Exercise as Medicine
Tommy Boone, PhD, MPH, FASEP, EPC
Professor and Chair
Department of Exercise Physiology
The
College of St. Scholastica
Duluth, MN 55811
The search
is what anyone would undertake if he were not sunk in the everydayness of his
own life….To become aware of the possibility of the search is to be onto
something. Not to be onto something is
to be in despair.
WALKER
PERCY
The Moviegoer
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If I
told you that I had a formula that would help you live longer, avoid-and even
cure-some diseases, relieve stress, and makes you stronger with virtually no
bad side effects, you’d probably be willing to pay a lot of money for it…what
if I told you it was free?...The truth is, I do have a formula like that…the
formula is physical activity-simple exercise.
– DR. DAVID C. NEIMAN
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IT WASN'T TOO LONG AGO THAT the medical
community paid little attention to a person's thoughts or feelings. After all, we are living in world of the
physical. Appearance is everything. At least this is the case for many of us. Looking good is even believed better than
feeling good. Perhaps, this is why we
pay so little attention to our actual thoughts.
The mental crisis in the United States, if not worldwide, is unprecedented. Moreover, it is just a matter of time the collapse of one's assumed
ability to handle psychological warfare will be all too obvious. Then, there will be a clear and distinct
alienation of the mind from the body.
Lost in the darkness of depression, exercise will be displaced by drug
abuse, alcoholism, dissatisfaction, sickness, disability, and
meaninglessness. Such an outcome raises
the question: What, if anything, can be
done? What, if anything, can turn us
around – to replace despair with hope? I
think the answer lies within us. We
have
the power to turn our lives around, if we really want to. Much of
that power is part of the profession of exercise physiology.
Nowhere
is it so plainly obvious that the person who exercises regularly is a person in
action. That person is less prevalent
than we would like to believe. To
support this point, keep in mind that only 10 to 15% of all Americans
exercise on a regular basis. It seems as
if life as we have come to think of it is more about money and power
than learning and living a meaningful life.
Of course, without question, it is understood that money and power are "believed"
important to get things. Having a big home, a vacation home, expensive cars, and yachts define the
successful person. Conversely, not having those
things often create the illusion of failure.
But, is it true that a happy life is defined by money and power? What if it is just a big lie? What if life is really about coming to terms
with the meaning of who you are? In short,
these questions raise more questions, particularly for college students:
- Why am I attending college?
- How does it define me personally?
- What is my purpose in life?
- How will I know when I am happy or a success?
- What will it mean when those close to me die?
- Where is the meaning in it all?
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The first step to knowledge is to know that we are ignorant.
-- LORD DAVID CECIL
Biographer
(1902-1986)
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Imagine life with meaning rather than without
meaning. Imagine caring and
nurturing others as well as yourself. Imagine a life with feelings for others. Clearly it is not
an easy thing to do, although common sense says it should be. Life is voyage of discovery and we approach
it like someone punching holes in his ship in the middle of the ocean. It doesn't take a lot of analysis to figure
out that it is just a matter of time the ship will sink. The point here is that it is important to
know we are responsible for keeping our mind and body complex afloat. The hitch is we go about life punching holes
in our chances of avoiding diseases and disabilities (i.e., if it is actually possible to do so).
We punch holes in opportunities to think, reflect, and understand,
perhaps even for the first time -- to love. None of this is
good. There is no reason whatsoever why we can't learn
to live life with reasonable certainty of our direction and destiny. However, that would require us to search for
meaning rather than power, to share thoughts rather than dominant others, and to look before we jump. This would also
require courage to ground oneself in the belief that life and living are more
about loving and sharing than about money and politics.
It would, therefore, require each of us to search deep, perhaps, deeper than we have ever done, within ourselves
to understand our true inner feelings and sense of being spiritual and yet intellectual and
physiological.
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Exercise as medicine is a powerful concept
with its own reality. Shouldn’t exercise physiologists think of
exercise as medicine? The first-half of their title is “Exercise,” in much
the same way that the word “Doctor” is taken to mean medicine. Exercise
physiology students should also be educated to think of exercise
as
medicine.
