A recent issue of the Annals of Internal Medicine tried to put a nail in the coffin of nutritional supplements. “Unregulated, not safe, harmful, and no benefits” shouted the authors of the Letter to the Editor of the journal. Yet another attempt by physicians and the pharmaceutical industry to put a damper on the use and sale of vitamins and minerals.
For many exercise professionals, the goal of training and educating clients is to improve health, increase strength and performance, and improve fitness parameters. The concept of reducing injuries may not be high on their radar screens.
Big data is here to stay within the healthcare profession. More and more engineers and data programmers are being hired to sift through the myriad of data that consumes the field. Of concern to executives at the top are certain attributes of healthcare that may need “fixing”. The aspects of this report are to highlight what are perceived as the biggest concerns in healthcare, and how the wellness industry – if they can stay on track – can supersede all of these types of issues as they transition to the data analytics side of their health offerings.
This is a very big concern for hospital systems and physician network groups, as patients have a tendency to switch providers if they think they will get better service, better medicine, or better prices. One of the reasons is that most patient contracts don’t require patients to stay in a network – which puts the responsibility of good care, competitive prices, and follow ups squarely on the doctors. If patients are unhappy with their doctor or practice for any reason, they can leave. Now that these organizations are getting bigger and more complex – it’s easier to see why patients may become disgruntled, and try to find a better solution in a private practice, or smaller group or hospital practice.
From the wellness side – it’s not uncommon for health club members to stay at their club or studio for years. Prices don’t change that much, and most members have a very personal relationship with their instructors and club owners. They have group classes, personal exercise programs, child care, plenty of free parking, and clean facilities that provide some of the latest in technology every few years. So – should healthcare systems look to health clubs to see why people stay in clubs longer? Perhaps they should be partnering with these health clubs for specific programs for their patients.
This is a priority in most businesses. Hospitals and physician practices are no exception. However, most people still associate going to the doctors with being sick. So there is already an inherent negative connotation to the doctor’s office. Therefore physicians need more than a lab coat and a prescription to make sure patients are getting what they need. They need a team-orientated approach that can help with the issue NOW, and use the team to follow up with the patient to make sure the situation and health concerns are taken care of over time.
Again – the health and fitness industry is concerned about customer satisfaction. With cut-rate gym memberships, and a new club coming into communities almost every month, clubs and owners need to offer clean facilities, professional trainers and instructors, and technologically advanced equipment that doesn’t break down and that is easy for members to take advantage of. The issue between the two programs – is that although some exercise programs push the body and may be painful – it’s a good pain and the rewards of long term participation should be better health and less risk of using the healthcare system over time. It’s the old adage of “pay me now, or pay me later” axiom, and more people are willing to put their trust in health clubs – and the risk of injury or illness or death is extremely low compared to even trips to the doctor’s office.
Again – this is a huge concern in healthcare – that doctors can’t read the thousands of new studies that come out in their field each month, so they rely more and more on their clinical experience (which may be a good thing), but they will stick to the tried and true methods they have always been using, and may not prescribe the most effective type of treatment for their patients. Big data in many instances can do two things – one is look over millions of studies in a particular field, and two – through machine learning, hone in on what may be the best type of treatment plan for a particular patient, based on their age, severity of disease, family history, weight, and other factors. This is a powerful tool to help doctors prescribe and treat better.
However, it’s still the same paradigm. They are looking over medical studies, many of which may not be in the best interest of the patient. One of the most cited studies in medicine came in 2005 when Stanford epidemiologist John Ionnidis reported that the majority of medical research finding are false, because they have inherent bias from their authors, their findings are not statistically significant, they were published by industry officials, and are not relevant, and conclusions may not match the actual results of these very papers. Ionnidis opened the floodgates for many professionals who have gone after medical research and institutions for publishing false studies. It is estimated that almost 40% of medical research studies are false, in that their findings do not hold relevance regarding the enhancement of patient care.
