if amenorrhea can be caused by just hard training (without weight loss)?

A: Answer by Professor Louise Burke, PhD & Sports Nutritionist. Australia’s multi-Olympic games sports nutritionist, lead Nutritionist at the Australian Institute of Sport and author of the definitive Clinical Sports Nutrition. Member of the IOC Consensus Statement group that described RED-S: the Relative Energy Deficiency Syndrome (read on).

Louise writes…”Being too thin or training too hard were some of the early suspects in our understanding of amenorrhea in athletes. The first version of the Female Athlete Triad syndrome added further confusion with its rigid definition of the co-existence of amenorrhea with eating disorders and osteoporosis. Over the last decade, however, an appreciation of the real dietary problem – low energy availability – has emerged. This new term helps to tie a number of issues and observations together, and provides a new perspective on why amenorrhea occurs, who is at risk, and why you should care. The answer to these questions lies in an understanding of how the body handles energy.

Energy balance just considers the difference between energy intake from food and daily energy expenditure/requirement. When daily energy intake and expenditure is roughly equal, you’re said to be in neutral energy balance (or just “energy balance”).  Energy balance can be changed by changing your intake, changing your expenditure, or changing both. If this change results in an energy intake that is less than expenditure (negative energy balance), there is a general expectation that body energy stores in the form of body fat and muscle are sacrificed to bridge the deficit.

Meanwhile, energy availability focuses on energy requirements, breaking them into two components: energy for exercise and energy for health and maintenance. In an ideal world, where you want to be in top shape and top function, your energy intake would cover both components. However, if we upset this equation by reducing our energy intake, increasing the energy we commit to exercise or a mixture of both, the result is a shortfall in the energy specifically available to support other body functions. Some of these functions are critical for keeping you alive while other functions are “nice to have” but can be turned off or turned down in an emergency.   This situation is termed low energy availability.

Although we’ve said that negative energy balance causes you to break down fat and muscle to contribute these energy stores to the energy deficit and try to address the low energy availability, your body is smart enough to know that this isn’t a good long-term solution. After all, you will eventually disappear if you keep sacrificing your body tissues! Your body’s solution to low energy availability is to turn down or turn off some of the less essential health and maintenance functions to save its energy costs and try to restore energy balance. The good news is that you are now more economical at being you, expending fewer Calories/kilojoules to get through the day. The bad news is that you are no longer maintaining your health and function at its top level. Loss of the menstrual cycle is one of the common casualties of the energy adjustments.

Honing back in on the MOOC question & periods stopping…

This concept raises three important findings of relevance to the current case. First, low energy availability can be associated with negative energy balance and weight loss, but not always. In some situations or some individuals, the body’s priority response to low energy availability is to adjust energy expenditure to restore energy balance at a lower energy intake. Thus, low energy availability can exist without the typical presentation of weight loss or becoming very thin.

The second update is the recognition the energy mismatch that causes low energy availability can occur in a variety of scenarios:

  • Disordered eating and eating disorders
  • Over-enthusiastic and/or misguided weight loss campaigns. Some athletes set unrealistic targets for weight/body fat loss; others have reasonable targets, but try to reach them way too quickly.
  • A high training volume or strenuous competition schedule – particularly when this represents a sudden increase in usual patterns. It can be difficult to get a handle on just how much more energy is needed to support the new exercise program, and your appetite may be blunted by fatigue rather than directing you to eat more
  • An environment in which access to food is difficult and prevents an athlete from finding food at the right time in the right amounts – tight finances, travel, boarding in residences with small windows for meal times, a hectic schedule that means always being on the run.

In other words, different types of factors can be represented in the development of low energy availability ranging from psychological problems to lack of knowledge or simply being in the wrong place at the wrong time in terms of food availability. We need to increase our recognition of the different types of athletes in which low energy availability can occur (including males!) and we need to have different solutions to fit the problem.

The third update on this syndrome belongs in the “why should you care” basket. Although amenorrhea is a common outcome of low energy availability adjustments, it is not universal (think of male athletes or post-menopausal athletes) and may not be recognised or considered problematic by some athletes. However, we now know that many other body systems are impaired by low energy availability, with casualties including poor bones and cardiovascular health, an increased risk of injury and illness, and impaired training adaptations and performance.

