The New Exercise Physiology
I am going to write about three things:
- The American Society of Exercise Physiologists
- Interdisciplinary healthcare opportunities, and
- Professional Concerns
At the age of 30, I earned the PhD in Exercise Physiology from Florida State University. During the following years, colleagues were always happy to share with me their 5 steps to being successful:
- Join the American College of Sports Medicine.
- Get published.
- Concentrate on one area of research only.
- Don’t disagree with peers, at least not openly.
- Become a runner or, at the very least, jog!
Interesting criteria for becoming somebody, don’t you think? Early on, I felt I was probably destined to fail at being a successful exercise physiologist. First, I was a gymnast in college, so running wasn’t all that exciting to me. It still isn’t. Later, I figured out that “how to think” for myself is much better than “what to think.” And, in terms of critical thinking, the learning process drives differences of opinion and, yes, disagreements among colleagues.
Today, as I look back on 35+ years of college teaching, I am still the same person. My needs, goals, and sense of responsibility haven’t changed. In many ways, then, and now, with a strange power of innocence and dreams, deep down, it has always been apparent to me that exercise physiology is more than research, more than an academic position, and much closer than we think to being medicine. However, for 20+ years I lived to do research and teach. Even when my son wrote about the need for exercise physiologists to have their own professional organization in 1991, it simply did not click. The inertia of sports medicine held me captive to a failed rhetoric.
The inadvertent but nevertheless unwarranted overemphasis on both sports medicine and exercise science resulted in decades of misuse of my time and that of my colleagues. The passage through this disillusionment has been (and still is) too long for most exercise physiologists. The extraction of ideas from exercise physiologists on behalf of sports medicine’s future has diminished exercise physiology. Ignoring this point will not correct it. The “other side” of disillusionment is where exercise physiologists manifestly understand the power and need for a collective, shared understanding of exercise physiology.
Or, if you will, stated understand differently, unlearning is far more difficult than learning. While the ways of unlearning are various, it was not until I became the Chair of the Department of Exercise Physiology at The College of St. Scholastica in Duluth, MN that it hit me my “son” was right. In 1995, I the Vice-President of St. Scholastica put up $600 to secure a lawyer in Duluth to oversee my writing of the ASEP Bylaws and Constitution. As they say, the rest is history – given that the American Society of Exercise Physiologists was incorporated as a non-profit professional organization in the state of Minnesota that same year.
The time had come to take risks, to articulate a new agenda, and to make a difference on behalf of our students. Exercise physiologists, after all, are not fitness professionals or personal trainers (not to imply anything negative about either). But, the bottom line, is simply this: My undergraduate students are required to take exercise physiology, sports nutrition, functional anatomy, psycho-physiology, physiological assessment, cardiac rehab, sports biomechanics, statistics, advanced exercise physiology, electrocardiography/stress testing, advanced laboratory research, of which 8 of the 11 courses have a required 2-hour lab in addition to the 400 hours of internship.
ASEP was founded to champion the “underdog,” to care for students in need, and to develop an infrastructure to help students be successful healthcare professionals. The failure of exercise physiologists to realize they needed their own professional organization decades ago is something I deal with everyday. Yet, ask a dietitian what it would be like without the American Dietetic Association? Without even thinking about it, you know in your gut it would be a major mistake not having your own professional association. You would wander aimlessly through your professional and personal lives, as graduates of dietetics, as 1000s of students do from exercise science, sports sciences, or kinesiology, without taking advantage of opportunities for professional growth because you would be unaware of such opportunities. Most unfortunately and sad, you would not think that you “measure up” to your colleagues.
The problem in exercise physiology is that there has been too much emphasis on “me, the researcher, or “me, the presenter.” Both have led to “it is all about me” way of thinking, when the truth is — it is about our students and doing the right things for the right reasons, especially academic accreditation that is linked to a degree title that bears the name of the profession. ASEP exists for those who get it, those who are willing to undertake a journey beginning with predictably rough roads ahead. It is for those who are willing to stand up for a cause, to network with others, and to do what needs to be done towards the professionalism of exercise physiology.