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Life is about connecting with other people,
about laughing and crying and, yes, suffering but understanding its purpose and
thus knowing why. It is not about misconstruing our own thoughts or even a mockery of the thoughts of others. And, it is most certainly can't be taken
over by businessperson per se or medical doctors as though either can do no
wrong! Take the latter as an example, based on large-scale studies, between 44,000 and 98,000 people die in
hospitals each year as a result of preventable medical errors [1-3], accounting
for more annual deaths than automobile accidents. Do I hear a "Wow…?" Remember the cliché, "Hello Huston, we
have a problem." Many people reject
the idea of any form of problem within business or medicine. In their view, it is all about someone with a problem or, perhaps, not
having any idea of what he or she is talking about. Well, please appreciate that the statement about preventable medical errors was taken from very credible medical
journals. None of this is new or, at
least, it shouldn't be. At the center of
every profession is the human being and human beings make mistakes. It is really that simple. It doesn't make it right, but it allows for
an understanding of life's challenges.
One
of the toughest challenges every person faces is the search for
saneness, hope, and possibilities. Of
course what is underpinning each is his or her spiritual awareness, emotional
development, intellectual and physical abilities, and the understanding of
absolute interdependence of the mind-and-body complex. Ultimately, understanding these things in
reference to "who am I" often becomes the light that allows us to see
and to feel without expecting something in return.
Such thinking or coming to such thinking is the origin of living a quality
lifestyle. For
years, many in the real-world felt medicine's light was out.
After all, medical costs are almost incomprehensiable. Medicine
was not originally about money. And, to some degree, it is better
in certain parts of the profession more so than other parts. Psychoneuroimmunology is one of the better parts. It is such a big deal within the infrastructure of medicine that
medical doctors have formulated new and interesting personal strategies for
helping their patients. Medicine
is in a
better position now than ever before to help patients shape their
future and what it means to live a meaningful and engaging life.
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What is important now is that exercise physiologists should commit
to fostering high ethical standards for the implementation of the exercise
prescription. This distinction is a professional one, driven by
necessity and the purpose of exercise physiology to benefit society and to
do
so safely.
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Psychologists,
neurologists, and immunologists and others have come together to figure
out and promote the mind-body connection, especially as it relates to health
issues. The journey has been long getting to this point. Part of
the problem has always been that medicine has been about drugs versus other
road maps to better health. Now, the experts have a better picture and
more knowledge of where they are going. So, frankly, this brief short
story (so to speak) should be an interesting read, if not, a brief escape from
the otherwise ups and downs of life. Hence, given this as a beginning point, and given the complexity of the mind and, yes,
mind-over-matter kinds of thinking, the question is this: Can the human being,
whether he or she has or does not have money or power learn to heal him or
herself? Is this the emphasis in healthcare of the future, that
is, not your future but the future of your children or loved ones?
Certainly a lot remains to be seen, understood, and discussed, especially when
it comes to being angry, depressed, and suicidal.
In
many ways, this is the point – isn't it?
We must learn to connect with ourselves and with others. As human beings, we need each other to
fulfill who we are and why we exist.
Our interconnectedness grounds us with purpose in our lives. Yet the physical condition of Americans,
often triggered by the absence of regular exercise, comes together at the door
of many hospitals. Point in fact:
Estimates are that 9,100,000 people in the United States suffer from angina
pectoris [4]. Of course in the middle of the hopeful likelihood of a new
medical paradigm, the problem is that the old system is not going to change
very quickly if at all. This is a sad
state of affairs, given that the meaning of life has come down to "healthcare
as a business." Indeed, the only thing
better for some medical doctors, as is evident by the fraud in healthcare, is to make even more money. Unfortunately, as long as this kind of thinking
and, in fact, selfish thinking prevails, the cost of healthcare in the United
States is not just going to skyrocket, it is going to actually shake the very
foundation of the practice of medicine.
At first glance some years ago, I thought it was unlikely or not
possible that this could happen. Now
I realize that I was wrong. I know that the very core of medicine is under attack, and it is in
full swing, often fueled by the complex maze of new technology and big dollars. And, in this regards, I heard recently from a
colleague that "…medicine is no long a profession of care givers. Medicine is now a big time business." There may be no escape from this viewpoint,
but I don't want to believe it.
I
must believe in the good of human beings, especially those who have reached out to help others.
In fact, I have to if life is to have any meaning whatsoever. The point of my friend's comment, however, cannot be completely
overlooked. Despair and the emotional
price of being sued are serious impediments to straight thinking. There is no escape from the thought that failing to do the right thing with legal and financial consequences takes
the fun out of doing it. Others
have said it is unfair to the medical profession. Where did it all go wrong someone else said? Where were the wrong turns? Are the issues of commericalization of medicine real? Certainly, the overriding concern today must be the
professionalism issue. Hence, it is
hardly surprising that so many articles can be located about
"professionalism in medicine."
Here is just a sample quote from the Medical Professionalism Project
published in 2002 [5].
