- Email: [email protected]
Response to W. Brown
Journal of Science and Medicine in Sport (2006) 9, 38—39
COMMENTARY
Response to W. Brown David Bishop University of WA, Australia
In September 2005, I was invited to write an editorial regarding the inclusion of AAESS Accredited Exercise Physiologists in the Medicare Plus Scheme.1 Around this idea, I chose to raise a few issues regarding the blurring of the distinction between physical activity promotion and exercise prescription. I also argued the need for trained exercise professionals (including exercise physiologists) to deliver prescribed exercise to certain populations. I believe that this is an important debate and I thank Prof. Brown for her response.2 I would, however, like to clarify my position on a few points: 1. Nowhere in my editorial do I state that ‘‘only exercise physiologists can or should be involved in the tertiary prevention or management of health problems’’.2 In my editorial, I wrote that ‘‘exercise physiologists . . . will complement the services of other allied health professionals’’.1 I do, however, believe that exercise physiologists represent the highest standard within the Australian Health Sector for the delivery of exercise prescription to a wide range of special populations. This seems also to be supported by Prof. Brown who agrees that exercise physiologists should ‘‘play a leading role in . . . the prescription of individual exercise programs.’’2 2. I agree that ‘‘we are not striving for them all (the general public) to become marathon runE-mail address: [email protected].
ners’’.2 Considering that the current women’s world record marathon time is only slightly less than the recommended 150 min of physical activity per week and that marathon runners can spend in excess of 15 h/week training, it is not clear how the above statement contributes to a debate on the importance of prescribed exercise for certain populations. I would also like to further stress a few of the original issues raised in my editorial. 1. I originally suggested that I would like to see all researchers accurately detail the qualifications of those who administer the exercise (and physical activity) interventions in their studies. This may help to clarify why some exercise intervention trials seem to obtain positive results while other seemingly similar studies do not. An interesting parallel might be the work of podiatrists. Is it the orthotics themselves that alleviate certain foot problems or the fact that they are correctly tailored to the individual by trained professionals (i.e., podiatrists)? In my view, a similar distinction could be made between a generic exercise intervention (or physical activity) and a specific, targeted, and prescribed exercise intervention implemented by exercise physiologists. Interestingly, Prof. Brown’s reply was that her study found that ‘‘GPs and exercise physiologists were equally effective in getting people to be more active.’’3 While no indices of health improvement were made, what appears to be
1440-2440/$ — see front matter © 2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2006.03.010
Response to W. Brown the published version of this study reported that additional research is required to investigate ‘‘the ‘added’ advantage of referral to an ES (exercise scientist).’’4 2. I also argued that we need to distinguish between general physical activity and specific, targeted, and prescribed exercise. Subsequently, two of the world’s leading physiologists (Profs. Pedersen and Saltin) have published a comprehensive article arguing the need to individually prescribe exercise to treat chronic diseases.5 To support the role of prescribed exercise, I cited evidence that while physical activity in general appears protective, additional benefit may be obtained by performing more vigorous activities more frequently during the week.6 Space prevented me from also citing other findings such as 170 min of exercise/week improved insulin sensitivity more substantially than a program utilizing approximately 115 min of exercise/week7 or that a good correlation has been reported between exercise intensity and post-intervention change in HbA1c in individuals with type 2 diabetes.8 This seems contrary to the opinion that ‘‘there is little evidence to suggest that more vigorous or more frequent exercise will result in greater improvement in population health outcomes.’’2 3. While there are many studies reporting that a range of approaches can increase time spent in physical activity, I suggested that we need more evidence that this will actually translate to improvements in health. I therefore asked the question ‘‘will greater promotion of physical activity alone be able to combat this chronic disease epidemic?’’. A recent quote from a general practitioner similarly noted that ‘‘. . . lecturing a patient to do more exercise is one thing — referring them to a program that puts them on a supervised, achievable program quite another.’’9 Interestingly, a recent study has reported that ‘walking for pleasure’ is not
39 sufficient to improve cardiovascular fitness in normal-weight individuals.10 In summary, this is not an argument for physical activity promotion or prescribed exercise; both have their place. There is no doubt that we all have a role to play in promoting the physical activity message of 150 min of moderate-intensity, physical activity per week. However, I believe that an additional, and important tool to help combat the complex health questions that we must answer is specific, targeted, and prescribed exercise interventions supported by exercise physiologists.
