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Journal of Exercise Medicine online
December 2016
Volume 1 Number 6
JEMonline
Official Research Journal
of the American Society of
Exercise Physiologists
ASEP’s Exercise Medicine Perspective for Better Public
Healthcare
ISSN 2378-4083
Tommy Boone
Member of the Board of Directors, American Society of Exercise
Physiologists, USA
ABSTRACT
Boone T. ASEP’s Exercise Medicine Perspective for Better Public
Healthcare. JEMonline 2016;1(6):1-7. The purpose of this paper is to
further the emphasis on exercise medicine and the role of the primary
care physician and the Board Certified Exercise Physiologist working
together to safely individualize the prescriptive dimensions of regular
exercise. After all, the pandemic of physical inactivity is the greatest
public health threat of the 21st century, which is linked to staggering
productivity losses due to disability and early death. The ASEP
leaders created a credible certification for exercise physiologists as
healthcare professionals who are responsible for prescribing exercise
medicine (i.e., Board Certified Exercise Physiologists). Unfortunately,
the medical community is more often than not predisposed to medical
training that addresses treatment rather than prevention. The ASEP
leaders believe it is imperative that physicians find the time to talk
about promoting physical activity with their patients, particularly since
even moderate levels of physical exercise (e.g., 150 min·wk -1) are
linked to a dramatic reduction in mortality. When done professionally,
exercise medicine (such as walking 30 min·d-1, 5 d·wk-1) not only
prevents and helps to manage heart disease, blood pressure, stroke,
and diabetes, it helps to control body weight, improves the strength,
endurance, and flexibility, delays cognitive impairment, decreases the
risk of falls, raises the red blood cell count, improves sleep quality,
reduces migraine suffering, decreases the risk of osteoporosis,
improves the muscles’ use of fat during exercise, improves agility and
co-ordination, and reduces death from any cause by 14%. By working
together, physicians and exercise physiologists can provide the
patients the individualized attention that is necessary to achieve
important behavioral changes in the patients’ lifestyle.
Key Words: Board Certified Exercise Physiologists Exercise
Medicine, Exercise Prescription, Primary Care Physicians
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The decrease in the physical demands of everyday life and the increase in caloric consumption is
a lethal combination that is responsible for the increase in non-communicable diseases. In fact, the
World Health Organization (WHO) ranks physical inactivity, in particular, as the fourth leading risk
factor for overall morbidity and mortality worldwide (1). The reason for this conclusion is that the
majority of adults do not meet the 150 min·wk-1 of physical activity (2), which is an important
contributor to negative clinical outcomes such as obesity, increased blood pressure, as well as the
increase in the risk of depression and decreased cognitive function in older adults with dementia
and Alzheimer’s disease (3,4).
Physical inactivity is “the” public health threat of the 21st century (5,6) that is linked to not only the
staggering healthcare costs and productivity losses, but also early death and disability. This point
gives rise to two important factors in the analysis of major non-communicable diseases. First, if
qualified healthcare professionals were to prescribe and supervise exercise medicine programs,
such programs would help cut the costs, deaths, and disabilities that result from chronic diseases.
Second, if society deems it important to embrace regular exercise as an “exercise medicine” to
improve its health and well-being, then, the physical inactivity related mortality and disability would
decrease.
With regard to the first point, one vitally important step that can no longer be ignored is the work of
ASEP to produce credible healthcare professionals responsible for prescribing exercise medicine.
The healthcare professionals are referred to as Board Certified Exercise Physiologists (7). As
college-prepared exercise physiologists (who understand the client’s time constraints due to work
and family matters, the lack of motivation, the lack of training or education of individuals with an
interest in promoting physical activity, and the complex problems that associate with a range of
chronic diseases and early deaths), they are committed to providing a comprehensive exercise
medicine strategy to improving clients’ health and well-being. They understand the work of Ding et
al. (8) that speaks to physical inactivity related productivity losses, the economic burden of physical
inactivity, and related deaths and disabilities from coronary heart disease, stroke, type 2 diabetes,
osteoporosis, and certain cancers.
Unfortunately, the primary care physicians’ job from a healthcare perspective is all about the
treatment of chronic diseases and disabilities. This appears to result from a twofold problem. First,
the medical community is predisposed by their medical training to “treatment vs. prevention”.