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At present, the medical
profession is confronted by an explosion of technology, changing
market forces, problems in health care delivery, bioterrorism, and
globalization. As a result, physicians find it increasingly
difficult to meet their responsibilities to patients and society.
In these circumstances, reaffirming the fundamental and universal
principles and values of medical professionalism, which remain
ideals to be pursued by all physicians, becomes all the more
important.
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There is no
escape that dealing with professionalism in medicine is important
[6]. In
addition to the medical doctor's spirited argument for autonomy and
absolute
control over the medical practice, there are many concerns about what
is behind
the commercialization of medicine [7]. But, for the moment, it is
important to get back to the subject of mind and body medicine.
What I
have learned, however slowly, is that the body has a head. Yes, I
realize
it may be obvious to most. This is indeed a powerful concept
however basic, yet
absolutely an imperative beginning point in this essay. The head
or, if
the will, the mind is inextricably woven throughout the body; both are
one! Yet, some of us, even young children, seem to have
understood this
point for many years. Why the liberation from past thinking has
taken so
long is a study in itself. Others think of human disease and pain
in
terms of body parts. Just think about it: There are people dying
of
broken minds or, at the very least, failed thinking. Why
professionals in all walks of life
lack the will to discipline what they do is hard to understand.
Even healthcare professionals don't get it fast enough. They, it
would seem, know so much, and yet they convey information in fragments
and bits of data without a
hint of back and forth interplay between and/or among body
systems. If we
would just try to understand the big picture we would stand a much
better
chance of coming face to face with our mind-body reality.
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There is a scientific consensus and, now, a scientific rationale
that supports regular, low to moderate intensity exercise as medicine and,
therefore, improvement
in health.
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The time to discuss this thing called the
mind-body medicine is before disease becomes obvious. It is surely a powerful and fascinating part
of us, if not an incredible, mysterious, and complex part of us. But we act out our lives in ways that
demonstrate all too clearly that we leave it out of the inventory when
searching for meaning and happiness. And
it is easy to do since it is done repeatedly throughout much of medicine and
other forms of healthcare, much less within our own lives.
We believe doctors
listen to our complaints. Or, at least, we think they are listening. After dealing with a herd of people, young
and old everyday with all kinds of denial of the human condition, the
collection of similarities in symptoms becomes a blend of mundane comments –
often without significance followed first by the prescription and later by pills
and then the bill. The latter often
leads to despair. In addition to the pain and little money left at the end of the month to pay for medical costs,
there is alienation, anxiety, and a sense of separation. Many people simply feel an emptiness that
results from the boredom of competitive purchasing of things. Because the mind has a hard time getting
accustomed to the numbness of life and the unbelievable charges for just 5
minutes or, maybe, 10 minutes with the medical doctor, it loses its ability to
adapt or even care. While there are no
quick-fix solutions, one could expect the doctor to take the time to say a few positive,
hopeful, or even dignified comments (yes, even something about regular exercise). Contrary
to what some may say, the doctor has little or makes little time to talk to
the patient after the general procedural things are done. Talk
about preoccupation and a quick run back to their place of existence before the
next encounter with raw life. So, in the
spirit of being attentive and needing help as well, you wait for the piece of
paper that tells you what is what as if you understood or believed it was okay to ask a question (but there was no time left).
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It is nothing more than a cliché to speak of
prevention in healthcare terms.
Doctors aren't comfortable dealing
with prevention.
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If
all this sounds disheartening, then so be it.
It is the truth and, most unfortunately, much of the healthcare in the United States
is all about mindless applications of technology. Medicine celebrates its technology everyday,
often allowing it to mask their real feelings while largely ignoring the
patient. In some sense, it all makes sense, but in a crazy way. Perhaps, the medical doctors and the
medical journals do only what they think they can do – "look out for
number one." There is evidence of
this everywhere [8], and the idea that prevention is important – forget it –
yes, I mean forget it completely. No one is truly
interested in prevention or at least not those who are emotionally prepared
to embark on the medical money pilgrimage along with the big drug industry.
The
typical American may already understand this point. Few are
trying to figure how they can change it. But, changing something
within from without is hard to do. It takes a magic! And,
today, there is less of it than there used to be. The
importance of regular exercise is an easy concept to get one's head
around. People know what is necessary to deal with diseases and
disabilities. The naked truth is that many Americans and many members of the healthcare
industry are not interested. The
unfortunate consequences of such thinking are not good, as is obvious in thousands of ways. There is a big reason why healthcare is
really all about "disease care."
