ASEP's Exercise Medicine Text for Exercise Physiologists

Physical inactivity is a major public health problem of the 21st century. The spiraling cost of a sedentary lifestyle on morbidity and mortality isn’t just dramatic, it is devastating, with an estimated 250,000 premature deaths annually in the U.S. These deaths are directly a function of physical inactivity, which constitutes the 4th leading cause of death globally (with about 3.3. million attributable deaths per year). Exercise medicine serves as a resource for physicians and other healthcare professionals, while providing the unique opportunity for Board Certified Exercise Physiologists to further establish themselves as advocates of the benefits of exercise medicine, physiological assessments, and the exercise prescription. This chapter makes the connection between the benefit of regular exercise on both the primary and secondary prevention of coronary heart disease, obesity, type 2 diabetes, low back pain, hypertension, breast and colon cancer, depression, dementia, and osteoporosis. Without a doubt, exercise is medicine that should be prescribed by Board Certified Exercise Physiologists.

Cardiopulmonary exercise testing (CPET) determines the client’s functional capacity by measuring pulmonary, cardiovascular, and muscular exercise responses. Generally, two modes of exercise are used in CPET: treadmill and cycle ergometer. The test protocols are either incremental or a constant work rate. There are accepted contraindications to CPET, indications for a CPET, and criteria for terminating the test that involves measuring oxygen consumption (VO2), carbon dioxide output (VCO2), and expired ventilation (VE), blood pressure (BP), and electrocardiography (ECG). These variables and others reflect the maximal ability of the client to take in, transport, and use oxygen. They also allow for the evaluation of client’s submaximal exercise responses as well as the client’s VO2 max response that represents the maximal level of the body’s oxidative metabolism.

Physical activity has a positive influence on mind and body health. ASEP Board Certified Exercise Physiologists are healthcare professionals responsible for developing individualized exercise prescriptions to help manage coronary risk factors (physical inactivity, hypertension, high serum cholesterol, cigarette smoking, obesity, family history, psychological stress, and diabetes mellitus) associated with the sedentary lifestyle and the pathophysiology of coronary artery disease. Regular exercise increases the delivery and utilization of oxygen that produces high-energy compounds, adenosine triphosphate, for efficient and sustainable muscle contraction and relaxation. Chronic adaptations to regular exercise consist of positive structural and functional changes to the lungs, heart, and skeletal muscles. The profession of exercise physiology is witnessing an unprecedented opportunity to prescribe exercise medicine to manage chronic diseases and disabilities. This is good because 45% of the U.S. population has a chronic medical condition.

Obese people in the United States will increase from 99 million in 2008 to 164 million by 2030, and the cost to treat obesity will increase to 66 billion per year by 2030. These figures and the knowledge of real life events with family and friends clearly indicate that the U.S. and its population are in the midst of an epidemic of health and economic consequences. It is pastime that the scope and ramifications of obesity and the effects of a sedentary lifestyle should be taken much more seriously by the American population. Board Certified Exercise Physiologists are prepared to educate, evaluate, and supervise exercise prescriptions that can be incorporated in the client or patient’s lifestyle to help prevent weight gain, premature death, and overall metabolic risk for diabetes, heart disease, hypertension, and stroke.

Type 2 diabetes mellitus (T2DM) is the most common form of diabetes in which the body does not use insulin properly (i.e., insulin resistance). At first, the pancreas makes extra insulin to make up for it. But, over time it does not keep up and cannot make enough insulin to keep blood glucose at normal levels. In adults, T2DM accounts for ~90% of all diagnosed cases of diabetes. Type 2 DM is a significant cause of premature mortality and morbidity related primarily to cardiovascular disease, kidney and nerve disease, blindness, and amputation that cost the U.S. ~$245 billion in 2012. Extra body fat is highly correlated with developing T2DM. Regular exercise helps to decrease body fat and improve insulin action. The ASEP Board Certified Exercise Physiologists can help T2DM clients become physically active.

Hypertension is a major risk factor and contributor to premature death and disability from stroke, acute myocardial infarction, cardiac insufficiency, and sudden death. A person with a systolic blood pressure of 140 mmHg has twice the risk of cardiovascular death as a person with a systolic blood pressure of 120 mmHg. Aside from drugs, regular exercise and lifestyle changes are significant treatments in correcting hypertension. It is important to help clients and patients achieving a certain minimum exercise level along with appropriate lifestyle behavioral changes. It is especially important to prescribe low to moderate 30 min of continuous exercise with a frequency of 3 to 5 d·wk-1 along with a certain amount of resistance training to maintain lean muscle mass.

An estimated 7 million Americans are living with a stroke, which is a leading cause of long-term disability. The major contributor to the anticipated increase of 4 million strokes by 2030 is hypertension, which is close to a ~25% increase in prevalence from 2010. Survivors are more sedentary than the average person, thus increasing the likelihood of falls and other chronic diseases. To increase their cardiovascular health, regular exercise is recommended. Also, regular exercise can help decrease the ~800,000 annual strokes in the United States. This is important in that strokes are the 3rd leading cause of death with huge medical cost. Fortunately, it is now medically recognized that exercise medicine improves aerobic capacity, physical functioning, and quality of life.

Peripheral artery disease (PAD) is a disease of the lower extremities that is a component of the chronic, progressive atherosclerotic process. In the United States, there are 8 million adults with PAD. Aside from the increased risk of cardiovascular morbidity and mortality, it leads to altered skeletal muscle energetics linked to mitochondrial dysfunction that hastens physical decline and disability. Fortunately, exercise medicine benefits clients with PAD by increasing walking time, walking distance, and functional capacity that reduces the risk of cardiovascular events while improving quality of life. The benefits of exercise medicine in PAD are linked to the enhanced distal blood flow and O2 supply due to vascular adaptations.