Second, medical treatment with drug prescriptions is quicker than the implementation of prevention
strategies to deal with tobacco use, poor diets, and the lack of regular exercise. Therefore, very
little time is spent in the doctor’s office discussing the patient’s unhealthy lifestyle and causes of
chronic diseases. Even with the ever-increasing list of publications that speak to exercise medicine
and prevention, there has been little change in healthcare during the past 8 years (i.e., since the
former ACSM President Robert Sallis, MD, spearheaded the initiative, Exercise Is Medicine). Why
is this case? On average, how many primary care physicians ask their patients during the brief
visit, “Do you engage in regular exercise?” or “How many minutes a day do you walk or exercise?”
Not many, and essentially a very small percent of primary care physicians evaluate their patients’
physiological capacity via an exercise ergometer and heart rate and/or oxygen consumption
monitor or use the well-recognized regression equations before providing a written prescription
with weekly exercise and lifestyle goals.
While society’s lifestyle behavior is not the responsibility of just the medical profession, the
traditional non-commitment to discussing health values inherent in regular exercise should be
viewed as a major public health concern. The ASEP leaders believe it is imperative that physicians
find the time to talk about promoting physical activity with their patients, particularly since Zhao et
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al. (9) pointed out that moderate levels of physical exercise (e.g., 150 min·wk -1) were associated
with a dramatic reduction of 36% in mortality. In agreement, Thornton et al. (10) said “Effective
counseling requires physicians to clearly explain to their patients what is meant by moderate-tovigorous physical activity and offer advice on ways to limit sedentary behavior.” Note the words
“effective”, “clearly explain”, and “advice” suggests more than saying to a patient, “Get some
exercise.”
Is it any wonder why physical inactivity and obesity are increasing if the patients’ sedentary lifestyle
is not clearly addressed and explained by the medical community? Elizabeth Joy (11), a medical
doctor with an MPH degree, reported that “…it’s estimated that half of all adults in the U.S. will be
obese by the year 2030 …, which would mean 7.8 million extra cases of diabetes, 6.8 million extra
cases of coronary heart disease and stroke, and 539,000 extra cases of cancer … not to mention a
$66 billion per year increase in health care costs….” And yet, according to Thornton et al. (10),
“Fifteen minutes of moderate-to-vigorous physical activity per day (or 75 min·wk-1) is associated
with ~15% relative mortality risk reduction, and benefits increase with the dose.”
Although generally healthy but inactive individuals with and without chronic disease can safely
engage in low-to-moderate exercise while increasing exercise duration over time, the role of the
Board Certified Exercise Physiologist is to ensure safe and progressive adaptation to individualized
exercise medicine programs. When done professionally, exercise medicine (such as walking 30
min·d-1, 5 d·wk-1) not only prevents and helps to manage heart disease, blood pressure, stroke,
and diabetes, it helps to control body weight, improves the musculoskeletal strength, endurance,
and flexibility, delays cognitive impairment, decreases the risk of falls, raises the red blood cell
count, improves sleep quality, reduces migraine suffering, decreases the risk of osteoporosis,
improves the muscles’ use of fat during exercise, improves agility and co-ordination, and reduces
death from any cause by 14% (12,13). These changes are critical to aging without major medical
problems.
Physicians should be proactive in looking to Board Certified Exercise Physiologists to prioritize the
patients’ exercise medicine. The winning strategy for individuals of sedentary lifestyles is the
exercise prescription and not more scripts for medication. After all, it is clear that the self-care
exercise medicine plan is cost-effective with the greatest influence on quality of life and life
expectancy (14). Simply put, when clients and patients ignore their obesity or poor physical shape,
the end result is sickness and premature death. Self-care improves mental and physical health and
happiness by engaging in behaviors, such as regular exercise, progressive relaxation, focusing on
the present, being happy, listening to music and dancing, reading a good book, laughing out loud,
walking, jogging, and running, and stepping back from the phone and laptop (15).