There are many incentives to tackle the problems of low energy availability. Indeed, many experts in sports science/medicine have identified the need to re-badge the syndrome so that it casts a wider net on the populations at risk and the problems it causes, as well as focusing attention on the underlying problem. The result is coining of the term “RED-S” (Relative Energy Deficiency in Sport) as a larger umbrella and spotlight on a common problem among athletes. RED-S promotes our new insights and provides a platform for a new approach to recognise, treat and prevent this issue.”


Listen to Dr Margo Mountjoy, MD, PhD, sports physician & MOOC lecturer – outline Relative Energy Deficiency Syndrome (RED-S) in this BJSM podcast


Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. The IOC relative energy deficiency in sport clinical assessment tool (RED-S CAT). Br J Sports Med. 2015;49(21):1354.

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport(RED-S).

Br J Sports Med. 2015;49(7):417-20.

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency inSport (RED-S). Br J Sports Med. 2014;48(7):491-7


What are the benefits of exercise on cognition/memory? (Answer to a question from McGill University’s MOOC – Massive Open Online Course – ‘The Body Matters’

27 Feb, 16 | by Karim Khan


Dr Julia Alleyne (@JKAlleyne) is a specialist sports medicine physician whose experience includes having been Medical Officer for Canada at multiple Olympic Games and CMO at the Pan Pacific Games (2015). She has held numerous leadership posts in the Canadian Academy of Sport & Exercises Medicine (CASEM), a BJSM member society. She combines academic work at the University of Toronto with being a clinician at Toronto Rehabilitation.

Worldwide, the incidence of dementia and related cognitive disorders is estimated to affect 44 million people (CDC 2014) The benefits of exercise for people with dementia far outweigh the risks, despite the person’s level of cognitive impairment. The type of exercise best suited to improve cognitive processing is aerobic and resistance training or a consistent active lifestyle.

The most common cause of dementia is aging compounded by vascular impairment. Therefore, since exercise reduces the incidence of hypertension, coronary artery disease and strokes, exercise also reduces of vascular aging in the brain.

Proof of exercise effect

To assess brain anatomy, Colcombe et al (PNAS, 2004) studied MRI scans in older adults who walked 3 x week for 6 months and found significant increases in gray and white matter volumes. BJSM Senior Associate Editor Teresa Liu-Ambrose used functional MRI to examine brain function (Arch Int Med 2010) I in older adults who participated in resistance training twice weekly. She found significant improvement in brain functions which then persisted for at least 12 months after training had stopped. These changes included memory recall, time duration for cognitive response and ability to follow instructions.

What about the personality and mood changes that occur with cognitive decline? Behrman et al (Practioner, 2014) took a similar approach extrapolating the known benefits of exercise on adult depression symptoms and studied the effect of exercise on older adults of various ages. They found that with increased activity including walking and dancing, patients with mild to moderate depressive symptoms associated with dementia improved their feelings of self-esteem and mood while decreasing negative distracting thoughts. They compared the gains to pharmacology treatment and exercise was as effective and often reduced the need for medication with potential side effects.

In a 2010 meta-analysis conducted by Sofi et al (J. Int Med 2011) the authors reviewed studies that enrolled adults without dementia symptoms and monitored cognitive function versus anatomical presence of disease to see if the risk of cognitive decline changes in exercising adults. 15 prospective studies were found on mid-age adults participating consistently in an active lifestyle. The overall analysis followed over 30,000 subjects for 1-12 years and found that there was a 38% reduced risk of cognitive decline in subjects with high levels of physical activity and 35% reduction risk in low-to-moderate levels of activity compared to sedentary subjects.

What about adverse events?

In my attempt to present balanced research, I did a literature scan of adverse effects on cognitive function in exercising older adults. The result only unearthed a few logical warnings…start low and go slow to avoid musculoskeletal strain, maintain appropriate energy input and ensure supervision and instructions for new training techniques. The main finding was that cognitive function does not worsen with exercise and that is a critical take-home message.