Strangely enough, it never occurred to me in 1995 just how many academic exercise physiologists would resist change. In my naïve way of thinking, I thought that if you built it, they would see the light and come running. The truth is that too many colleagues are comfortable with what they are doing, which seldom involves thinking about students or even the future of exercise physiology. Also, in all fairness to them, after having invested so much of our identity with sports medicine, after committing so much of our research, and squandering so much of our power with sports medicine, many exercise physiologists remain vulnerable to the mysterious link, if not, the negative powers of groupthink.
Those who understood the need for their own professional organization created the ASEP professional infrastructure. Members like Robert Robergs of New Mexico, Matt Lehn of Indiana, Matt Wattles of Idaho, Jesse Pittsley of North Carolina, Don Diboll of California, Lonnie Lowery of Ohio, and others are to be remembered as creating the 21st century history of exercise physiology. Now that exercise physiologists have an academic accreditation process, board certification, code of ethics, standards of practice, and two electronic journals and newsletter, what is their destiny? How should they practice exercise physiology, and how should it change in the foreseeable future? Those who are at the heart of ASEP give it legitimacy, particularly, in an entrepreneurial sense. They also provide the necessary guidance for the long haul, starting with the basics, having articulated a student-focused attitude towards the professionalism of exercise physiology. ASEP has continued to focus on principles, like the ones Registered Dietitians acknowledge to ensure the quality and continued improvement of dietetics.
The increasing complexity of exercise physiology, like dietetics, demands constant updating of the practitioner’s knowledge and hands-on laboratory skills. Professional development is the continuous process of learning for practitioners, seeking to maintain and advance their professional competence. Exercise physiology is a vital, growing profession with many career possibilities, particularly in the areas of prevention (given that exercise is medicine). And, yet there is still so much to learn, given the brief history of ASEP compared to 1917 when the ADA was formed (which is also the same year Occupational Therapy began its Society of professionals). By 1921, the American Physiotherapy Association was founded, and by 1924, dietetic education included a four-year course of academic study plus an internship. ADA established educational standards, and dietitians supported the association and its activities. I am also reminded of the fact that the first school for training practical nurses was in 1897, which was 50 years after the first official meeting of the American Medical Association.
Like the ADA is the professional organization of dietitians. ASEP is the professional organization of exercise physiologists. Clearly, the founding of professional organizations is not a new idea. It is nonetheless an imperative reality, as Max DePree once said: “The first responsibility of leaders is to define their reality.” The future of exercise physiology lies in better leadership who are willing to build a better relationship with students, colleagues, and healthcare professionals (like you). There are many things we can learn from dietitians? And, the good news is that this is happening, and it will set the stage for increased “interdisciplinary healthcare possibilities” between the members of ASEP and dietitians, which moves me to my second point.
Interdisciplinary Healthcare Possibilities
No doubt you have noticed that scientific medicine seems to be all about personalized prescriptions, stem-cell therapies and the silver-bullet cancer drug. Researchers are working to devise different treatments for different subtypes of depression. The possibilities are endless, particularly with stem-cell research. My bias however is that the secret to improved healthcare does not exist with molecular tools to switch genes on and off. No doubt America has built the world’s highest-tech medical system, yet the nation ranks 46th in life expectancy. Healthcare costs are exploding, meanwhile, as technology expands and the population ages, America’s 45 million uninsured is growing. Healthcare costs continue to skyrocket. Will the emphasis on technology be the answer? I don’t think so. Yet, even now, Harvard University researchers are working to develop protein-based drugs that encourage the regrowth of muscle tissue that has died after an MI. No doubt molecular biology is believed to the key to transform medicine and healthcare.
We live in a breakthrough era. Just recently, I read that in 20 or 30 years, people will have an implanted chip that will monitor a wide range of indicators of their state of health, coupled remotely to an internet-based personal prevention diagnostic system. There isn’t any question that United States faces a healthcare epidemic of unparallel proportions. Over 18 million in the United States suffer from diabetes. Heart disease is the #1 killer. Osteoporosis, chronic respiratory diseases, and strokes are all preventable by lifestyle changes. Arthritis is the number one cause of disability, affecting 1 of every 3 adults. And, still it seems that we are over-invested in molecular biology, if not, technology and under-invested in lifestyle management strategies.
