The Future of Chronic Disease Management and the Role of Sport and Exercise Medicine Physicians

This article examines the role of the emerging specialty of Sport and Exercise Medicine, both within medicine and more specifically in the management of chronic disease. Sport and Exercise Medicine was formally recognized as a discrete specialty of medicine in the United Kingdom in 2005. The British Association of Sport and Exercise Medicine has been in existence since 1953, but it is only in the last decade that particular attention has been paid to the potential of this specialty to provide a major input into the management of patients with chronic disease and musculoskeletal ailments. In the United States, through the American Medical Society for Sports Medicine, there has been the potential to be board eligible in the subspecialty of sports medicine since 1993. Similar developments have taken place across the world through Europe and into Australasia, with 2010 being the year that Australia received specialist status for Sports Medicine and the Canadian Academy of Sport Medicine became the Canadian Academy of Sport and Exercise Medicine.

HISTORY

Historically, the development of medical specialties initially revolved around the specific skill sets of physicians and surgeons and then expanded to doctors caring for specific populations: pediatrics, gynecology, and geriatrics. There then followed a series of system or technology-based specialties. There exists a further group of specialists based around occupation, such as doctors who specialize in occupational health or military medicine. Increasingly, and perhaps led by North America, we have seen a tendency for ever-increasing specialization in medicine. As a result, within secondary care, as opposed to family practice, we have lost “generalists.” Sport and Exercise Medicine may reverse this trend because its broad scope covers men and women, young to old, and fit and frail. Sport and Exercise Medicine by definition is a broad church concerned with the management of ailments from tip to toe, both musculoskeletal and medical. Importantly, the role and power of physical activity in the maintenance of health and the management of chronic disease have been appreciated and integrated within this newly emerging specialty.

SPORT AND EXERCISE MEDICINE

Much has been written about the role of sports medicine physicians in caring for the musculoskeletal and medical needs of those who exercise for health and perhaps more specifically those with an interest in performance optimization, such as elite athletes. Sport Medicine, in its most narrow form (the care and performance enhancement of the elite), risks marginalization by losing focus on the health issues facing modern society. This article examines how the same physicians can play a role at the other end of the human performance continuum, which is to provide advice and help for those who wish to become or remain physically active to promote better health.¹ Furthermore, their role covers those individuals in society who have become “suboptimal performers” through injury or, more particularly, illness. It is this focus on chronic disease management that has become so important in our world today because we face a global obesity epidemic. As the foresight report indicated, the etiology of this problem is extremely complex and multifactorial, but central to it is the recognition that physical inactivity is detrimental to health and wellness.² This is by no means a new concept; as Thomas A. Edison (1847-1931) noted, “The doctor of the future will give no medication, but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease”. This statement is consistent with one of the key philosophies of Sport and Exercise Medicine, which is that all our patients exercise to a greater or lesser extent. Thus, we have a particular interest and responsibility in maintaining health and managing chronic disease through physical activity and exercise.

The case for tackling the diseases of modern day living and our increasingly sedentary lifestyles has been ably made in 2 reports from Wanless and from a report from the Surgeon General of the United States.^3-5 We know that the incidence of obesity in developed countries is spiraling and that sadly, this trend is being followed in developing nations. Thus, the global burden of chronic disease is increasing, and as our population ages, the health care implications and costs are enormous. Hence, the prevention of obesity and related hypertension, type II diabetes, heart disease, stroke, and other diseases associated with our modern lifestyles is of paramount importance. Although this is a complex and broad societal issue, there are specific advocacy roles and responsibilities for the medical profession. It has been previously acknowledged that broadly public health physicians and government policymakers have not been particularly successful in this area, with an emphasis on short-term targets and a lack of much needed coordinated national action.⁶

Thus, the Sport and Exercise Medicine physicians should be at the vanguard of efforts to encourage all people to become more physically active as part of healthy living. Physical activity has long been regarded as the best buy in public health, and the evidence for this is extremely compelling. Nonetheless, there remain practical issues and obstacles for members of the public and thus our patients accessing appropriate information and care. National recommendations as to the amount of physical activity required to maintain or improve health have varied, with changes being made as new evidence comes to light. In the past year, we have seen the new guidance in both the United States and the United Kingdom.^7,8 What is now required in both countries and others are comprehensive national plans (for physical activity) to promulgate and deliver these messages while avoiding the perception of overbearing government. Although the evidence for physical activity improving health may be extremely strong, what is more challenging is to comprehend what methodologies are most efficacious in improving the uptake of physical activity within our populations. It is generally accepted that there is a paucity of information rather than poor information, but it is also increasingly appreciated that the evaluation of complex interventions, such as physical activity and wellness programs, may require mixed methods and analysis rather than randomized controlled trials.^9,10

The United Kingdom National Health Service (NHS) health checks will be introduced for people aged between 40 and 74 years, in whom it has been estimated that 48% of whom will require a physical activity intervention. This “short intervention” will be based on a behavioral change model and for the most part be delivered in primary care. The Sport and Exercise Medicine physicians working across primary and secondary care can have a role to play supporting and providing exercise advice, particularly in patients with comorbidities and for those with common musculoskeletal ailments, preventing uptake. It is accepted that a recreational runner will typically develop 1 injury per year, which will require specific and prompt treatment to avoid the development of chronic overuse problems that may discourage the individual from remaining physically active. Thus, the Sport and Exercise Medicine physician can help with the delivery of exercise and manage its side effects and in doing so help prevent and treat many chronic diseases.