References 1. Bishop D. If physical activity is the answer, what is the question? J Sci Med Sport 2005;8(4):vii—x. 2. Brown W. Individual or population approaches to the promotion of physical activity . . . is that the question? J Sci Med Sport 2006;9:1. 3. Armit C, Brown W, Ritchie C, Marshall A, Trost S, Green A. Promoting physical activity to older adults in general practice. J Sci Med Sport 2004;7(4 Suppl.):53. 4. Armit C, Brown W, Ritchie C, Trost S. Promoting physical activity to older adults in general practice: a preliminary evaluation of three general practice-based strategies. J Sci Med Sport 2005;8(4):446—50. 5. Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports 2006;16(Suppl. 1):3—63. 6. Slattery ML. How much physical activity do we need to maintain health and prevent disease? Res Quart 1996;67:209—12. 7. Houmard JA, Tanner CJ, Slentz CA, et al. Effect of the volume and intensity of exercise training on insulin sensitivity. J Appl Physiol 2004;96:101—6. 8. Boule NG, Kenny GP, Haddad E, Wells GA, Sigal RJ. Metaanalysis of the effect of structured exercise training on cardiorespiratory fitness in Type 2 diabetes mellitus. Diabetologia 2003;46:1071—81. 9. Cresswell A. Keeping medicare fit. The Australia 2006;February 18—19:25. 10. Hills AP, Byrne NM, Wearing S, Armstrong T. Validation of the intensity of walking for pleasure in obese adults. Prev Med 2006;42:47—50.
COMMENTARY
Response to W. Brown David Bishop University of WA, Australia
In September 2005, I was invited to write an editorial regarding the inclusion of AAESS Accredited Exercise Physiologists in the Medicare Plus Scheme.1 Around this idea, I chose to raise a few issues regarding the blurring of the distinction between physical activity promotion and exercise prescription. I also argued the need for trained exercise professionals (including exercise physiologists) to deliver prescribed exercise to certain populations. I believe that this is an important debate and I thank Prof. Brown for her response.2 I would, however, like to clarify my position on a few points: 1. Nowhere in my editorial do I state that ‘‘only exercise physiologists can or should be involved in the tertiary prevention or management of health problems’’.2 In my editorial, I wrote that ‘‘exercise physiologists . . . will complement the services of other allied health professionals’’.1 I do, however, believe that exercise physiologists represent the highest standard within the Australian Health Sector for the delivery of exercise prescription to a wide range of special populations. This seems also to be supported by Prof. Brown who agrees that exercise physiologists should ‘‘play a leading role in . . . the prescription of individual exercise programs.’’2 2. I agree that ‘‘we are not striving for them all (the general public) to become marathon runE-mail address: [email protected].