Disease care is big money in the United States. This is a shame because it is probably the greatest moral
cowardice, that is, the obedience to money. Human
suffering hardly makes the list. Knowing
that the denial of human suffering diminishes each of us, we nonetheless do little to
condemn it. Only a few people are
looking for answers, often in the wrong places.
The big and multi-level hospital complexes are all about the bottom
line, and that my friend is money generated from people with diseases.
Here is the bottom line: It
is nothing more than a cliché to speak of prevention in healthcare terms. Doctors aren't comfortable dealing with prevention. If they were, they would have done
something about it decades upon decades ago.
No, in very simple language, their job is to develop financial ties to
dozens of drug and biotech companies to make big money [9]. This conclusion is so self-evident that a
child can get the picture. There
is nothing new about this point. Far too
many of us fail to speak about it, however.
Increasingly, medical education comes across as deeply rooted in turning
out robots with the declared responsibility to promote and serve the big drug
companies. It seems to me that this is
not why most students go into medicine in the first place. Meantime, think about the following quote from
the article, Doctors Without Borders [9]: "More than 60 percent of
clinical studies--those involving human subjects--are now funded not by the
federal government, but by the pharmaceutical and biotech industries. That
means that the studies published in scientific journals like Nature and The
New England Journal of Medicine--those critical reference points for
thousands of clinicians deciding what drugs to prescribe patients, as well as
for individuals trying to educate themselves about conditions and science
reporters from the popular media who will publicize the findings--are
increasingly likely to be designed, controlled, and sometimes even
ghost-written by marketing departments, rather than academic scientists."
People who cannot invent and
reinvent themselves must be content with borrowed postures, secondhand ideas,
fitting in instead of standing out.
– WARREN
BENNIS
The old way of
"doctoring" for healthcare reasons is over. The
trust that the average person placed in the medical profession is over
today. And, the question of who is writing the articles in the
medical and/or scientific journals
is a valid one, too. In short, too
many published papers have been distorted by the authors' conflict of
interest. Of course, they will just
laugh at you as being silly to speak of such things. Look around you though, and you will
recognize that many science-oriented academics in particular have lost their way. Many of them, particularly those with an interest in sports nutrition, are complicit in promoting
performance-enhancing substances to student athletes [10]. One can only guess the money some exercise
physiologists, who speak of themselves as sports nutritionists, make
from promoting sports supplements such as creatine. In fact, it is very likely the
case that at the top research universities around the country, those who
promote sports supplements in athletics enjoy perks like laboratory equipment,
paid trips, and consulting fees. For
these reasons, there is significant concern.
Nowhere is the case so obvious than in exercise physiology than sports nutrition. By penetrating the academic setting, CEOs of
supplement companies have gained access to important leaders in exercise
physiology; those with the credentials to promote products and to mesmerize
their students. These academics actually
believe that they aren't influenced by their association with the supplement
companies. The problem, it seems to me,
is that if the sports supplement companies are the single largest supporter of
sports nutrition research, then, sports nutritionists are going to teach the
sports nutrition that the sports supplements industry wants them to teach. Frankly, such behavior is pathetic and
despite numerous warnings [11], many of the sports nutritionists continue doing
what they have always done.
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At the end of the day, it is obvious that
medical doctors and others will be prescribing exercise as therapeutic medicine.
Thus, my question is this: Why aren't exercise physiologists considered an
important part of the multidisciplinary approach to healthcare? Is it
not logical that the profession of exercise physiology can stand up to a
rigorous comparison to other conventional specialties?
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Not
unlike the problems in sports nutrition, Ross and Scott [12] state that
"…the kind of big-money splurge that some say drives up the cost of
prescription drugs and corrupts the practice of medicine. Further investigation
into the $6 billion spent by drug companies for what they say is a way to
educate doctors showed that tactics like lavish gifts and trips are
surprisingly common." The end
result is these doctors do not think twice to promote the company products even
if they should cost more or even if they don't work. This is really bad for the medical profession
but let us not forget it is the same across the spectrum of occupations and
professions. Everybody is interested in
the almighty dollar and status. In very simple terms, just as some American
doctors are calling for a reform in the medical profession, saying that doctors
shouldn’t accept drug samples, clocks and ballpoint pens from drug or
medical-device companies, exercise physiologists shouldn't either.