We know that exercise and prevention can help with the pathophysiology of obesity, hypertension, and cancer. Prevention is the first line of defense against disease. Yet, more often than not, healthcare is all about dealing with the disease or dysfunction in the clinical setting. Perhaps, with more interdisciplinary sharing among healthcare professions, such as exercise physiology and dietetics, more people will come to understand the power in prevention. After all, as educators, we have an ethical responsibility to communicate the use of exercise and nutrition as medical treatment.
As you know – your professional organization, ADA, states strongly that nutrition assessment, counseling and intervention by registered dietitians is the best long-term strategy for prevention and treatment of disease. ASEP board certified exercise physiologists are in 100% agreement. Exercise physiologists and dietitians are uniquely qualified to provide the highest-quality cardiovascular assessment, exercise prescription, nutrition, and weight-loss counseling for obesity, hypertension, heart disease, and diabetes. This is especially an important healthcare reality.
For decades, scientific evidence shows that regular exercise and sound nutrition are cost-effective for individuals and the health-care system as a whole. Epidemiologic studies have consistently shown an inverse association between participation in regular physical activity and total mortality and morbidity from diabetes, cancer, heart disease, hypertension, hypercholesterolemia, and osteoporosis. The proportion of preventable deaths from coronary heart disease attributable to physical inactivity is estimated to be between 27 and 40%. But, unfortunately, less than 25% of the 300 million people in the United States exercise. Physical inactivity is our way of life, and it contributes to disease and disability, accounting for 22% of colon cancer, 18% of osteoporotic fractures, 12% of diabetes and hypertension, and the proportion of preventable deaths from coronary heart disease attributable to physical inactivity is estimated to be between 27 and 40%. With a direct medical cost of inactivity estimated to be at least $24 billion a year, exercise therapy and nutrient therapy are timely and critical to the prevention and the treatment of most diseases and disabilities. Both might very well be the medicine of the future.
Recommendations suggest that adults should accumulate at least 30 minutes a day of moderate intensity activity on most days, and preferably all days of the week. Interpreting “moderate” intensity to mean three or more METs per minute and “most days” as at least 5 days per week, this is equivalent to a minimum of 64 physical activity kilocalories expended per day per week. The Institute of Medicine recommends 1 hour of physical activity per day at a minimum of 180 kcal for adults to maintain weight and cardiovascular health. The evidence for regular exercise and sound nutrition is so strong that exercise physiologists and dietitians are likely to become the doctors of a collaborative and integrative medicine. And, frankly, sometimes it is obvious that less is more!
The simplest “exercise prescription” is to “exercise 30 to 60 minutes each day at low to moderate intensity, keeping in mind that physical activities of low intensity, such as MET level 3 to 4, may not be sufficient to prevent weight gain even if performed daily for 60 minutes. This kind of thinking requires a new paradigm and, as such, is one of many reasons for the founding of the American Society of Exercise Physiologists in 1997. And, as briefly mentioned, it is not an easy task to question an existing paradigm. Few exercise physiologists have attempted it, and fewer still have mastered it. However, regardless of the thorny issues that underlie decades of embracing the wrong model, ASEP exercise physiologists have overcome their thinking that the only thing important is “just exercise” or “just research.” They understand that exercise and research must still be done, but now EPs have a vision for the profession.
The ASEP exercise physiologists support the thinking that illness is almost always multifactorial in cause and, therefore, exercise physiologists should use a multitude of healthcare resources with clients. One such approach, although a beginning point is that of regular exercise and sound nutrition. Both are important in the prevention and treatment of disease and dysfunction. As a parallel in thought, regarding other healthcare models, in 2004, British researchers found that acupuncture for chronic headache gave patients in the intervention group 22 fewer days of headache per year and sets the stage for 25% fewer visits to general practitioners and to take 15% fewer sick days, compared with the control group. And, similarly, in 2000, Canadian researchers found that teaching meditation to heart patients greatly reduced healthcare costs by controlling levels of stress.