In summary,  the protective effect of physical activity on cognitive function relates to maintaining good cerebrovascular supply to the brain through blood flow and oxygen as well as via direct endocrine mechanisms. Through the positive effects of exercise on cardiovascular risk reduction, the incidence of associated cerebrovascular events from diabetes, hypertension, obesity and dyslipidemia is greatly reduced and thus reduces disease induced cognitive decline. An active lifestyle also likely protects the brain by stimulating neurotrophins – as their name suggests the factors promote neural growth and survival. Lastly, there is ongoing research suggesting that through exercise there is a reduction in stress related cortisol levels which may also help preserve cognitive function.

All science aside, I recall a public campaign years ago that proudly announced the slogan, “Be Smart, Exercise your Heart” … I think the underlying meaning is finally coming of age, no pun intended!

PS: Dr Alleyne is a member of the Global Expert Panel that answers questions from students in the MOOC.



  1. Stanley J. Colcombe et al; Cardiovascular Fitness, Cortical Plasticity, and Aging Proceedings of the National Academy of Sciences of the United States of America. Vol. 101, No. 9 (Mar. 2, 2004), pp. 3316-3321.
  1. Liu-Ambrose T et al, Resistance training and executive functions: a 12-month randomized controlled trial, Arch Intern Med. 2010 Jan 25;170(2):  (See also

3. Behrman S, Ebmeier KP.Can exercise prevent cognitive decline? Practitioner. 2014 Jan;258(1767):17-21, 2-3.

  1. Sofi et al, Physical activity and risk of cognitive decline: a meta-analysis of prospective studies, Journal of Internal Medicine,Volume 269, Issue 1, pages 107–117, January 2011




February 10th Re-launch of hugely popular: BodyMatters, Massive Open Online Course

27 Jan, 16 | by BJSM

BodyMatters, Dr. Ian Shrier’s free Massive Open Online Course (MOOC) in Sport and Exercise Medicine is re-launching for the 2nd time on Feb 10, 2016 (registration open now).

Last year, over 30,000 students from 185 different countries participated. This relaunch provides an opportunity for those who were unable to see it the first time around. Based on past experiences of other MOOCs, Dr. Shrier expects to have 8-10,000 students in this session.


Image from:

The MOOC is divided into three parts:

  1. Why physical activity is important,
  2.  How to train without getting injured, and;
  3. What to do if you do get injured.

The guest lecturer roster includes leading experts from around the world: Paul McCrory, Kerry Gordon, and Steven Blair, to name a few. Although many past students were from health and fitness industries, the content is accessible to a broad audience, and designed for the lay public.

Dr. Shrier has learned a lot himself, “I had never heard of physical literacy before [I listened to the talk by Patrice Aubertin], and the history of the anti-doping movement by Andrew Pipe was fascinating”.

The innovative format, along with guest lecturers that all have something unique to offer, is sure to make MOOC #2 a lot more valuable than the free registration suggests!

For more information and to register follow THIS LINK.


Activity among people with chronic low back pain: How activity behaviours reflect beliefs

10 Apr, 15 | by BJSM

For Body Matters, the Massive Open Online Course (MOOC) 23,000+ participants, led by Professor Ian Shrier, hosted by McGill University, Canada.

By Kieran O’Sullivan (@kieranosull)

University of Limerick Kieran O'Sullivan.  .  Pic Sean Curtin Photo.Disability due to chronic low back pain (CLBP) has actually increased in recent decades, indicating a need for significant change in CLBP management1. Improved outcomes in other chronic health conditions (e.g. cardiovascular diseases, cancer), illustrate the requirement of changes in both (i) beliefs and (ii) behaviours. For example, for cigarette smoking rates to be reduced, both clinicians and the public had to (i) really believe smoking was a major concern and (ii) only then did smoking behaviours shift to reflect this evidence.

While we know that increasing activity levels among people with CLBP significantly reduces disability, people with CLBP often remain relatively inactive2. While this “behaviour”may be criticised, one may argue that this is a sensible strategy to adopt based on their existing (albeit inaccurate) beliefs. For example, let’s look at some common inaccurate beliefs held by people with CLBP:

  1. The idea that pain is always an accurate indicator of whether a body part is damaged is still widely held3, despite being completely out of touch with contemporary neuroscience4. For example, people with what appears to be significant tissue “damage” often report no pain, while others with seemingly “normal” scans can report terrible pain5.
  2. Many forms of activity, e.g. running6 and bending7, 8 which are not harmful to the body, are considered somewhat dangerous and a potential cause of “wear and tear”3.
  3. Finally, recuperation from CLBP is considered to be more related to the “magic” hands (or needle / scalpel / scan) of the clinician or health service rather than factors the person themselves can learn to control such as physical activity, stress management, sleep and thoughts9.