In contrast, sports medicine has been methodological in its research for a century – from the basis of treadmill cardiac and performance testing in the 1930s, to the onset of physical activity studies in the 1950s and 60s, to cardiac rehab and exercise safety studies in the 1980s, to the onset of exercise for special population groups in the 1990s. There are very few reports on sports medicine research fraud, and the foundation of this research usually shows some level of benefit to those who participate. In almost all cases, no harm is done to subjects while performing these studies. This has now transitioned into many successful clinical health club programs for persons with cancer (Sunflower Wellness, Cancer Well-fit, Fast Trac Cancer Program), spinal cord injury (Claremont Club), multiple sclerosis, diabetes, hypertension, weight management, bariatric recovery, and medical fitness in general.
One of the biggest attributes of big data and population health is to drive policymakers and physicians to deliver the highest quality care at the most competitive prices. In many opinions, this is a misnomer of sorts, and medicine is continually advancing technology, which is very expensive, and works through a third party reimbursement system — which is many times more expensive than if they offered the service or procedure or product at market value. Many hospitals are undergoing facelifts (no pun intended) and look more like five-star hotels than medical centers. All of these amenities cost the patient and insurance pool more money. This is why healthcare costs usually rise at more than twice the rate of inflation, and have some of the highest costs of any industrialized business model.
As far as health and fitness, the rate of price changes for the average health club has held steady at just below inflation for years. The prices for café food, personal training, specialty exercise, or apparel has also held steady. Even with the rush of new technologies for equipment and personal monitoring devices (such as FitBit), prices have remained constant.
Big data in the health and fitness setting should be concentrated on health outcomes. There are many software programs in the industry now that look at finances, front desk management, club administration, and human resources. They do their functions well.
If big data is going to continue to look at all aspects of healthcare, and continue to miss the boat regarding improved patient health and well-being, then no amount of data can help repair the continual dysfunction that exists between an over-burdened and (in many opinions) under caring system, and the continued increase in poor health in the US. Prescribing more pain meds, vaccines, or antibiotics will not help improve health – and in many cases is making health worse.
The health and fitness profession is on the mark moving into the realm of special populations at every level. As the amount of population health and data analytics becomes a more ingrained part of wellness, we will see at many levels how these types of interventions improve health, reduce costs, and vastly improve patient satisfaction and retention to their favorite health club, exercise program, or personal trainer.
Eric Durak is President of MedHealthFit – a health care education and consulting company in Santa Barbara, CA. A 25 year veteran of the health and fitness industry, he has worked in health clubs, medical research, continuing education, and business development. Among his programs include The Cancer Fit-CARE Program, Exercise Medicine, The Insurance Reimbursement Guide, and Wellness @ Home Series for home care wellness.
References
https://www.optum.com/content/dam/optum3/optum/en/resources/gated/Optum_NYUPN_Topic_Spotlight.pdf
Ionnidis, JPA. Why most published research findings are false. 2005. PLoS Medicine. Aug. 30. Doi: 10.1371/journal.pmed.0020124
The incidence rate of type 2 diabetes has been increasing in the United States for the past 40 years. In fact, the American Diabetes Association estimates that at least half of all US adults (over 65 million people) have pre-diabetes or full-blown diabetes. It is often underreported on death certificates, and is probably the third leading cause of premature death in the US.
So why is there such an increase in diabetes in this country? The biggest reason is diet.
From a young age, children are eating processed food. When they enter school – lunchrooms in many school districts are sponsored with food from McDonald’s, Pizza Hut, and Coca Cola. In college – most dorm food is also like fast food, and they can eat as much as they want. That and their foray into alcohol, and we have the beginnings of obesity, insulin resistance, and pancreatic damage. The very concept of type 2 diabetes used to be called “adult diabetes”. Since many teenagers are now diagnosed, it’s now time to change the name.
One would say that if diabetes is a disease of the foods that you eat, then simply change the foods you eat. Not that simple. Once you’re diagnosed with diabetes, you become a ward of the medical system. Doctors will perform a lot of tests, take blood, and prescribe both insulin and drugs to mimic the glucose-lowering effects of the body, and many spend a minimal amount of time counseling on the right type of diet for your needs.