Unfortunately, self-care is missing throughout the World, given that one in three people engage in
little if any physical activity or exercise to burn calories, regardless of whether it is for work, play, or
quality of health. Exercise medicine is physical activity that is planned, structured, and repetitive
with the purpose to improve fitness, health, and mental well-being (16,17). It is about decreasing
sedentary activities (e.g., watching television and using the computer) and staying active to
increase total energy expenditure in combination with a low calorie eating plan (18). It is medicine
in the form of exercise that offsets the changes of aging that become evident as early as the third
decade of life. Hence, rather than experiencing a decrease in cardiorespiratory function (i.e.,
aerobic capacity), exercise medicine allows for plenty of energy and endurance. Life is much better
with blood vessels that are not stiff, thus allowing for blood pressure to remain normal. The same is
true with either a normal or slightly increased number of red blood cells coupled with the less
viscous blood makes it is easier to pump to the active muscles and supply the necessary oxygen
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to the mitochondria to develop energy for muscle contraction. In fact, the deterioration in the
muscular system brought on by the lack of regular exercise and aging doesn’t happen with adults
who are regular exercisers. Moreover, the typical muscle weakness and disability (sarcopenia)
coupled with the thinning of bones (osteoporosis) that set the stage for the likelihood of falling with
an increase in the risk of fractures are not common among exercising adults.
The role of exercise medicine in health and disease isn’t a new concept or practice. The harmful
consequences of failing to exercise have been known for a long time, but society is made up of
individuals who are not interested in exercising. They have become complacent with the taking of
long-term medications to deal with chronic diseases and disabilities. If possible, given that they are
conditioned to take pills, they would take an “exercise pill” in a second to deal with their energy
metabolism issues and muscle and bone strength concerns. It is unrealistic to expect them to
change their lifestyle, especially since many children and adults simply have never exercised and
do not see themselves starting an exercise program (19). The bottom line is that, regardless of the
Board Certified Exercise Physiologists’ desire to help clients and patients improve cardiovascular
function to deliver oxygen-rich blood to the body’s tissues, the United States is a country of 300
million people who are apparently comfortable with the 15 million nuclear medicine scans, a 100
million CT and MRI scans, and almost 10 billion laboratory tests (20). Society has become very
willing and accustomed to the medical overkill. After all, regular exercise (even 150 min·wk-1, i.e.,
3, 50 min·d-1, such as MWF) is viewed as a distraction if not work.
Yet, if children and adults were to engage in regular exercise, they could expect a decrease in
resting heart rate, blood vessel stiffness, blood viscosity, blood pressure, body fat, insulin levels,
blood sugar, nerve conduction and reflexes, risk of depression and memory lapses, and an
increase in quality of sleep, increase in HDL cholesterol, increase in metabolic rate, increase in
muscle mass and strength, increase in calcium content and strength, and increase in maximum
cardiac output. Each of the changes resulting from regular exercise helps to keep the body as
young as possible for as long as possible (21) and yet, according to the Physical Activity
Guidelines for Americans, school-age girls are at a greater risk than boys in meeting the 60 min of
moderate-to-vigorous physical activity every day of the week (22). Overall, as adults, women and
men continue to experience the ill effects of sedentary behavior, given that sitting and watching TV
decreases years to life expectancy. In fact, according to an Australian study, the authors found that
people who watched an average 6 hrs of TV a day lived an average 4.8 yrs fewer than those who
didn’t watch any television (23). While getting up from the chair and walking around doesn’t
produce the same physiological benefits as 50 min·d-1 of exercise medicine, it does help decrease
the time sitting.
Exercise medicine is a drug (i.e., an “exercise” prescription) and, therefore, it is essentially the
same as prescribing a drug! Hence, Board Certified Exercise Physiologists who prescribe exercise
medicine or in effect prescribing a medicine in the form of exercise. In this case, it is an exercise
prescriptive medication due to the pharmacological benefits of exercise that promotes significant
health effects associated with longevity (24). This is true for both patients and healthy individuals,
given that the strength of the scientific evidence for exercise medicine is strong for a risk reduction
of 20 to 35% for death, coronary artery disease, and stroke, 35 to 50% for type 2 diabetes and
colon cancer, 20% for breast cancer, and 20 to 30% for depression (25). The benefits are evident
with moderate intensity exercise that occurs with brisk walking at 3.0 mph for 50 min 3 times·wk-1
or 30 min·d-1 5 times·wk-1 (to obtain 150 min·wk-1) (26). Also, it is evident that unfit clients and/or
patients who are elderly, pregnant, overweight/obese, or have cardiovascular disease or type 2
diabetes can improve their fitness status and achieve a significant decrease in mortality with a low
dose of intensity training (24,27,28).
