Sport and exercise science and medicine: building on the Olympic legacy to improve the nation's health - Science and Technology Committee Contents


APPENDIX 5: SEMINAR HELD AT THE HOUSE OF LORDS


29 May 2012

Members of the Committee present were: Lord Dixon-Smith, Baroness Hilton of Eggardon, Lord Krebs (Chairman), Lord O'Neill of Clackmannan, Lord Rees of Ludlow, Earl of Selborne, Baroness Sharp of Guildford, Lord Wade of Chorlton and Lord Winston. In attendance were Chris Atkinson (Clerk), Professor Ian Macdonald (Specialist Adviser) and Rachel Newton (Policy Analyst).

Presentation heard from Professor Myra Nimmo, Dean of the School of Sport, Exercise and Health Sciences, Loughborough University

Professor Nimmo introduced the field of sport and exercise science. Sports scientists apply science to the contexts of sport and exercise. She presented statistics about the exit routes of sport science undergraduate students. According to UCAS, there are approximately 114 sport science degree courses in the UK, although the make-up of the courses varies significantly. In the 2008 Research Assessment Exercise, 24 of the 40 institutions which offered "sport studies" had 10% of their papers awarded the class 'world leading' in scientific rigour and originality. There was no specific research council to support sport science research, academics applied to the relevant research council as other academics.

One example of ongoing research was the ESPRIT (Elite Sport Performance Research in Training) programme at Imperial College London. Sensors observed elite athletes, and the technology being developed would hopefully have a crossover benefit when applied to household and health environments.

UK Sport and BBSRC held an event considering how researchers could engage with their research agenda, and as a consequence they launched a joint call for research proposals. Only two proposals were funded, and Professor Nimmo argued that their focus on elite sport was "stripped out" because of an inability to control sufficiently and that this represented a missed unique opportunity to study the extreme of the phenotype.

Professor Nimmo explained that it was difficult to develop research purely in sport science of the elite performer, due to the inability to control these elite athletes in the traditional sense. As a result, much of the research was undertaken using QR (Quality-related Research) funding and industry funding. She underlined the quality of students attracted to SES, citing entry requirements and an estimated 85% employment rate at the end of courses at Loughborough University. Another measure of the quality of SES was that results are published in peer-reviewed journals.

She presented examples of work at Loughborough University which demonstrated how sport science informs health. One example was research to attenuate the risk of infection at the Olympic Village, exercise boosts the immune system however at higher intensity they have an increased risk of upper respiratory tract infection.

Another group vulnerable to immunosuppression was those with renal disease and patients receiving dialysis treatment. This was presented as an example of the knowledge gained in sport science being applied to other groups . Loughborough University worked with University Hospitals Leicester to assist these bed-ridden patients with low intensity exercise in order to boost their immune system. Renal failure patients become acidotic, which could be analogous to an elite sprinter, so they translated earlier studies on athletes which involved giving bicarbonate to elite athletes before high intensity training (to increase time to fatigue) to these renal failure patients, and found that it helped the patients become more mobile.

Another example was the application of the technique of intermittent high intensity training (which is used to improve the performance of athletes) to overweight and obese individuals. The non-athlete group undertook similarly strenuous intensity training (as a percentage of their maximum) and as a result of six sessions over two weeks they had improved glucose control, fat loss and a reduction in the level of inflammatory proteins, which accompany many chronic diseases. She explained that the underpinning mechanisms to explain this were being explored. Through the NIHR Leicester-Loughborough Diet, Lifestyle and Physical Activity Biomedical Research Unit they are exploring this response with a mechanistic study.

Professor Nimmo then introduced laboratory research with synthetic tissue cultures of muscles, being stretched to explore the growth and characteristics of muscle tissue being "exercised"; a "gym in a box". She said this allowed science to inform sport without biopsies from elite athletes or animal studies. She suggested that the possibilities of simulating the effects of ageing and diabetes on muscles could also be explored using this model, although this work was still at the pre-clinical stage.

Professor Nimmo presented epidemiological studies about the determinants of disease, physical activity and nutritional patterns in young people. She described work to gather information from different ethnic groups to understand the determinants of chronic diseases.

Finally, Professor Nimmo explained that not everybody benefits from exercise, in fact some respond negatively in terms of insulin response to exercise. She said that, as the pharmaceutical industry is working towards a personalised medicine agenda, the same needs to apply to exercise as medicine.

She concluded that work in SES is underpinned by the most rigorous science, as one would expect of any higher education establishment.