When we consider even just these three widely held beliefs, it seems clear why people with CLBP avoid activity, as it is often associated (at least initially) with some pain, which they deem to be an indication of further damage. Add in the fact that healthcare programmes often significantly understate the role of self-management strategies such as physical activity, and the observed low levels of activity are not at all surprising.

In summary, to increase activity levels among people with CLBP, we need to (i) shape their beliefs and better contextualise what is happening to their body (e.g. rarely is tissue damage the biggest concern); (ii) eliminate fears that everyday activities are dangerous even if they are difficult initially, and (iii) empower patients to regain control through active self-management strategies such as physical activity.

Finally, we could learn from other public health initiatives (e.g. non-smoking areas, taxation on cigarettes) and indeed other non-healthcare environments10, 11 on how we can help shape these behaviours to make it easier for people to make a better, more active lifestyle choice12 (e.g. why is the stairs usually harder to find than the elevator in a hotel; why are some cities more cyclist and pedestrian friendly).


  1. Deyo, R.A., S.K. Mirza, J.A. Turner, et al., Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 2009. 22(1): p. 62-68.
  2. Griffin, D.W., D. Harmon, and N. Kennedy, Do patients with chronic low back pain have an altered level and/or pattern of physical activity compared to healthy individuals? A systematic review of the literature. Physiotherapy, 2012. 98(1): p. 13-23.
  3. Goubert, L., G. Crombez, and I. De Bourdeaudhuij, Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain, 2004. 8(4): p. 385-394.
  4. Butler, D.S. and G.L. Moseley, Explain Pain:(Revised and Updated). 2013: Noigroup Publications.
  5. Brinjikji, W., P. Luetmer, B. Comstock, et al., Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 2015: In Press.
  6. Lane, N., J. Oehlert, D. Bloch, et al., The relationship of running to osteoarthritis of the knee and hip and bone mineral density of the lumbar spine: a 9 year longitudinal study. The Journal of Rheumatology, 1998. 25(2): p. 334-341.
  7. Wai, E., D. Roffey, P. Bishop, et al., Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J, 2010. 10(6): p. 554-566.
  8. Wai, E., D. Roffey, P. Bishop, et al., Causal assessment of occupational bending or twisting and low back pain: results of a systematic review. Spine J, 2010. 10(1): p. 76-88.
  9. Verbeek, J., M.-J. Sengers, L. Riemens, et al., Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine, 2004. 29(20): p. 2309-2318.
  10. Heath, C. and D. Heath, Switch: How to change when change is hard. 2010, New York: Broadway Books.
  11. Thaler, R.H. and C.R. Sunstein, Nudge. 2008: Yale University Press.
  12. Trost, S.G., S.N. Blair, and K.M. Khan, Physical inactivity remains the greatest public health problem of the 21st century: evidence, improved methods and solutions using the ‘7 investments that work’as a framework. Br J Sports Med, 2014. 48(3): p. 169-170.


Dr Kieran O’Sullivan is a lecturer at the Department of Clinical Therapies at the University of Limerick, Ireland. He has been awarded €1 million in funding and has over fifty peer-reviewed publications. He has been awarded ‘specialist’ status by the Irish Society of Chartered Physiotherapists. He has a particular interest in the management of chronic musculoskeletal conditions such as chronic low back pain.

Related links:

For the “Body Matters” MOOC (McGill University, Prof Ian Shrier): Exercise is medicine, for the body and the brain by Nagamatsu and colleagues.

9 Mar, 15 | by Karim Khan

YourBrainLovesTheGym Each week over 23,001 folks are learning about the power of exercise via a Massive Open Online Course (MOOC).

Generously, BJSM helps out Professor Ian Shrier by answering one question each week on this blog. Prof Shrier just has to answer the other 23,ooo students’ questions.

This week’s question is:

“What are the effects of exercise on the brain’s ability for computation and memory?”