There are, in fact, many good diets to lower blood sugar, like the well-known Keto diet, which emphasizes higher fats and low carbohydrates. This is something that doctors have been prescribing in one form or another since the Atkins diet in the 1960s. What about vegetarian and vegan diets? If you ask Dr. John McDougall, one of the nation’s leading plant-based doctors, he would advocate that a diet higher in plant-based carbohydrates is better for the body than high amounts of meat and cooking oils.
Both may have a point, but if you look at the food choices that most Americans have, they walk into a grocery store, and if they’re not savvy enough to shop on the outside isles (fruits, vegetables, meats, cheeses), they are trapped in an endless cycle of boxed cereals, candy bars, frozen foods, soft drinks and alcohol. It is almost impossible to go to a store and not pick up about 50-75% of food from a box, bucket or bottle. Many still haven’t put two and two together — that the foods they eat now will have an effect on their physiology and medical status in 5-20 years.
So what’s missing? I have been in an interesting position of working in diabetes research in the 1980s, and watching from the sidelines the work, research, and policy in this area of medical care for the past 30 years. Here are my thoughts.
First, although exercise is touted as part of the trilogy of treatment for diabetes (along with diet and insulin), it is the first to be discarded for another type of treatment that is expedient and profitable.
Second, there are little, if any, referrals to the health club sector in order to work on basic exercise programs for persons with diabetes. Even moderate types of programming will results in dramatic drops in body weight (and fat), daily blood sugars, and A1c levels. It simply is not being done. Many in allied health scream that personal trainers and fitness instructors are not qualified to teach exercise programs for diabetes. With the advent of medical fitness over the past 20 years, this simply isn’t the case today. I would think that having a mechanism to get patients into health clubs through their health plan, or Medicare, or a revolving door policy with their physician group, would be an outstanding way to get more patients into the exercise routine.
Third, people who work in the fitness industry should be looking very carefully in getting diabetic persons into their facilities in their communities. This takes an effort with health club trainers, club managers and company owners to reach out to the medical community through health programs, lectures, fairs and membership discounts in order to get patients in the door. It may even entail home exercise visits, or online coaching where patients are taught programs, and keep their exercise routines times and exercise notes.
Lastly, the fitness industry needs to move into the technology realm and look at the effects of exercise on patients both over 3-4 weeks, but also 3-4 years. This will be done through outcomes-based software programs that can be detailed to physicians, health plans, and sports medicine journals. Once the majority of medical fitness centers and health clubs are on board, we will see a changing of the guard in terms of what Americans think is the best type of treatment program to reduce diabetes symptoms, and look at the data of how people exercise, and how many of their health risks are being reduced by a challenging and consistent exercise program. This can be done at any age, and at almost every state of diabetes — whether they are newly diagnosed, or have basic complications that they are dealing with regarding long-standing diabetes.
It is time to embrace exercise as part of a diabetes prevention and reduction strategy. If not, in 20 years we will probably see the epidemic at such a high level, that a good portion of Americans will not be able to work due to their complications. The costs to society will be even higher than they are now. It’s a risk we don’t need to take, because of the untapped market of over 31,000 health clubs in the US, there is virtually no reason not to engage in exercise. It would seem that our nation’s health depends on our next steps – literally.
Eric Durak is President of MedHealthFit – a health care education and consulting company in Santa Barbara, CA. A 25 year veteran of the health and fitness industry, he has worked in health clubs, medical research, continuing education, and business development. Among his programs include The Cancer Fit-CARE Program, Exercise Medicine, The Insurance Reimbursement Guide, and Wellness @ Home Series for home care wellness.
When I was in graduate school, cardiac rehab was THE big issue in exercise science. Most graduates who wanted to work in clinical chose cardiac rehab as their mainstay. However, much of the discussion about the medical benefits of exercise changed in the late 1980s when Dr. David Nieman from Appalachian State University published the first in a series of reports on exercise and the immune system. In my opinion, Dr. Nieman changed the conversation on exercise as his research looked at one of the first biological mechanisms for change in the body due to acute and chronic exercise.