As an exercise physiologist, I must say, even though exercise is not normally viewed as an alternative medicine, exercise is clearly an integrative medicine. Wouldn’t it a good thing if exercise physiologists and dietitians (among other stakeholders in healthcare) were to create a healthcare service delivery model with the potential for wide-ranging lifestyle management and prevention possibilities? I believe adults in the United States are ready for this kind of thinking. One report, dated 1993, in regards to unconventional forms of healthcare (meaning, practices neither taught widely in the medical schools nor generally available in hospitals) reported 34% of adults used at least “one” alternative medicine.
My point is this: People are willing to pay out-of-pocket for these services. Even if exercise is medical treatment per se, and not an alternative medicine, much like psychotherapy is not viewed as an alternative medicine to treat depression, then, the relief of symptoms, like the result often reported with alternative medicine, is a central finding when concluding why people exercise. This thinking is also critical to the use of sound nutrition, when making informed, safe, and appropriate self-care choices. In fact, I’ve heard that diet plays a significant role in the onset and progression of 5 of the 10 leading causes of death but nutrition knowledge (like exercise knowledge) has not always been included in the catalog of required medical skills and competencies.
The need to incorporate nutrition into the medical school curriculum is widely recognized. Yet, in 97–98, despite awareness of the importance of nutrition as part of medical students’ education, the Association of American Medical Colleges (AAMC) reported that of 128 US medical schools, only 26% had a required nutrition course. Well, just for the record, I think a required exercise physiology course for medical students is probably “zero” in the United States. Yet, the primary reason for other professions failing to recognize the power of exercise resides primarily with exercise physiologists. They have failed to see the future before it comes into being because they have not had a vision beyond sports medicine.
Without a vision, there is little hope for a secure future. The ASEP vision is designed to give purpose and meaning to exercise for all exercise physiologists as healthcare professionals. Consider, for example, that exercise is (or can be) the key to dealing with depression. ASEP recognizes that a growing recognition and acceptance of chronic exercise is useful in treating depression, and been demonstrated to be as effective as antidepressants in treating older patients with depression. And, regular exercise has been shown to protect against relapse to previous levels of depression.
Most unfortunately, the majority of the so-called exercise physiology academic programs (such as exercise science, kinesiology, sports sciences, and human performance) lack the consistency and uniformity of course work, hands-on laboratory experiences, and the credentialing of other healthcare professions. This creates therefore a complex, uncertain terrain for our integrative approach to exercise and nutrition therapy, where homogeneity of education and training is critical for referring and/or co-managing clients.
With greater academic standardization, clear practice standards, which ASEP has established along with the board certification for exercise physiologists that hold them accountable to a Code of Ethics, there is increased public trust and validation by colleagues of appropriate professional bodies. Hopefully, you’ll agree that the ASEP infrastructure for professional development contributes to the “integration” of overlapping aspects of exercise physiology and dietetics. This doesn’t mean that it will be an easy integration of our two disciplines.
Collaboration is never easy. Of course the objective is an outcome that goes beyond the solution of any one discipline or single organization. Hopefully, at least, as I see it, and as I’ve written about it, the Exercise Physiology Healthcare Clinic will become the opportunity for multiple healthcare professionals with differing perspectives to work together and develop a shared vision of prevention and rehabilitation strategies for clients. We have a lot to learn from each other. Collaborative interaction is not automatic. We need to work together to find integrative solutions that will our needs and those of our clients. Collaboration is a complex partnership. It is a process that occurs over time. It is a synthesis of different perspectives to reach an integrative solution.
The question (and point three of my presentation): Are we willing to integrate our passion for prevention when so many questions remain unanswered, especially ethical issues and professional concerns that result from encouraging the use of performance-enhancing substances?
Ethical Issues and Professional Concerns
There are numerous valid reasons for believing that sports nutrition and the sports supplement industry are shaping sports and athletics (and, I might add — exercise physiology and, very possibly, dietetics). Until recently, there have been no guidelines as to how sports nutrition should be taught. The instructor can teach anything to unsuspecting students. Theoretically, the teacher is in charge and teacher is the expert. No teacher would knowingly use the classroom to promote his personal agenda — Right? Wrong. It is being done all the time right before our eyes. The importance of impartial judgment in regards sports supplements and athletics is often dismissed, thus allowing instructors to promote their particular products. The signs of this are everywhere! Some are the authors of research papers, and some of these experts are under instruction from the supplement industry to use research to promote the industry’s bottom line, while others represent private interest groups of varying size and financial incentives. The belief is that “athletes” make their own decisions after they are supplied with “objective” information by their professors, but actually the information which reaches the athletes is filtered in countless ways. The crisis of this age is multiple.