The
medical community understands that the public sector is being ripped off on
several fronts. It is so common that it
is accepted as reality. The problem is
that there is no incentive for medical doctors to change. And, forget about hospital CEOs changing
their approach to the problem. They
exist to make money for the business-oriented facility, known otherwise as the
hospital. The taxpayers are paying out
their noses in ways most people have no idea it is taking place or what to do
about it. And, on top of that, you have
one doctor doing this to you and another doctor doing that; neither treats the
whole person. No one doctor seems to
care enough to nurture what is good for the whole person. So now there are eye doctors, nose doctors,
toe doctors; heart doctors, foot doctors, kidney doctors -- you get the
point. Compartmentalized medicine is an
extremely important business strategy to earn big bucks. Forget about doing what it takes to value the
individual. Forget about the idea that
it is otherwise impossible to know the unknowns. It is possible, and it may very well be much
simpler when medicine isn't what it is today.
Okay, you say, you have convinced me and now what. Maybe you should have the courage to
rethink what you want in life.
Man is
what he makes of himself. And the
courage to be as oneself is the courage to make of oneself what one wants to
be.
-- PAUL
TILLICH
The Courage to Be
How about coming
to terms with your own personal power in life and what really matters to you? That is, why not turn to the power within you
to help yourself live a more quality life and to live a longer life at
that. While I appreciate it is true to
some extent that "the power of the mind" is a cliché, it is
nonetheless the truth and it is certainly not diminished either. There is considerable talk about it, but
reality is so few do anything about it. Self-actualization
is easy, at least in principle. Let me
repeat the sentence again, but slightly differently: "The power of the mind is
astonishing." Okay, there you have
it. My point is simple: How about learning more about your own
mind? How about stop giving up your
rights to others? How about empowering
yourself? That's right, why not believe
that you can enhance your ability to think right, and to create a better and healthier
future for yourself? After you think
about it for a moment, what do you value?
Maybe you should begin by making a list of what is important to
you? And, for sake of time, how do you
feel about dying? Death, in many ways,
like sex, isn't all that easy to talk about.
Yet, every single person must come to terms with both, especially
dying. The problem is that many people
have no idea how to feel about dying, much less their very own death. Here again, frankly, I don't think doctors
really help too much but shouldn't they?
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The need for physical activity is real
throughout the world. Not everyone is qualified or even has the desire to implement an exercise
program. Safety, effectiveness, and adherence are major concerns, thus
making the prescription quite a challenge.
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Thinking
about who you are and being yourself isn't magic, but it is close. Introspection and self-analysis even in the
basic sense of the term is as helpful as meditation, imagery, and other forms
of the mind experiencing itself.
Introspection and inner focus helps in connecting oneself with its
larger self, the body. Yes, that is what
I said. The mind and body are one and,
yet we live as though they are not physiologically connected – much less
connected in both directions. This is
usually where I bring up the topic of "cognitive strategies" since it
clear to me that our thoughts are reflected in our physiology and our
physiology shows up in our state of mind.
In other words, our brains define our outer being (i.e., our appearance
and function) while it reflects back and influences our conscious being. Both mind and body are interconnected and
aware of each other. However, we are disconnected until we learn how to use the power within us to change how we
think as well as arguing for directional changes in our physiology.
Imagine
having the power to prevent a heart attack and even to prolong life. That is the power of the mind. It is not a knee-jerk idea. Perhaps even more important is the quality of
life that can be driven by mental (behavioral) changes. The mind is a drug and a free one at that to deal
with debilitating emotions, anxiety, and depression. All we have to do is learn to use it. If we only exercise it, the mind has the
capacity to create an inner peace and well-being steeped in finding meaning in
life. We can choose to think right, to
avoid depression, and to be happy. All we
have to do is believe we have this power and, then, "Wow…we have it." No one else is going to bring us peace or
well-being. Call it if you will the
"personal health model," much like the thinking that underpins the
holistic health model, the scientific health model, or the spiritual health
model. What is important is that in all
likelihood a little of each actually contributes to the mix that is shared by
the mind-body complex. So, here again,
ultimately, the power of positive thoughts, either singly or collective as in
one's family, friends, or group gives rise to a mental strength and energy to
deal more effectively with life's challenges.
Unfortunately,
many in the medical community are not likely to agree with much of what I've
said. It isn't consistent with their
medical education and it works against the "big money pot at the end of the
day" theory. This is where exercise
physiology enters. To begin with, please
appreciate that exercise physiologists do not write drug prescriptions. That is what medical doctors do and,
remember, the insurance companies pay for the costs of the prescriptions or,
more likely, some of them. Hardly a month
goes by that I am thankful that exercise physiologists aren't licensed
healthcare professionals. Although I'm
sure many exercise physiologists would disagree with me, not having licensure
to practice exercise physiology is a blessing.
