Fergie lost it with the referee. The Manchester United manager’s public criticism of the referee’s fitness in their recent match against Sunderland made headlines. Although subsequently making a personal apology he did raise the more general issue of referee’s fitness. Perhaps it was because he knew about the long established referee fitness programme in Scotland pioneered by Stewart Hillis, the recently retired professor of cardiology in Glasgow and doctor to the Scottish Football Association. Dr John McLean continues this cardiovascular screening initiative at the outstanding sports medicine facilities at Hampden Park, and hosted last Friday’s meeting on the benefits of exercise. It is good to be fit- not a new message, even for referees- but there are still many questions for patients and doctors.

How do we get the population active; how much exercise is good and, what type of exercise? Nanette Mutrie’s research career has focused on how to promote the exercise message and one of her pioneering papers, published in the BMJ had a very straightforward message showing how you can encourage people to take the stairs by putting a notice up beside the escalators in a tube station. Simple things make a difference. Their continued research interest is walking but she pointed out that it is not enough to encourage active living on its own without thinking about the importance of the environment: street lights, cycle lanes, green space, accessible play grounds etc.

But, is walking enough? Current international guidelines that promote regular moderate activity are a pragmatic public health compromise. The reality is not as easy or, perhaps, as acceptable as a sound bite. David Swain, (Professor of Exercise Science, Old Dominion University, Virginia, USA) showed a clear dose response curve in the relationship between health and both physical activity and with fitness. More is better. But, what is more important – the volume or the intensity?  The evidence points to intensity: For those who are least fit even moderate intensity shows benefit. But, much more intensive exercise is needed for those who are already fit. Exercise enthusiasts need no encouragement. But, the positive aspect of this message is that, for our mostly inactive sedentary population, moving from unfit to fit paid the greatest dividends. If you want to exercise to lose weight, he had a very simple message; the volume or intensity doesn’t matter- it is the overall calorie expenditure that is important.

How do we get this message across to medical colleagues? In Scotland, they have an advantage.  Harry Burns, the Chief Medical Office, is convinced of the benefits of exercise and entitled his talk Exercise is Medicine, inspired by the initiative of the American College of Sports Medicine. Exercise is a fundamental component of what we were designed for- it is part of the essence of the species. But, he too, pointed out the difficulties of promoting exercise in socially deprived areas. Environment, stress, control, depression and exercise are all interrelated. Saying- just do it- is not enough.

But, who would have thought, even 10 years ago, that society would tolerate a ban on smoking in public places or have anticipated the profound cultural change where it is now completely unacceptable to drink and drive. Changing society and behaviour is not due to medicine alone. Social environment, government policy and personal awareness are just some of the factors. Influencing change is complex. What few seemed to appreciate was how having the Chief Medical Officer as an active and enthusiastic participant was part of this process. He completed his talk with a cartoon showing a doctor -patient consultation- asking if it is better to exercise for one hour each day or to be dead for all 24. His commitment is clear.

Domhnall MacAuley is primary care editor, BMJ