You could ‘Google it’ and you will find that the past 2o years has seen an explosion of literature on this topic. Fueled by? You guessed it – the wonder of MRI (magnetic resonance imaging) that provides structural images to complement tests of brain function (formerly pen and paper tests, now largely converted to computer/tablet tests). I don’t fully understand it yet, but MRIs can also show us changes in brain FUNCTION. So if exercise improves brain performance (which it does), some of these changes can be seen during ‘functional’ MRI of the brain. Wow!!  It used to thought that one exercised ‘for the heart’ but my feeling is that ‘exercise for the brain’ is even more important.

So, down to the nitty-gritty! “Show me the money” or, in this case – Show me the evidence!

And here I take you to a 2014 BJSM article –

LiuExerciseExercise is Medicine for the Body and the Brain


It is by Lindsay S Nagamatsu, Leon Flicker, Arthur F Kramer, Michelle W Voss, Kirk I Erickson, Chun Liang Hsu and my hero, Teresa Liu-Ambrose.

Cognitive decline is one of the most pressing healthcare issues   of the 21st century. Worldwide, one new case of major cognitive decline (ie, dementia) is detected every 4 s. Given that no effective pharmacological treatment to alter the progress of cognitive decline exists, there is much interest in lifestyle approaches for preventing or treating dementia. Ideally, such strategies should be cost-efficient and widely accessible at a societal level to have the largest benefit for older adults with varying income and functional status levels.

One attractive solution is exercise. However, despite a large and consistent pool of evidence generated over the past five decades linking exercise to improved cognitive functions in older adults, there is a reluctance among academics, healthcare practitioners and the public alike to embrace exercise as a prevention and treatment strategy for cognitive decline. For example, the National Institutes of Health (NIH) consensus statement from 2010 concedes that there appears to be preliminary data to support the efficacy of exercise in improving cognitive function. However, they caution that there is currently no strong evidence to suggest that modifiable lifestyle factors can alter the trajectory of cognitive decline.

Adding fuel to the fire are publications such as a 2013 systematic review of randomised controlled trials (RCTs) (prior to 31 October 2011) reporting ‘weak’ evidence for the effects of exercise on cognition. However, the search strategy used in that systematic review failed to capture many pertinent papers providing evidence from RCTs that exercise promotes cognitive and brain plasticity not only in healthy older adults but also in those with cognitive impairment. Animal studies that provide insight into the molecular and cellular mechanisms by which exercise promotes neuroplasticity.

In a previous commentary,(Liu-Ambrose, BJSM 2009)  we outlined studies that provided compelling evidence that exercise should undoubtedly be considered as a promising treatment strategy for cognitive decline. Our present commentary aims to provide a brief update, as well as to discuss factors that have continued to hinder the adoption of exercise as a legitimate medical strategy for the prevention of cognitive decline and dementia.

Since 2010, we have additional evidence from RCTs that exercise, both moderate-to-vigorous intensity aerobic and resistance training, promotes cognitive and brain plasticity and have gained further insight into underlying mechanisms. Notably, the behavioural and mechanistic outcomes converge and support a cohesive picture. In 2011, Erickson et al demonstrated that aerobic exercise resulted in increased hippocampal volume in healthy community-dwelling older adults. Furthermore, changes in hippocampal volume in the aerobic exercise group were significantly associated with increased levels of serum brain-derived neurotrophic factor and spatial memory performance. In the same RCT, Voss et al  demonstrated that aerobic exercise also improved the functional connectivity or temporal coherence of brain regions that are functionally related in a network known to decouple with ageing.

For resistance training, Liu-Ambrose et al  demonstrated increased functional plasticity after 12 months of training with corresponding improvement in selective attention and conflict resolution in healthy older women. Critically, the benefits of exercise extend to those with mild cognitive impairment (MCI) and dementia. Among older women with MCI, Nagamatsu et al  demonstrated that 6 months of resistance training led to improved executive functions, spatial memory and associative memory with concurring functional plasticity. In the same study, the authors also found that aerobic training improved verbal memory and learning. These findings indeed support the findings from a recent systematic review on exercise and cognition in those with dementia, although to our knowledge no such systematic reviews exist for those with MCI.