From war there is death, disability, and depression. From the inability to pay for healthcare costs, there is the fear of loneliness, despair, and death; and from greed there is quackery, deception, and mistrust. The latter is one of several ethical problems before all healthcare professionals. Indeed, the idea that the use of performance enhancing substances is not unethical is largely an uncontested matter of interest on behalf of exercise physiologists who adopt the sports nutritionist title. In short, an honest professor with a transparently genuine concern for students and the public good cannot be questioned and is what every student has a right to as well as society’s interest in credible professionals.
As we all know, quackery in healthcare is especially dangerous. It can harm and kill people. And, in light of the “win at all cost/winner take all” way of thinking, the emphasis on sports supplements (however unrecognized by those involved) is having a profoundly unsettling effect on athletics. To forestall the irretrievable disaster that the use of sports supplements foreshadow in an uncontrolled athletic world, driven by the idea that winning at all cost is the only reason for participation, our first responsibility as educators is to strengthen our sense of connectedness with ethical thinking, including the professionalism of teaching and research.
In fact, until a few years ago, the language of sport nutrition was written like any other scientific paper. Then, with important implications in education, nutrition, and athletics, sports nutritionists/exercise physiologists (and others) started publishing papers with an awesome and agonizing obvious intent. Consider the following phrases taken from a review article written by a sports nutritionist: (1) “may explain” (2) “may help” (3) “may affect” (4) “may lead to” (5) “may hasten recovery” (6) “may contribute to”. Altogether, the author used such phrases nearly 50 times in the article.
This kind of writing constitutes a declared science, not an actual science, and the tragic downside is the teaching of misinformation for profit as well as the fragmentation of a profession and its loss of a moral perspective. It seems fair to say that the article (and many like it) is not a scientific publication. After all, isn’t scientific writing and knowledge driven by objective thinking, meaning that it is free of bias or, if you will, a personal agenda? And, if so, where have educators failed when the thinking of their students, now as authors of papers and books, is no longer sound? While one way of dealing with unpleasantness of this kind is not to notice it, we cannot as educators ignore our obligation to stand for integrity. We must be fully aware of the threat of influence of business on academics. So much is at stake, yet so little is presently being done. Indeed, we have the freedom we need to create change and yet, in some sense, we are watching it slip away behind the constraints of an exhaustive effort.
There is of course the need to work together, however long and hard to make the effects of ethical thinking manifestly evident in athletics and our professions. Or otherwise, it is just a matter of time that full disclosure of the texture of the athlete’s moral education will be inevitable. To educators who care about students and athletes, no wonder time seems so short when circumstances are so evident. This, it seems to me is our most dishonorable moment, when we either condone by our silence or promote because of our choices, coaches, colleagues, and educators who speak of the “necessity” of using performance enhancing substances to win.
Perhaps, it is little understood that engaging in any kind of behavior that alters fair play in sports or in one’s profession is cheating. The fact that some sports nutritionists, dietitians, and EPs promote sports supplements argues against the understanding of sportsmanship. In my opinion, this type of behavior is inappropriate because it violates the nature of what sport is about. Coaches, trainers, college professors, exercise physiologists, and dietitians should consider the following statement: “Does the supplement work? If it is a fake, it cannot work. If it does work, is it ethical to use it? Is it deception and/or cheating if is used and works?” Also, if it works, does this fact alone argue against the moral implication?
Make no mistake that building character is more important than running faster and getting bigger. Exercise physiology is not about spot reduction, pills that are said to increase lean muscle issue or gimmicks said to strengthen the low back or increase flexibility of the shoulders, or any other impoverished views of athletics that set the stage for unsportsmanlike behavior. The pressure to publish, to access grants, and to be recognized has led to the belief that it is appropriate to research supplements to enhance athletic performance as long as the supplements are not illegal or banned. The upshot is the unethical thinking that snuffs out the spirit of play in athletics.