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These outcomes are primarily a function of the increase in mitochondriogenesis, the shift in muscle
fiber distribution from glycolytic to oxidative steps in the development of adenosine triphosptate,
enhanced muscle contraction, and the increase in fatty acid oxidation. Collectively, each outcome
working together leads to the increase in aerobic capacity (VO2 max) and, ultimately, the increase
in the expenditure of energy and loss of body fat (24). Exercise medicine also decreases systemic
inflammation and blood coagulation while improving coronary blood flow to the myocardium (29),
thus helping to enhance cardiac function and transport of oxygen to the peripheral tissues. There
are also numerous physiological benefits of exercise medicine at the tissue and organ level that
help to improve psychological well-being (30), which is especially important in the prevention and
treatment of costly and debilitating chronic diseases.
In conclusion, given that the primary care physicians have contact with more than 80% of the
adults and 90% of the children (31), they are in an important position to promote exercise medicine
and to refer their patients to ASEP Board Certified Exercise Physiologists for exercise-related
advice, counseling, and supervision. Unfortunately, though, due to the physicians’ “uncertainty
about the impact of the counseling, low self-efficacy for exercise prescription, and lack of time,
training, and reimbursement” (32), the primary care physicians are not participating in the patients’
need to get involved in the exercise medicine movement. Less than 10% of total outpatient visits
have included exercise counseling or education (33). Hence, as a critical component of the
healthcare system, the primary care physicians’ reluctance to refer patients to healthcare providers
serves to diminish the potential to positively impact disease management either by prevention or
treatment. This can be corrected by the primary care physicians’ willingness to refer their patients
to the Board Certified Exercise Physiologists. By working together, both the physicians and the
exercise physiologists can provide the patients the individualized attention that is necessary to
achieve important behavioral changes in the patients’ lifestyle (34,35).
REFERENCES
1. World Health Organization. WHO Global Recommendations on Physical Activity for
Health. Geneva: World Health Organization, 2010, (Online). http://apps.who.int/iris/
bitstream/10665/44399/1/9789241599979_eng.pdf
2. Boone T. ASEP’s Exercise Medicine Text for Exercise Physiologists. Bentham Science
Publishing, 2016.
3. Beaulac J, Carlson A, Boyd RJ. Counseling on physical activity to promote mental health:
Practical guidelines for family physicians. Can Fam Physician. 2011;57:399-401.
4. Groot C, Hooghiemstra AM, Raijmakers PG, et al. The effect of physical activity on cognitive
function in patients with dementia: A meta-analysis of randomized control trials. Ageing Res
Rev. 2016;25:13-23.
5. Blair SN. Physical inactivity: The biggest public health problem of the 21st century. Br J
Sports Med. 2009;43:1-2.
6. Kipps C. International perspectives on exercise medicine. Exercise in the prevention and
treatment of chronic disease. Winston Churchill Memorial Trust Fellowship Report.
2010.
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7. American Society of Exercise Physiologists. ASEP Board Certification. 2016, (Online).
https://www.asep.org/index.php/epc-online/epc-missionpurpose/
8. Ding D, Lawson KD, Kolbe-Alexander TL, et al. The economic burden of physical inactivity:
A global analysis of major non-communicable diseases. Lancet. 2016;388(10051):13111324.
9. Zhao G, Li C, Ford ES, et al. Leisure-time aerobic physical activity, muscle-strengthening
activity and mortality risks among US adults: The NHANES linked mortality study. Br J
Sports Med. 2014;48:244-249.
10. Thornton JS, Fremont P, Khan K, et al. Physical activity prescription: A critical opportunity to
address a modifiable risk factor for the prevention and management of chronic disease: A
position statement by the Canadian Academy of Sports and Exercise Medicine. Br J Sports
Med. 2016;0:1-6.