Prevention aside, there is a further role of physical activity in the successful management of many of the lifestyle-associated chronic diseases. Evidence has been presented for the successful efficacious and cost-efficient use of physical activity programs in the management of specific elements of chronic diseases related to metabolic syndrome and the risk of a sedentary lifestyle. For example, some studies showed that elements of lifestyle modification may result in more cost-effective positive health outcomes than coronary artery stent procedures.¹¹ Others have shown the impact of a diet modification and walking program for the optimal control of high blood pressure.¹² Others showed the impact of regular physical activity for the reduction of diseases associated with obesity in at-risk youth.¹³ The challenge with these studies is that they are long-term (require time), are longitudinal (require an investment in a cohort of subjects), and require a complex analysis of interrelated variables. From an economic perspective, they have largely fallen short in convincing insurance companies that up front money invested in behavior change related to diet and exercise are worth the cost. Thus, while the Sport and Exercise physicians believe that these interventions work and thus have a role, health insurers and commissioners of health care remain to be convinced that these interventions are cost-effective.

ADVOCACY

How do the Sport and Exercise physicians become involved addressing this apparent disconnect? Most answers to this question force the physician out of our area of expertise, out of our “comfort zone,” and into areas beyond our typical training. The American College of Sports Medicine has taken the role of public health advocate in the “Exercise is Medicine” campaign, asking physicians to serve as health educators, and the patient advocates beyond our role in the office setting.¹⁴ For some, the answer is in the area of politics, in the role of moral lobbyists to key decision makers (politicians). All of these paths have a common element, and the Sport and Exercise physician should not shirk the role of public health advocate. We have a specific role to lead the medical profession in ensuring that physical activity becomes a “vital sign” that is integral to all medical consultations.

The First Lady in the United States, Michelle Obama, has targeted the critical problem of childhood and adolescent obesity as her 4-year strategic goal.¹⁵ The solution to this problem is not simple nor straightforward. Access to health care, let alone proper advice is denied to nearly 30% of at-risk youths in large inner-city populations.¹⁶ Underfunded school districts in America struggle with hiring and maintaining vibrant teachers and maintaining vigorous curricula, let alone focus on diet and exercise. Should Sport and Exercise physicians be involved in advising school systems about addressing the problem of obesity and exercise because they actively seek our advice?¹⁷

The cost to society and more importantly to the individual for managing the consequences of chronic diseases associated with obesity and physical inactivity continue to mount. Our countries recognize this problem and muster a call to action. We can, as Sport and Exercise physicians, choose to address the problem patient by patient in the setting of the clinic and in the role of advocates, such as the “Exercise is Medicine” campaign. We can become informed and motivated advisors to school systems, government, and wellness advocates in a broader and less medically defined role as part of a social movement to tackle a major and complex societal issue.

WORKPLACE WELLNESS

Finally, a further specific role for Sport and Exercise Medicine physicians is the development and encouragement of workplace wellness programs. Globally, the evidence is compelling that the workplace is a particularly appropriate and useful setting for wellness programs. We know that so many doctors fail to practice what they preach, and consequently, there is a requirement to educate doctors at all levels as to the importance of wellness in general and specifically when applied to the workplace. In the United Kingdom, the NHS employs between 1.1 and 1.3 million individuals, a number that is greatly expanded if one considers the close contacts. The recent Boorman report has indicated that there is a need within the NHS to develop wellness programs not only in large hospitals but also throughout the health care sectors.¹⁸ This provides an opportunity to think beyond absence of disease and instead concentrate on promoting worker health and well-being, which includes both physical and mental health. In doing so, we have the opportunity to engage in programs that prevent the development of chronic diseases and reduce the future-associated health and economic burden.

In both Canada and Great Britain, we have “metamorphosed” our specialty titles from Sport/Sports Medicine to Sport and Exercise Medicine. This change reflects the power of exercise as a lever for health optimization and a treatment option for many chronic conditions. Our present global challenge is for Sport and Exercise Medicine physicians to be advocates for physical activity and exercise for better health. Through example, we can lead the medical profession and, as a start, routinely assess physical activity levels in all our patients, a vital sign. In doing so, we can help spearhead this initiative across all health care for the better health of our patients and a reduced burden of chronic disease.