Naturally, there is a sense in which we always need help. This is nowhere more evident than in athletics or, more precisely, the quest to win. And, perhaps, a clear distinction should be made the desire to win and to “win at all costs.” The trouble lies not with desire to win but the latter, which is irresponsible behavior easily warped in predictable, temporary truths. Cheating in sports is simply unacceptable as it is in academics and business. Although it may be a question of whether it is legal or not, it is a matter of deception and integrity. And, just as there exists the notion of “respect for the game,” or respect for the stockholders of a business, like Eron, isn’t there the “respect for the profession” too?
When taken literally, if a colleague is only interested in winning his or her share of supplement consulting fees, it is a victory without honor. In this case, the person reduces the profession to an instrument for achieving external goods. He is, in essence, thumbing his nose at the ethical thinking that underpins professionalism. The cheater should be shunned and judged accordingly by the profession. In fact, it is a conflict of interest when corporations fund the scientific research of sports nutritionists and exercise physiologists. Whether it is a medical doctor or a sport nutritionist, controversy exists when either has regular contact with the respective industry, pharmaceutical or sports supplements and the representatives thereof. This means that grants to purchase laboratory equipment, free meals, travel subsidies, sponsored teachings, and symposia are real dilemmas for the professional exercise physiologist. The conflict of interest creates a way of thinking that threatens the integrity of exercise physiology, medicine, dietetics, and so on.
Professionalism is critical to the success of all healthcare professionals. Integrity is everything. It is critical to credibility. Without professional integrity, society will not grant credibility to its services. University teachers, in particular, should share this truth not their deception. They should share insight into ethical thinking not their research agenda for fame and recognition. It is time to draw a line in the sand. Everybody loses when coaches, teachers, and others encourage the use of performance enhancing substances. Parents and professionals should be concerned about the unethical coaches who are willing to do “anything” to win. They should argue for their children’s right to be exposed to fairness, decency, and sportsmanship rather than professors who pay more attention to their publications than their students. And, frankly, no one should be surprised that cheating destroys sports and those who participate.
Obviously, there is competition in athletics but, as Randolph Feezell wrote in his book, Sport, Play, and Ethical Reflection, “…sport isn’t war…opponents aren’t enemies…winning isn’t all that matters, that external goods aren’t the only justification for playing a sport, and that the product shouldn’t overshadow the process.” Hence, it follows that the indiscriminate extrapolation of the conclusions from sports nutrition studies beyond the scope of the research data and the ethical implications is a moral problem. Of course professionalism takes time along a specific course that ultimately drives the commitment and accountability of its members. However, when members alter the content of an article to read more favorably for the supplement industry (as I am thoroughly aware of having been done on more than one occasion), the dark side of the research process shows its ugly face.
Professors cannot ignore unprofessional or misguided behavior. Surely that’s not what professionalism is about. And, every professor must live a shared responsibility and passion for growing the profession as well as the collaborative effort and work between professions. Respect for “what we do” requires accepting responsibility for our shared failure to think ethically and graciously acknowledge that credible healthcare professions are historically larger than the misplaced thinking of a few. Healthcare professionals, like dietitians and exercise physiologists, aren’t doing what they do for the money (although important). They are doing it for their students, clients, and patients to help them with the game of life. Also, what they do and how they do it is for each other and their passion for dietetics, exercise physiology and others like us in nursing, physical therapy, and so forth.
In summary, I would like to read a small paragraph from my book, Is Sports Nutrition for Sale? – “Exercise physiology is a healthcare profession. It is responsible to the public, not to just athletes. At one end of the spectrum is health and at the other end is a huge role in rehabilitation. It is the exercise physiologist’s responsibility to know both ends of the spectrum and to know everything in between. This thinking is at the heart of the exercise physiology Standards of Professional Practice. The American Society of Exercise Physiologists exists, in part, to proclaim this truth. Also, it exists to protect and refine the standards on behalf of its members and the public. By working together, professionals define their professionalism and situational ethics. After all, what matters is the character and integrity of the members.”