The American College of Sports Medicine is one of the leading organizations in the United States that champions measures that will improve public health. The efforts by ACSM to increase physical activity in all segments of the population and to transfer information to members of both the scientific community and the general public are well known. In this context, previous News Briefs have focused on a variety of public health issues, including how much exercise will make a difference, what to do about the epidemic of obesity and lifestyle-related diseases in the “developed” world, and how exercise might be an especially important intervention to limit the impact of aging and lifestyle-related diseases in our society.
In this general context, a recent supplement to The Lancet (vol. 356, December 2000) highlights and contrasts the major challenges to public health in the developed world and those in the less-developed countries. In general, there are strikingly different challenges to public health that depend in large part on the level of economic development in a given country. In the developed countries, the major threats to public health are those associated with smoking, a fat-laden diet, obesity, and inadequate physical activity. Another major challenge to public health in developed countries is an aging population. By contrast, in countries with “economies in transition” or those that are still “developing,” the major threats to public health are generally thought to be poverty, illiteracy, malnourishment, and inadequate “public health” measures such as clean water, basic nutrition, inadequate vaccination, and limited access to primary medical care. However, many of these countries are beginning to see a rapid increase in cardiovascular and other diseases of developed countries. With this general information as a background, the supplement to The Lancet highlights several issues of interest to members of ACSM.
In a commentary entitled “Let’s not make the same mistakes,” Arun Chockalingam, from Health Canada, discusses some alarming trends in cardiovascular disease mortality that are occurring in countries with economies in transition and developing countries in comparison with those with “established market economies.” The author points to increases in the rates of cardiovascular disease in the less-developed countries and those that have economies in transition. In addition, the public health authorities and government structures in many of these countries have not come to terms with the burden that cardiovascular disease as a public health challenge is likely to be. The key observation is that as countries gain economic strength, many will achieve success in controlling and preventing the typical infectious and communicable diseases that can devastate the lives of those who live in poverty. However, these countries will then be subject to many of the “noncommunicable diseases,” such as atherosclerosis, cancer, and diabetes, that are the hallmarks of the developed countries. Although globalization and economic growth can increase the prosperity of these countries, these factors have also made them targets of the multinational tobacco companies. This has led to an increase in the number of cigarette smokers. Also, as populations in these countries urbanize, they can quickly adopt a “fast food diet,” which is rich in fat and high in salt, and their lifestyles can become more sedentary.
Dr. Chockalingam points out that all of these factors can contribute directly to an increased prevalence of noncommunicable diseases and of cardiovascular disease in particular. In addition to the shifting types of diseases that afflict these countries, the countries have very limited public health spending. Many seem to be adopting a disease treatment strategy rather than a disease prevention strategy. Because the most developed countries, such as the United States, fail in their efforts to use technology-based treatment for cardiovascular disease, it is imperative that the countries with economies in transition and the developing countries adopt an aggressive public health approach to the prevention of cardiovascular disease before it becomes epidemic in their countries. Dr. Chockalingam’s comments conclude by pointing out that we have the information necessary to prevent this epidemic, but do we have the organizational ability and political will to make it happen?
ACSM has been active in promoting physical activity and recreational opportunities for the physically challenged. Opportunities for health-based participation, recreational athletic activities, and full-blown elite competition are now widely available for the “disabled” in developed countries. Indeed, many individuals with a variety of physical challenges now gain the benefits of regular physical activity as a result of efforts by members of ACSM. The achievements of these courageous participants is especially laudable. However, the situation is much different in developing countries.
In a commentary entitled “Being disabled in Cambodia,” Tun Channareth, a leader in the international campaign to ban landmines, and Denise Coghlan, an Australian Sister of Mercy, point out how difficult it is to be disabled in the developing world. In this commentary, they point out that more than 1000 people per year continue to be injured by landmines.
This moving essay highlights the social and psychological isolation felt by many whom become disabled as a result of dramatic injuries. More specifically, it highlights the lack of simple rehabilitative services (much less any opportunities for recreation and sport) that plague disabled individuals in developing countries. This lack of services includes inadequate resources for simple mobility devices such as wheelchairs, inadequate access to high-tech prosthetic devices that can restore a high level of functionality in many conditions, and the lack of access that many individuals in these countries have to advanced reconstructive surgery techniques. So, although in the developed countries we endeavor to maximize the ability of individuals with disabilities to participate fully in all aspects of life, many barriers remain in the developing countries. Public health in wealthy countries means we need to encourage physical activity for all. Public health in the developing countries means that many disabled citizens need the basic tools to improve their mobility and autonomy.
Obesity is a major public health problem in developed countries and is emerging as a problem in less-developed countries. In a commentary entitled “Treatment of obesity: mission possible,” Alain Golay, in the Division of Therapeutic Education for Chronic Diseases in Switzerland, points out that there are three basic conditions for the successful management of weight in obese patients: (1) obesity must be seen as a disease; (2) there must be widespread knowledge of the risks associated with obesity, including the increased risk of cardiovascular, metabolic, bone and joint disease, and cancer (in general, these risks are elevated 2 to 10 times above those for the nonobese); and (3) a management strategy that stresses long-term modest and sustainable changes in combination with behavior modification must be emphasized over “miracle diets.” The role of these key elements is discussed in the context of how in general to structure a weight loss program and how to deal with the inevitable setbacks the obese patient is likely to encounter. The importance of cognitive “restructuring” is emphasized. The keys are to maintain motivation, to reinforce modest improvements, and to emphasize progress to date. Dr. Golay concludes on an optimistic note. However, the prevention and treatment of obesity remain daunting problems.
Cultural Issues and Public Health
In a review entitled “Public-health priorities in the industrialised world,” Barry R. Bloom, from the Harvard School of Public Health in Boston, reviews the striking improvements in public health in the developed countries during the past 100 to 200 years. However, the author points out that the “prevention of major public health achievements in the new century is difficult, but some priorities are clear.” He goes on to state,
“A major priority will be to make inroads into preventable disease burdens, which account for as many as 50% of all deaths in the U.S. One of the myths of the modern world is that health is largely determined by individual choice. In reality, most behaviors are ‘socially patterned’ and reinforced in groups. Health information alone is seldom useful for motivating behavioral change. For making a difference to the major preventable disease problems such as smoking, alcohol and drug misuse, obesity, hypertension, and sexually transmitted diseases, a public-health approach to prevention strategies for groups, not just individuals, will be essential.”
These comments clearly apply as much or more to the current crisis in physical inactivity in the developed countries as they do to any of the other issues raised above. In addition, this means that the fundamental issue is one of how we build societies and cultures that work to reinforce positive lifestyle choices. Dr. Bloom comments on the potential role of the genome to create a kind of “boutique medicine” that is tailored to the needs of individuals but is available only to the wealthier members of society. He states that unless “population-based preventions or therapies result, this new and expensive technology will only increase the disparities in access to health between rich and poor.”
In the commentaries discussed, and indeed in the entire issue related to public health, the role of society and culture at multiple levels in promoting or limiting public health measures is emphasized. Although the challenges that each country faces are a unique combination of biological, economic, cultural, and other factors, we have a great deal of information that can aid in the development of strategies to address a variety of problems. Everyone is interested in using physical activity to prevent many of the problems associated with the “Western” lifestyle, and it is also useful for us to see that these strategies may be applicable in the developing countries and to learn more in general about the problems faced by such societies. As globalization increases, the need for access to physical activity, recreation, and sport will accelerate in the developing world and the need for individuals and cultures to address issues related to preventable lifestyle-associated diseases is likely to increase. As Dr. Chockalingam reminds us, “Let’s not make the same mistakes” over and over again!