Despite these recent positive findings, scepticism remains. Enthusiasm for increased exercise as a prevention strategy is often tempered by the fact that no RCT until now has demonstrated that exercise can actually reduce the incidence of MCI or dementia. Is the absence of such a definitive trial reason enough to disregard the evidence until now? We contend that the answer to this question is a resounding ‘no’ when the following points are considered:

  • The number of individuals with dementia will exponentially increase in the next 20 years.

  • There is now a large and consistent pool of animal and human data demonstrating the cognitive benefit of exercise. Importantly, recent randomised studies show a convergence among behavioural, neuroimaging, and serum biomarker outcomes. Furthermore, large cohort studies have demonstrated significant associations between exercise and reduced risk of cognitive impairment and dementia.

  • Exercise has a multitude of established health benefits with minimal side effects and is cost-effective. Even in older adults, exercise increases the chance of survival and healthy ageing.

  • Exercise significantly reduces the key vascular risk factors (eg, hypertension, diabetes type II, hypercholesterolaemia, etc) for Alzheimer’s disease and vascular dementia—the two most common types of dementia.

In fact, exercise should be promoted as an essential component of healthy ageing given that reducing physical inactivity by 25% could prevent as many as one million cases of dementia worldwide.

Providing healthcare practitioners and seniors with specific and individualised recommendations regarding the type, intensity, and frequency of exercise for benefit is critical to successfully advocate exercise as a treatment for cognitive decline. (FOR MOOC STUDENTS, THIS IS WHAT PROF SHRIER WILL COVER NEXT WEEK – THE PRINCIPLES OF EXERCISE PRESCRIPTION)

However, we are limited by the fact that dose and type of exercise have been utilised in different studies with varying success. For example, Baker et al  found that older women with MCI who engaged in aerobic exercise four times per week exhibited improved cognitive function, whereas in a similar population, aerobic exercise twice per week did not yield the same benefits. Further, confusion centres around the type of exercise (eg, aerobic vs resistance training) and sex differences.

Evidence strongly suggests that exercise does have benefits for cognition—and critically, the magnitude of the benefit can exceed that of pharmaceutical approaches. It is estimated that if the onset and progression of dementia could be delayed by a mere 1 year, there would be nearly 9.2 million fewer cases in 2050. Given that exercise can be promoted at a population level with relatively low risks and costs, we highly recommend that older adults should be encouraged to engage in regular exercise to boost cognitive function as further research is concurrently conducted, rather than wait until all the intricacies of the relationship between exercise and cognition have been resolved.

We recognise that a large proportion of the population is sedentary and that successfully changing behaviour to a more active lifestyle is challenging. To effectively advocate exercise, we emphasise the need for a cross-disciplinary collaborative effort among researchers and healthcare workers to develop consistent standards and a united message of the multiple benefits of exercise. In light of the recent support for exercise in preventing cognitive decline, we stress that endorsing exercise as an effective strategy for improving health and well-being among older adults should be indisputable. Given that it may potentially have a high impact for mitigating multiple health concerns, including dementia, exercise should therefore be considered as a leading treatment strategy to delay or prevent dementia.

Thanks to BJSM for allowing us to reproduce the paper:

Exercise is medicine, for the body and the brain.

Nagamatsu LS, Flicker L, Kramer AF, Voss MW, Erickson KI, Hsu CL, Liu-Ambrose T.

Br J Sports Med. 2014 Jun;48(12):943-4. doi: 10.1136/bjsports-2013-093224. Epub 2014 Mar 21.

Karim Khan (@BJSM_BMJ)
One of the 3 lead editors at the BJSM – along with Babette Pluim (@DocPluim) and Jill Cook (@ProfJillCook).

If you use Google+, consider joining the Sports and Exercise Medicine community for sports medicine updates. (Search in ‘communities’ or follow this link).

The Body Matters: Massive Open Online Course (MOOC) via McGill University, Canada.

3 Mar, 15 | by Karim Khan

MOOCTo all 23,000+ participants in Body Matters, the Massive Open Online Course (MOOC), congratulations on a wise choice and thanks for asking a BJSM opinion. What a great set of lectures to open the course! Kudos to Professor Ian Shrier and McGill University.

For those not privy to the MOOC, the class posed this question. ‘Is there anything to the idea that exercising way over the minimum requirement has harmful effects? Assuming no injuries etc. are people who run ultramarathon distances doing more harm than someone who puts in 150 minutes per week?’