Approximately 17 million adults in the United States are diagnosed with chronic obstructive pulmonary disease (COPD), which is the third leading cause of death in America with more females dying from COPD than males. Yet, despite the death rate due to COPD and the awareness of smoking as the primary risk factor, 80 to 90% of the patients with COPD smoked cigarettes. Because the shortness of breath increases the likelihood of a sedentary lifestyle with decreases in functional capacity, skeletal muscle mass, and quality of life, COPD patients should be encouraged to participate in an exercise medicine program that is safe and effective.

Osteoporosis is increasingly a global disease in which the remodeling process (i.e., replacement of new bone for the old) results in an excessive loss in bone mass to the point that they fracture easily. Although weak bones are more common in older men and women, it can begin in childhood. The risk of developing osteoporosis and the risk of falling and susceptibility to fractures can be reduced by eating a healthy diet and engaging in regular exercise. In fact, regular exercise is believed to be the most important factor to increase or maintain bone mass density (BMD). The mechanical forces placed on the skeletal system during exercise stimulate bone size, shape, and strength by increasing BMD at weight bearing sites to promote bone mass.

Nearly 14.5 million children and adults with a history of cancer were alive in 2014 in the United States. A total of ~1.7 million new cancer cases and 589,430 cancer deaths are projected to occur in the United States in 2015. While it was common for physicians to advise cancer patients to avoid physical activity, the recommendation today is low- to moderate-intensity exercise of 150 min·wk-1 (i.e., 50 min·d-1, 3 times·wk-1). Board Certified Exercise Physiologists pay close attention to cancer survivors’ responses to exercise training to ensure their safety. Exercise medicine improves aerobic fitness and muscle strength, and increases the cancer survivor’s quality of life. Regular exercise is safe, and it does not interfere with the client’s medical condition. In fact, it helps to offset the increased risk for chronic diseases (such as T2DM and CHD).

The aging population is presently healthier and better educated about lifestyle risk factors than ever before. This fact as well as the improvements in healthcare represent why ~60% of the older adults are healthy at age 65 and expect to live another 15 to 20 yrs. But, this does not mean that everything is great. The high percent of heart disease, hypertension, stroke, respiratory disease, peripheral vascular disease, arthritis, and falls in adults 65 yrs of age and older requires specialized attention from Board Certified Exercise Physiologists to prescribe exercise medicine to lower the risks of living with or dying prematurely from chronic diseases.

Depression is a widespread mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor cognitive function. While the use of drugs is a common practice, exercise is an effective therapy in the treatment of mild to moderate depression. Exercise is also an excellent complementary therapy to the treatments of antidepressant medications and psychotherapy for severe depression. Also, there is strong evidence that regular exercise is effective in the treatment of depression related incidence of co-morbid somatic illnesses (e.g., coronary heart disease, type 2 diabetes, and osteoporosis). Board Certified Exercise Physiologists are in an excellent position to motivate physically inactive and depressed clients to become physically active and to optimize the mind-body effects of exercise medicine.

The epidemic of sedentary behavior is a serious public health issue that requires the attention of exercise physiologists. The American Society of Exercise Physiologists (ASEP) is playing a key role in providing a profession-specific infrastructure for exercise physiologists as healthcare professionals. After all, exercise medicine is a credible treatment and should be prescribed by Board Certified Exercise Physiologists. Exercise medicine is the new treatment for heart disease, hypertension, hyperlipidemia, osteoarthritis, stroke, type 2 diabetes, cancer, obesity, osteoporosis, sarcopenia, aging, sleep apnea, and depression. Aside from Board Certified Exercise Physiologists practicing exercise medicine guided by their own Code of Ethics and Standards of Practice in their own healthcare clinics, it is inevitable that they will become members of the medical team. Exercise physiologists should join the ASEP organization, support it, and speak up to help with the professionalization of exercise physiology.

Physicians need to prescribe exercise. Will they do so? Not likely in the foreseeable future. Yet, exercise can prevent chronic disease and premature death. Then, who will share the message that physical inactivity is the biggest health problem of the 21st century? Who is ready to do something about the ~50% of all adults in the U.S. will be obese by 2030? There will also be “7.8 million extra cases of diabetes, 6.8 million extra cases of coronary heart disease and stroke, and 539,000 extra cancer cases” (Wang et al. 2011). Board Certified Exercise Physiologists are scientifically educated to take on obesity, diabetes, and cardiovascular disease as well as depression and hypertension by prescribing exercise medicine. They understand the science of designing personalized exercise medicine programs to fight illness and poor health by promoting healthy lifestyle behaviors.

ASEP Board Certified Exercise Physiologists’ education and laboratory skills are decades ahead of fitness instructors or personal trainers. This is why they are recognized as a healthcare professional and entrepreneur. While the idea of starting a healthcare business driven by the scientific knowledge that is identified with exercise physiology is relatively new in academia, it is becoming increasingly popular. Given the health issues from chronic diseases, it is an opportune time to start a business that evaluates and prescribes individualized exercise medicine to patients and clients of all ages. This means that students should take several business courses while in college. Starting a healthcare business requires a lot of work, persistence, and passion along with consulting with an attorney as well as an accountant. But, like life itself, the declaration of intent and personal permission to “just do it” are a sufficient beginning to setting the course to be successful. It all begins in the mind of the believer. Belief is power!