11. Joy E. Exercise is medicine: A focus on prevention. ACSM Public Information Articles.
(Online). http://www.acsm.org/public-information/articles/2016/10/07/exercise-is-medicine-afocus-on-prevention
12. Gupta S. The best anti-aging medicine? Exercise. Everyday Health. (Online). http://www.
everydayhealth.com/news/best-anti-aging-medicine-exercise/
13. Nordqvist C. Exercise: Health benefits, types, how it works. MNT. http://www.medicalnews
today.com/articles/153390.php
14. Thornton J. Exercise isn’t just prevention, but treatment too. Healthy Debate. (Online).
http:// healthydebate.ca/opinions/exercise-prescription
15. Duron A. 25 science-backed ways to change your life by taking better care of yourself.
Greatist. 2015;1-5. (Online). http://greatist.com/happiness/ways-to-practice-self-care
16. World Health Organization. Notes for the media: New physical activity guidance can help
reduce risk of breast, colon cancers. 2011.
17. Caspersen CJ, Powell KE, Christenson GM, et al. Physical activity, exercise, and physical
fitness: Definitions and distinctions for health-related research. Public Health Rep. 1985;
100:126-131.
18. U.S. Department of Health and Human Services. 2008 physical activity guidelines for
Americans. 2008.
19. Stetka B. The ethics of exercise pills. The Atlantic. 2015;1-2. (Online). http://www.
theatlantic.com/health/archive/2015/10/will-exercise-pills-really-make-us-healthier/411049/
20. Gawande A. Overkill. Ann Health Care. (Online). http://www.newyorker.com/magazine/
annals-of-health-care
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21. Harvard Medical School. Exercise and aging: Can you walk away from Father Time?
Harvard Health Publications. 2009. (Online). http://www.health.harvard.edu/stayinghealthy/exercise_and_aging_can_you_walk_away_from_father_time
22. Gallagher S. Few children get 60 minutes of vigorous physical activity daily. Science Daily.
2016. (Online). https://www.sciencedaily.com/releases/2016/04/160405122618.htm
23. Park A. Want to live longer? Cut off your TV. Time. 2011. (Online). http://healthland.time.
com/2011/08/17/want-to-live-longer-try-turning-off-your-tv/
24. Vina J, Sanchis-Gomar F, Martenez-Bello V, Gomez-Cabrera MC. Exercise acts as a drug;
the pharmacological benefits of exercise. Br J Pharmacol. 2012;167:1-12.
25. Nunan D. Doctors should be able to prescribe exercise like a drug. Bri Med J. 2016;353355. (Online). http://dx.doi.org/10.1136/bmj.i2468
26. O’Donovan G, Blazevich AJ, Boreham C, et al. The ABC of physical activity for health: A
consensus statement from the British Association of Sport and Exercise Sciences. J Sports
Sci. 2010;28:573-591.
27. Wannamethee SG, Shaper AG, Walker M. Changes in physical activity, mortality, and
incidence of coronary heart disease in older men. Lancet. 1998;351:1603-1608.
28. Warburton DE, Nicol CW, Bredin SS. Prescribing exercise as preventive therapy. CMAJ.
2006;174:961-974.
29. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: The evidence.
CMAJ. 2006;801-809.
30. Dunn Al, Trivedi MH, O’Neal HA Physical activity dose-response effects on outcomes of
depression and anxiety. Med Sci Sports Exerc. 2001;6:S587-S597. Discussion 609-610.
31. Centers for Disease Control and Prevention. Ambulatory care use and physician office
visits. 2012. (Online). http://www.cdc,gov/nchs/fastats/physician-visits.htm
32. Hebert ET, Caughy MO, Shuval K. Primary care providers’ perceptions of physical activity
counseling in a clinical setting: A systematic review. Br J Sports Med. 2012;46:625-631.
33. Tulloch H, Fortier M, Hogg W. Physical activity counseling in primary care: Who has and
who should be counseling? Patient Edu Couns. 2006;(1-3):6-20. https://www.ncbi.nlm.nih.
gov/pubmed/16472959
34. Muth ND, Vargo K, Bryant CX. The role of the fitness professional in the clinical setting.
Curr Sports Med Reports. 2015;14(4):301-312.
35. Campkin L. Doyle-Baker PK. Exercise counseling and use of exercise professionals by
physicians: Findings from a scoping review. WellSpring. 2015;26(4):1-3. (Online). https://
www.centre4activeliving.ca/news/2015/07/physician-exercise-counselling/