No-one has all the answers so I plan to make 5 comments to stimulate more discussion. And remember, it’s a safe place to disagree.

1. 150 minutes per week is a minimum – it represents 22 minutes a day! These 22 minutes are the most valuable in your day to promote health. Interestingly, a recent BMJ Analysis paper (not open access) and podcast (open access) suggested that this was too much – a ‘stretch goal’ as it were. Really? I was shocked! Isn’t 22 minutes equal to one minute per hour? OK – let’s say you have narcolepsy (no offence) – then 22 minutes is 2 minutes every hour of the 11 hours you are awake. Too much? Wow!! Listen here and make up your own mind. Of course one could argue that public health advice should be based on the data. In that case one wouldn’t negotiate the minutes depending on what might be palatable. You might want to discuss this in your MOOC.

2. Would it be more palatable to call the ‘150 minutes a week’ just 23.5 hours of sitting and lying a day? ‘Look, you can sit around, watch TV, lie on a floating device in a massive Caribbean hotel pool, get hours of massage and spa treatment, sleep, but try to limit that to 23.5 hours a day, OK?’ Seem unrealistic? Impossible? Many of you will be familiar with this idea – as popularized (‘viralized’?) by the indomitable Canadian doctor – Mike Evans (@DocMikeEvans). Is he a guest professor in this MOOC? Watch the 23.5 hours YouTube video here. I would DEMAND that your professor, Ian Shrier, gets Dr Mike on board! When the class has 23,000 votes you should be able to beat a professor into submission. Please don’t take that literally.

3. Doses beyond 150 minutes per week. Is 60 minutes the magic number?

Do you drive the worst car possible? The bare minimum to get from A to B. Do you have the worst possible accommodation and food? Just to survive? Unfortunately, that’s all many people can afford to do. But many others are in a position to upgrade beyond basic food, shelter and transport. They are prepared to pay for what they perceive as value.

The bare minimum of physical activity is 22 minutes a day – 150 minutes per week. That is an appropriate public health guideline and the correct focus for the committees that made these recommendations. The most bang for very little buck. However, the evidence is very clear that an additional 30 minutes a day of physical activity (let’s call it 60 minutes in total for convenience) brings substantial additional benefit. This will prevent cardiac disease, cancers and dementia. My favourite paper capturing this is by the quietly spoken Professor Ken Powell in partnership with – you guessed it – Steven Blair. I’ve reproduced the key graph here.







On the vertical axis, ‘Relative Risk’ of 1.0 represents risk of many chronic conditions in the setting of physical inactivity (first column, 0 minutes of physical activity daily). On the horizontal axis, you can see how various doses of physical activity reduce the risk of diseases. Move one bar to the right, and notice that at 30 minutes of physical activity daily (‘150 minutes a week’) there is a Relative Risk of 0.7 (compared with 1.0) which represents a 30% reduction in risk of disease. Moving further along to the right, 60 minutes of physical activity a day provides a Relative Risk of 0.5, a 50% reduction in major diseases.

Can you imagine the popularity of a drug if one were to provide such benefits? Would you want to take one pill (30% risk reduction – 22 minutes a day?) or would you sneak a 2nd pill when the supervisor was distracted on Facebook (this would give you a 50% reduction in risk of major diseases).

If you were not already aware of this, then you have learned something very practical in this course – you can reduce your risk of the major killers grouped as ‘non-communicable diseases’ by an additional 20% just by building an extra 30 minutes of physical activity into your day. Walking is fine – no lycra required. 10 minute bouts are fine – you learned that on Monday.

Two points to go – what about long distance running/ultramarathons – safe or harmful? I’ll share some thoughts about (4) running and the risk of osteoarthritis, and (5) many many marathons and the heart.

But not today. I’m choosing to boost my physical activity dose from 30 minutes to 60 minutes by riding home from work. I’ll answer the rest of the question tomorrow, all being well.

Karim Khan (@BJSM_BMJ)
One of the 3 lead editors at the BJSM – along with Babette Pluim (@DocPluim) and Jill Cook (@ProfJillCook).

Map of where participants in the MOOC are based

Map of where participants in the MOOC are based


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