ners’’.2 Considering that the current women’s world record marathon time is only slightly less than the recommended 150 min of physical activity per week and that marathon runners can spend in excess of 15 h/week training, it is not clear how the above statement contributes to a debate on the importance of prescribed exercise for certain populations. I would also like to further stress a few of the original issues raised in my editorial. 1. I originally suggested that I would like to see all researchers accurately detail the qualifications of those who administer the exercise (and physical activity) interventions in their studies. This may help to clarify why some exercise intervention trials seem to obtain positive results while other seemingly similar studies do not. An interesting parallel might be the work of podiatrists. Is it the orthotics themselves that alleviate certain foot problems or the fact that they are correctly tailored to the individual by trained professionals (i.e., podiatrists)? In my view, a similar distinction could be made between a generic exercise intervention (or physical activity) and a specific, targeted, and prescribed exercise intervention implemented by exercise physiologists. Interestingly, Prof. Brown’s reply was that her study found that ‘‘GPs and exercise physiologists were equally effective in getting people to be more active.’’3 While no indices of health improvement were made, what appears to be
1440-2440/$ — see front matter © 2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2006.03.010
Response to W. Brown the published version of this study reported that additional research is required to investigate ‘‘the ‘added’ advantage of referral to an ES (exercise scientist).’’4 2. I also argued that we need to distinguish between general physical activity and specific, targeted, and prescribed exercise. Subsequently, two of the world’s leading physiologists (Profs. Pedersen and Saltin) have published a comprehensive article arguing the need to individually prescribe exercise to treat chronic diseases.5 To support the role of prescribed exercise, I cited evidence that while physical activity in general appears protective, additional benefit may be obtained by performing more vigorous activities more frequently during the week.6 Space prevented me from also citing other findings such as 170 min of exercise/week improved insulin sensitivity more substantially than a program utilizing approximately 115 min of exercise/week7 or that a good correlation has been reported between exercise intensity and post-intervention change in HbA1c in individuals with type 2 diabetes.8 This seems contrary to the opinion that ‘‘there is little evidence to suggest that more vigorous or more frequent exercise will result in greater improvement in population health outcomes.’’2 3. While there are many studies reporting that a range of approaches can increase time spent in physical activity, I suggested that we need more evidence that this will actually translate to improvements in health. I therefore asked the question ‘‘will greater promotion of physical activity alone be able to combat this chronic disease epidemic?’’. A recent quote from a general practitioner similarly noted that ‘‘. . . lecturing a patient to do more exercise is one thing — referring them to a program that puts them on a supervised, achievable program quite another.’’9 Interestingly, a recent study has reported that ‘walking for pleasure’ is not
39 sufficient to improve cardiovascular fitness in normal-weight individuals.10 In summary, this is not an argument for physical activity promotion or prescribed exercise; both have their place. There is no doubt that we all have a role to play in promoting the physical activity message of 150 min of moderate-intensity, physical activity per week. However, I believe that an additional, and important tool to help combat the complex health questions that we must answer is specific, targeted, and prescribed exercise interventions supported by exercise physiologists.
References 1. Bishop D. If physical activity is the answer, what is the question? J Sci Med Sport 2005;8(4):vii—x. 2. Brown W. Individual or population approaches to the promotion of physical activity . . . is that the question? J Sci Med Sport 2006;9:1. 3. Armit C, Brown W, Ritchie C, Marshall A, Trost S, Green A. Promoting physical activity to older adults in general practice. J Sci Med Sport 2004;7(4 Suppl.):53. 4. Armit C, Brown W, Ritchie C, Trost S. Promoting physical activity to older adults in general practice: a preliminary evaluation of three general practice-based strategies. J Sci Med Sport 2005;8(4):446—50. 5. Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports 2006;16(Suppl. 1):3—63. 6. Slattery ML. How much physical activity do we need to maintain health and prevent disease? Res Quart 1996;67:209—12. 7. Houmard JA, Tanner CJ, Slentz CA, et al. Effect of the volume and intensity of exercise training on insulin sensitivity. J Appl Physiol 2004;96:101—6. 8. Boule NG, Kenny GP, Haddad E, Wells GA, Sigal RJ. Metaanalysis of the effect of structured exercise training on cardiorespiratory fitness in Type 2 diabetes mellitus. Diabetologia 2003;46:1071—81. 9. Cresswell A. Keeping medicare fit. The Australia 2006;February 18—19:25. 10. Hills AP, Byrne NM, Wearing S, Armstrong T. Validation of the intensity of walking for pleasure in obese adults. Prev Med 2006;42:47—50.