Why are we discussing exercise and the immune system? Because thirty years and hundreds of papers on the effects of exercise on immune enhancement, we are still as a nation not educated (let alone convinced) that exercise should be a mainstay of maintaining and improving overall health – especially in persons with infectious disease.
Let’s look at some of Nieman’s work. First, Dave was a marathon runner, who noticed that after long races he and his friends felt “drained” and some came down with colds. He took blood samples pre- and post-marathon race and found on numerous occasions that specific immune cells such as lymphocytes dropped dramatically after races – leaving persons (himself as well) more likely to come down with colds. So, his response was to train accordingly and get plenty of rest in days after races.
His second area of research looked at the chronic effects of exercise on the immune system, such as white cells, natural killer cells, and other specific immune groups. His conclusion after his research is that exercise does stimulate immune cell function, and this may help in persons with cancer (immune damage due to chemotherapy), and other metabolic diseases.
Over this same 30 years the nation has gotten fatter, lazier and sicker. To the point where many people have no idea that their diet and exercise regimens can actually improve their immune function – so they resort to medications.
Today we are faced with a COVID infectious disease, where many people literally fear for their lives. The crux of this report isn’t to cherry-pick statistics, or to point fingers, but the bottom line is that persons who are physically fit suffer much less severe symptoms of COVID, the flu or other infectious diseases than sedentary counterparts.
The immune system is one of the strongest areas of biology that cement the strength of regular exercise. Along with changes in blood chemistry and telomere length, immune changes represent one of the foundations of clinical exercise benefits for young and old. Especially old.
Physical fitness has been left out of the discussion relating to COVID. This, along with proper nutrition and supplementation are not only NOT mentioned in the media, but many are disregarding the basics in favor of specific medical therapies.
Exercise should be touted if not for just ONE area of concern – and that is obesity. As one of the main comorbidities for severe COVID, losing weight would reduce severity in many people. This alone would reduce the burden of the disease from a death, healthcare expense and severity aspect. Of course, there are other complications relating to COVID, but in general, exercise has many positive effects, with few side effects. Its contribution to enhancing immunity is one of the biggest attributes.
Using proper assessment and outcome metrics, trainers and coaches can correlate the effects of their programs with other health and medical scores (such as a change in blood sugar or blood pressure each session, or loss of body fat over a one-month period). These are important because they will correlate to changes in overall blood labs, which will have both an acute effect (reduction in the risk of heart attack, stroke, or asthma attack), or long-term effects, such as reduction in diabetic complications, risks of falls, and peripheral vascular disease. Trainers may not understand just how powerful regular exercise can be for specific medical populations, but since the 1970s, the data is clear that exercise has an effect on almost every type of medical condition – even relatively new conditions to exercise training such as autism and Ehlers-Danlos Syndrome.
If we understand that just a moderate amount of exercise will improve circulation enough to enhance the immune system, then we should be detailing it to new members as they come into the health club setting.
Even mom and pop clubs can play a role in improving health. The first is to have a member tracking system that can keep people coming to the club, at least twice a week. For health’s sake, perhaps 3-4 days per week would be preferable. The “essential” label is a bit misleading because there are no true metrics for what an “essential” business may be (outside of trash collection, medical triage, and grocery stores). Clubs can position themselves through medical fitness and in the near future, have the technology and assessments necessary to look at health outcomes as persons who normally would not be in a health club see the benefits of a medically based program that will cater to their needs while improving their health along the way.