If they were licensed, like physical therapists or nurses, they would
likely do as they have done. This
doesn't mean that exercise physiologists can't make a living as
professionals without licensure. Forget third party
payers. They have made a mess of
healthcare in this country. Instead,
require the client interested in lifestyle changes to pay a reasonable fee for
the exercise physiologist's professional services.
Consider the importance of the comment by Gould
[13] who concludes that, "More Americans are uninsured because of the continued
erosion in employer-provided health insurance, the most prominent form of U.S. health
insurance." As the number of people
without health insurance grows year after year due to medical inflation and the
employer's inability to pay the costs, the number of uninsured will continue to
increase every year. Now is a critical
time to recognize the role of exercise as being an affordable healthcare
prescription. Exercise physiologists are
the experts who understand and prescribe exercise as medicine. This is true even if the personal trainer and
the fitness professional believe it is their work to do. This is true even if all other healthcare
professionals, including medical doctors and nurses, believe it is their right
by status. They are not the experts in writing
the exercise prescription no more so than the exercise physiologist is an
expert in writing drug prescriptions.
The number
of uninsured Americans rose by nearly 7 million, from 39.8 million in 2000 to
46.6 million in 2005. This increase was
due primarily to the precipitous decline in employer-provided health coverage
for workers and their families.
-- ELISE
GOULD
EPI Briefing Paper
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This is more evidence that exercise is one of
the best medicines that we have.
-- DR. RANDAL THOMAS
Director
Cardiovascular Health Clinic
Mayo Clinic
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Key Point: Most
unfortunately, if the medical people figure out how to connect third party
payment with exercise prescriptions, it can only hurt the profession of
exercise physiology. All
healthcare professionals can speak about and encourage lifestyle changes. Obviously, it is important to help the public
sector to commit to the caring and nurturing of their health. Shared values and common aims are important
but, here again, the medical doctor writes the drug prescription and the
exercise physiologist writes the exercise prescription. Everyone should be skeptical of physical
therapists who want to write an exercise prescription without having the
academic background of the exercise physiologist. There are no shortcuts to doing it right. This is why weekend certifications and other
approaches to personal training is the wrong approach. The point here is that a certain degree of
exclusivity is necessary to ensure an ethical and professional prescriptive
process. The same is true of a nurse or
an occupational therapist. That is why
they have their own accredited programs of study. And, this point also gets to the crux of the reason
why professionals have their own professional organizations.
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Exercise is the "health pill" the world has been waiting
for, and the person with the pill is the Board Certified EP.
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Despite
all the attention given to it, medicine is not the answer. It has reached diminishing returns due to
medical inflation. Doctors are not the
answer either. The primary reason is
that they are too busy dealing with their economic and political power
base, as often defined by the medical education. Obviously, the American Medical Association has not
helped in the financial cost containment of healthcare in the United States. Their involvement with the drugs companies
has moved them away from the true vision of medicine. No longer are medical doctors driven by the
idea that caring for the patient is the most important goal of
their practice. Now, they are defined by
the obvious, which is: Nothing is more
important than ensuring the financial base and business side of their medical
practice. Yes, understandably,
such a comment seems harsh if not down-right inappropriate. Unfortunately, it is true and millions of other
people know it too. Cost containment in
the United States
is a joke. It has been for decades. Healthcare is an absolute
mess in the United States. That is why there must be an
alternative to the present system, such as the profession of exercise physiology that is not drive by
the bottom line. After all, isn't it
clear to everyone by now that regular exercise can help people of all ages
either avoid or deal more effectively with cardiovascular disease, diabetes
mellitus, colon and breast cancer, obesity, high blood pressure, osteoporosis,
osteoarthritis, and depression.
Exercise
is the "health pill" the world has been waiting for, and the person
with the pill is the Board Certified Exercise Physiologists. Perhaps, first, the point should be cleared up:
Exercise physiology is no longer just about sports physiology. The exercise physiology practice, as defined
by the American Society of Exercise
Physiologists, encompasses health, fitness, rehabilitation, and
athletics. It recognizes and promotes
the cardiovascular, muscular, and cognitive health benefits of regular
exercise. Also, the good news is that
for the first time in the history of exercise physiology, there are accredited academic
programs of study that graduate credible exercise physiology professionals who
understand the importance of professionalism and their responsibility to a code
of ethics and standards of practice.