Eric Durak is the President of MedHealthFit, and founding partner in the Fitness Is Medicine Initiative. He is a 35- year veteran of the health industry. He has worked for health clubs, medical research centers, and continuing education. He has been at the forefront of the medical fitness movement and appreciates the opportunity to work with MedFit Network to move medical fitness to the forefront of health care. Email him at edurak@medhealthfit.com
References
Everyone in the industry knows how tough 2020 was regarding work, planning, staffing, and getting by. While many in the industry look to digital and video health programs, the integrity and growth of the fitness industry by no means will mean that health clubs will be a thing of the past (Segran – 2021). On the contrary – clubs will play a critical role in changing the face of healthcare in the United States – which is also on life support. The recent article by Elizabeth Segran in Fast Company states that many Americans will forego health clubs in favor of other types of exercise. She states that 59% of Americans won’t return to health clubs. This may be 59% of current health club members, and not the 65% of Americans who don’t belong to health clubs.
Here are some things to look for when working with a client with Atrial Fibrillation (A-fib).
What types of medications are they on? Calcium Channel Blockers, blood thinners (Coumadin)? These may have an effect on the intensity and type of exercise performed. You know that people who have A-fib are at increased risk for strokes, and may have hypertension and get dizzy more often. The medications – while they may help with some factors – may preclude a well-designed exercise program just because they may not tolerate some types of exercise.
What are the exercise goals? Are they wanting to tone up? Lose some weight? Get stronger? Train for a tennis match or 5K? This would help in structuring the program. The type / intensity / duration are all dependent on what the client wants. If they are just coming off surgery or a new prescription – this is important to build the foundation (which you know).
Does the doctor have any contraindications for exercise? Usually, it’s not to “overdo”, which means building up a program. I read a good article by Dr. Bill Sekula on a program for A-fib. It’s essentially a “step down, time up” program, where patients go from a few minutes of exercise a few times per day – to building up to an hour of exercise one time per day. However, I am going to recommend more of an ITP (interval training program) that concentrates on moderate strength programs (using the 40-50% rule similar to cancer patients), so they don’t use the Valsalva maneuver while lifting, but still use a progressive resistance approach.
Monitoring with a HR monitor, and having good hydration status are both important. Of course, you probably have them using the smart water bottle. Because of the heart dynamics and possible Coumadin Rx, the hydration is important. I assume you do a HR variability test with your client. This may be a very important test to do, as over time it may be instrumental in reducing A-fib occurrences.
I like the article by Dr. John Mandrola on the amount of exercise. He states that A-fib is completely controllable through specific lifestyle changes. He states that low inflammation exercise (high intensity endurance / triathlon, etc.) training needs to be modified, as do other lifestyle issues. I really like the discussion on inflammation, which may be one of the biggest issues in cardiac care of late. He talks about the “J curve” of exercise and that the more intense actually increases the odds ratio (OR) for sudden cardiac events and other abnormalities related to A-fib.
I think he is on to something, and you should look into some other lifestyle aspects such as meditation and heartbeat regulation through mindful breathing and relaxation. I know that excess stress, lack of sleep and poor diet have effects on the electrical system, including SA node and conductivity. Regular relaxation may do a LOT to improve the normal sinus rhythm and reduce resting HR to a more manageable level.
Dr. Mandrola also recommends regular monitoring of BP, keeping the use of warm exercise clothing due to peripheral circulation issues, and not overheating.
I like the issue of ITP and progression. I also am more of a fan of modified strength training for most clinical conditions. I think it would work for AF because if you think of the strength of contraction during exercise (even moderate) – it will have a strong steady beat during exercise (in most cases).
Eric Durak is President of MedHealthFit – a health care education and consulting company in Santa Barbara, CA. A 25 year veteran of the health and fitness industry, he has worked in health clubs, medical research, continuing education, and business development. Among his programs include The Cancer Fit-CARE Program, Exercise Medicine, The Insurance Reimbursement Guide, and Wellness @ Home Series for home care wellness.
References
I am reading a recent article by Jonathan Mike (in PFP Winter 2019 issue) regarding scope of practice for personal training. I feel that I should respond to this for a couple of reasons – first to add some clarity to his foundation of SOP in wellness, and second…
In July, I had the opportunity to deliver a webinar for MedFit Network on data analytics and population health for the medical fitness profession. I believe the MFN is spot on in their interest in data, and here’s why….