Graduates are trained to prescribe exercise in a scientific manner to
help the public sector achieve a healthier lifestyle to prevent and control
disease, injury, and disability. They
understand that in addition to regular exercise decreasing the risk of
developing hypertension, diabetes, and colon cancer, it increases muscle
strength, endurance, and flexibility; and improves mental and emotional health
and psychological well-being.
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If
all of the benefits of exercise could be packaged in a single pill, it would
be the most widely prescribed medication
in the world.
-- DrNick.com
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An
interesting question is how does regular exercise result in these outcomes? There are many different twists and turns in
answering this question. Perhaps,
the best (and shortest) and shortest answer is that exercise maintains
and builds bodily structure and therefore function. Some changes
that are
considered specific to one outcome in one person might actually be more
important
to another outcome in another person at different times. Certainly, by now it is clear that there is
incontrovertible evidence that regular exercise improves body composition, glucose
homeostasis and insulin sensitivity, and coronary artery blood flow, decreases blood
coagulation, systemic inflammation, triglycerides and low-density lipoprotein cholesterol,
and increases high-density lipoprotein cholesterol. All of this has been documented so many times
that it is rather common knowledge among exercise physiologists. However, for the person who is driven by
documentation, an interesting paper with considerable detail is the one by Warburton and colleagues [14].
Aside
from the role of exercise in the prevention and/or postponement of heart
disease, cancer, and other causes of premature death, there are also numerous
benefits that improve the body's psychophysiology function. From increased quality of life to improved
cardiovascular and respiratory function, there are many indicators of increased
efficiency of daily activities. Several
of these include a decrease in resting and activity heart rate along with
positive changes in blood pressure; both decrease the work of the heart as
measured by myocardial oxygen consumption or, more simply, via double
product. The end result is an increase
in stamina, resistance to fatigue, and better range of motion of a joint or
groups of joints. And, what is
down-right important to remember is that these benefits result from low
intensity exercise prescription interventions.
A person does not have to exercise at a moderate or even a high heart
rate intensity to realize positive effects of regular exercise [15].
A little
bit of exercise goes a long way….Thirty minutes a day, five days a week of
brisk walking is likely to reduce the risk of mortality by 50 percent if not
more."
– PETER
KOKKINOS [16]
This thinking isn't new! Exercise
physiologists have known for decades that physical inactivity is the fastest
growing public health problem in the United States. It contributes to a variety of healthcare problems,
from diseases to disabilities. Many
people would be astounded to learn from exercise physiologists how much
difference a 30-minute walk several times a week makes in the quality of their
health. The prescription recommended by
the Board Certified Exercise Physiologist is simple and consistent with the
content within the "benefits of walking" document published in
Publications International [17]. The
United States Department of Health and Human Services [18] agrees that exercise
is medicine or, perhaps, better than medicine.
Think about the future of healthcare:
Board Certified Exercise Physiologists will write prescriptions
for
a medicine that decreases blood pressure, blood sugar and weight. That
is exactly the point, isn't it? They will write "exercise
prescriptions" that improve cholesterol, sleep, and bone and heart
health; and
decreases the risk for cancer. In
addition, exercise will be used to detect, prevent, and manage nicotine
addiction, diabetes mellitus, affective disorders, and age-related declines in
muscular strength. Exercisers will feel
stronger, healthier, and less anxious or depressed.
These
benefits speak to the overwhelming importance of regular exercise. Yet, according to the 1997 Behavior Risk
Factor Survey [19], only 15% of the adults in United States engage in the recommended
amount of physical activity. ASEP Board
Certified Exercise Physiologists are in an excellent position to help others
start an exercise program. Members of
other professions, particularly medicine, are not prepared to do so. In fact, between 1992 and 1998, when the
medical community was asked about providing regular exercise prescriptions for
patients, they concluded that the following [20-22]: "Insufficient time,
lack of reimbursement, and inadequate training in physical activity counseling." These responses are indeed quite revealing,
as is the 2001 research by Connaughton and colleagues [23]. Not only do the graduates of medical school
lack educational training in exercise prescription, they are certain to tie a
price tag to it.
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Americans have the money to pay for services
and time on alternative medicine, and exercise physiologists are in a great
position to provide the services.
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The latter point
is another reason why exercise physiologists must oversee the exercise
prescription if it is going to be credible, safe, and offered at a fair
fee. Americans can't take additional healthcare costs. For one
thing, medical doctors already have their plates full. It makes sense,
given the relationship between obesity and lack of exercise, that exercise
physiologists are central to increasing awareness of the benefits of exercise,
the "how to" individual initiation of exercise, and personal responsibility
for reducing calorie consumption and increasing caloric output. Here, the
point isn't just the prescription of 30 minutes or more of exercise per day,
but the ability to use exercise physiology laboratory equipment to evaluate
improvement and motivate individuals accordingly. This type of
intervention as a non-drug therapy along with that of the dietitian's expertise
allows for a process of education that reduces body fat to help prevent and
control Type 2 or non-insulin dependent diabetes and the complications
associated with it.
However,
to create such interventions in a prescriptive sense is not without certain
concerns even within exercise physiology. For example, in 2001, Weber
[24] concluded: "In the absence of serious disease or injury, exercise
should not be prescribed. The use of physical activity as a
prescriptive tool should only be necessary in the presence of those diseases
and injuries where the risks associated with safety, cure, rehabilitation,
and/or palliation significantly outweigh the benefits. To express exercise as a
prescriptive activity for healthy and low risk individuals is to stress its
clinical nature at the expense of its intrinsic value. We should avoid
unnecessary exercise prescription paradigms and concentrate more on
educating and motivating these adults to be active without the clinical
implications. Rather than prescribing for them we should be guiding,
motivating, planning, programming, or strategizing with them. We should
invest our time, energy, and resources into developing an exercise culture
where daily physical activity is appreciated and practiced for its own
enjoyment, satisfaction, and rewards. Only then will exercise compliance
improve as adults become self-motivated rather than directed to become
physically active." Unfortunately, what Weber seems not to appreciate
is that the exercise physiologist's use of the term "prescription" is
not that of the "medical prescription as though exercise is a drug per
se." Rather, "prescription" is used in exercise physiology
in much the same way that he talks "investing time, energy, and resources
into developing an exercise culture…." Of course what is expected is
that the heart of matter is an increased appreciation for regular exercise
defined by the individual's specific exercise considerations.
The
exercise physiologist's "prescription" is more of a physiological
statement and/or interaction with the client that sets out the particular
knowledge and skills required to exercise safely. In other words, it has
more to do with measurable criteria, often specific to the exercise physiology
laboratory, that guide the appropriateness of the exercise sessions, responses,
and actions. The prescription criteria may include exercise safety, heart
rate intensity, exercise economy, lifestyle management, spiritual counseling,
and even legal considerations. My point is that individuals outside of
the ASEP perspective, including members of other professions, must be
"deschooled" in order to think as ASEP exercise physiologists
do. Naturally much of this thinking is part of the unfolding process and
transformation that occurs with most new professional organizations. This
is the sort of thing that is required of all who embark on new paradigms.
Rather than see or experience what to think in the old context, perhaps, that of
sports medicine, the quest for meaning often comes from thinking outside the
box.
Hence, the act of establishing a safe and
educationally sound direction for regular exercise is also a prescription. In this sense, it has "zero"
reference to the medical prescription of drugs.
It is the act of prescribing exactly why and how to exercise safely to
realize the benefits of regular exercise. This
focus on executing a well-planned and deliberately designed exercise program is
part of the exercise physiologist's oral and written directives. And, when view in this manner, the exercise prescription
takes on a legal importance to it. That
is why the instructions, preparation and provisions for regular exercise must
be defined by a Board Certified Exercise Physiologist. Literally speaking, the prescription is a
"recipe for success" when an exercise physiologist develops it. Contrary to popular belief, therefore, it has
nothing directly to do with the prescription per se that a medical doctor would
write a drug. In short, it is the
professional act of prescribing exercise, directing the client or patient how
to exercise within a safe and beneficial heart rate range, direct the client or
patient to indications and/or contraindications for exercise, and the follow-up
with regards to cardiovascular, musculoskeletal, and mental and/or emotional benefits.
For example, a brief overview of an "exercise-only"
prescription for a pregnant woman might constitute the following criteria and
directives: (1)
Evaluate the client's cardiovascular capacity using a
metabolic analyzer and related hemodynamic equipment. (2) Determine the client's exercise history, including
personal and family risk factors for disease and disability. (3) Develop an individualized low-impact/low-intensity
exercise prescription defined by heart rate intensity, exercise frequency
(usually, 3 times/wk on non-consecutive days) and duration (20 to 30
minutes/day), such as 40 to 50% of VO2 max. (4) Identify the mode of exercise such as walking,
cycling, swimming, and stair-climbing. (5) Follow-up face-to-face consultations for further
cardiovascular and behavior lifestyle evaluations, mental health
assessments, along with discussions and advice to prompt increased
adherence. (6)Where deemed necessary, the client is supervised and
instructed in specific exercises, including muscle strength, endurance,
and range of motion exercises.