Short discussion considering:

  • The susceptibility of elite athletes to infection. The design of athletes' facilities at the Olympic village was informed by this research. UK Sport document the illness rate of elite athletes and worked with the British Olympic Association to reduce the risk of illness, which included both environmental design of the Olympic Village and building the immunity of elite athletes.
  • A clarification that much of the research presented had been small-case, laboratory studies. The preliminary observations from these laboratory studies, and from case studies, were being worked up into randomised controlled trials with larger sample sizes.
  • The lack of evidence on how exercise affects asthma.
  • Sports and exercise graduates. Most secure jobs in the sports and exercise field and some go on to complete fast-track physiotherapy and dietetic courses.
  • The risks of sedentary behaviour.

Presentation heard from Sonia McGeorge, Director of the British Heart Foundation National Centre for Physical Activity and Health

Ms McGeorge introduced the process for producing the CMOs' Physical Activity Guidelines and the evidence base to support them. She first presented the literature survey conducted in the United States to support their equivalent guidelines which found that physically active people have higher levels of health, and a lower profile for medical conditions and chronic disease than those who are inactive. This survey considered clinical and epidemiological surveys. They found clear evidence of health benefits from being physically active, for all age groups. The recommendations made were based on a range of evidence from randomised controlled trials to case controlled studies, and from small to large sample sizes; but recommendations were made where there was consistent evidence across them all. The UK drew heavily upon this work when developing their guidelines.

She described the growth of research in this area since the 1960s. The World Health Organisation (WHO) have found that moderate intensity physical activity helps prevent and manage over 20 chronic conditions. There are also additional health benefits such as improved quality of life and psychological wellbeing. At a population level, she suggested that tackling those who were least active would have the greatest effect. In relation to studies across the whole lifetime, it has been found that the risk of disease was 30% less for the active when compared to the least active. She presented examples such as an inverse relationship between physical activity and the risks of cardiovascular disease, coronary heart disease and stroke. She also presented research about the benefits of physical activity for colon and breast cancer. Physical activity can also reduce the risk of falls in the elderly population.

Ms McGeorge also presented the negative effects of inactivity, such as premature mortality, reduced growth, and increase risk of chronic disease. She emphasised that there were also short term benefits from physical activity. Much of the existing evidence is for adults, but some research for young people exists. The evidence for under-fives is much less strong and not as developed, but the UK expert group who helped produce the CMO Physical Activity Guidelines found sufficient evidence for some specific guidelines.

Physical activity plays a key role in the management and treatment of chronic conditions too: these had been considered in a series of Cochrane systematic reviews.

Ms McGeorge discussed the costs of inactivity. The WHO consider physical inactivity to be the fourth risk factor responsible for global deaths—6% deaths globally. Work has been done to research the economic costs too. It is estimated that it costs the NHS £0.9 billion a year, and that lost productivity costs UK Plc approximately £5.5 billion. The costs of premature death of work-aged people is estimated at £1 billion, and the physically inactive spend 38% more days in hospital than the active. Sonia described several global conferences and meetings which identified the risks of physical activity as modifiable.

The revised UK Physical Activity Guidelines were published in July 2011. The revision process started in 2009, when it was decided that the evidence base had developed sufficiently to justify a review of the evidence and to consider the implications for the guidelines. Furthermore, despite strong evidence of the benefits of physical activity, high levels of inactivity across UK persisted. There was also emerging evidence for under-fives and the elderly. Finally, there was inconsistency in guidelines across UK. The guidelines produced are evidence-based summary statements on the benefits of physical activity. They represent a consensus of experts on evidence and recommendations for a population based approach to physical activity. The process to develop was collaborative, and was led by the British Heart Foundation and DH. Expert groups contained international experts with experience of developing guidelines in other countries. The consultation process led to the development of a technical report. Then guidelines were produced which had to be workable and easily understood.

First roundtable discussion considering:

  • Evidence about chronic disease prevention. This was primarily epidemiological. Evidence for the use of exercise in the treatment of specific conditions varies—some was supported by randomised controlled studies. However, it was argued that, due to funding limitations much of this work was not well followed-up, and generally the transition to community based self-management was poor.
  • The reasons underpinning the reduction of risk of coronary heart disease by physical activity: physical activity reduces blood pressure, improves the blood lipid profile and improves insulin sensitivity.
  • Early stage research about muscle activity reducing the production of inflammatory cytokines, which has a positive influence on plaque formation in coronary arteries, and reduces inflammation in adipose tissue.
  • Whether the overall health benefits of exercise outweighed the risks. There are risks associated with vigorous exercise and over-exercise.
  • The difficulties of accounting for environmental stress factors in epidemiological studies.
  • The elevated risk of disease in sedentary populations. For example, research suggests that the risk of myocardial infarction increased 2.4x in the hour after intense exercise among those who report reported to undertake regular, intense physical exertion, compared to a 107x increase in risk for those who rarely exerted themselves.
  • The underpinning mechanisms explaining findings, which are not well understood. It was suggested that funding had been primarily for epidemiological studies. Recently, charities such as the British Heart Foundation, Macmillan and Arthritis Research UK had provided some funding for this type of work. It was suggested that currently we can explain 65% of the benefits, but 35% are unexplained by conventional science.
  • The types of work undertaken and modern lifestyle, which mean that much of the population are spending increasing amounts of time in a sedentary state.
  • The dangers of health inequalities, such as having the time and access to facilities to exercise. It was suggested that there were policy implications for health, transport, and school playing fields, for example.
  • Evidence that even if one meets the recommended levels of physical activity, health risks still rise if significant portions of time are spent sedentary.
  • The absence of longitudinal data regarding the life expectancy of elite athletes. However, the risks of overuse of joints have been explored and those working with elite athletes try to prevent that abuse and monitor activities undertaken to try and prevent long term health problems.
  • The relevance of principles of elite training to non-elite athletes, in that baseline fitness is incrementally enhanced.
  • Ongoing research into the economic benefits of regular exercise. It is thought that exercise boosts productivity and saves money for healthcare.
  • Research suggesting that the life expectancy of elite American football players is reduced.
  • The side effects of exercise.
  • Lessons from injury prevention with elite athletes informing school sports. For example, warm-ups to reduce ham string injury have been shared. The Federation of Association Football (FIFA) have a programme in schools to reduce knee injury through exercises.
  • Avoiding injury not forming part of the physical activity guidelines. The dissemination of these guidelines, it was argued, was not that wide to public or professional groups and consequently there was not the desired level of awareness among health professionals.
  • The differences between exercise and fitness.
  • One example of the health benefits of exercise: the use of strength training and balance training to reduce falls.
  • Physical activity as an indicator in the Public Health Outcomes Framework. This was measured through the Active People Survey, a self-reporting questionnaire about sporting participation. It was acknowledged that there is a risk of overestimation in this work.
  • The NICE guidance on exercise referral schemes which contained a cost effectiveness component. This found that the benefits justified the costs of short interventions.
  • The standards and qualifications for exercise professionals. Skills Active and the Register of Exercise Professionals have level one to four qualifications, but these are not compulsory for exercise professionals. There is work at a European level to raise standards in this field.
  • Awareness of the physical activity message among health professionals. This was not considered to be effective. For example, in an informal survey, less than 30% of GPs in Northwest England were aware of the latest UK physical activity guidelines. It was suggested that adding physical activity or exercise to the GP Quality and Outcomes framework would encourage GPs to learn more about this area.
  • Cultural barriers to exercise. It was suggested that, for many people, exercise was not the social norm, and so physical activity was a public health issue—the question was asked: how do you make society live an active life? The benefits of dance as a socially acceptable form of exercise were discussed.
  • The paucity of randomised controlled trials undertaken with elite athletes. However, it was thought that they are providing good case studies and research which can be translated into benefits for other groups.
  • The addressing of gaps in translational research by the Biomedical Research Units at UCL and Loughborough, and the Centre for Diet and Activity Research (CEDAR). It was suggested that BBSRC, MRC and NIHR pass applications submitted to the wrong organisation to each other, as each has a specific remit: BBSRC and MRC fund more fundamental science, and NIHR fund research for patient benefits.

Presentation heard from Professor Fares Haddad, Director of the Institute of Sport, Exercise and Health, University College London Hospital

Professor Haddad presented about the NHS' provision of exercise treatments. The NCSEM will, through collaboration, support the use of SEM in the NHS and to promote translational research. The Centre will help translate research from elite athletes and from exercise studies to public health benefits. They will help focus on physical activity and health, improved care for sportsmen and women, improving musculoskeletal health, exercise for chronic disease, mental wellbeing and performance.

SEM used to be a special interest of a few medical practitioners, now there is a specialist stream being developed. New jobs are currently being created and consultants are being trained. SEM specialists will provide knowledge and the infrastructure will be developed to allow them to deliver across the NHS. They will explore, for example, exercise as treatment for obesity, diabetes, cancer. They will consider new models for delivering exercise.

Professor Haddad described how elite athletes are different physiologically but can offer principles which can be learnt from. They also have the potential for promoting physical activity by acting as role models. He said the NCSEM want to translate findings from elite athletes to the wider population.

He described the use of exercise to improve, avoid and delay osteoarthritis by reducing muscle wasting. Ultimately this can reduce the need for knee surgery.

He gave a further example of the use of sport science for health: findings from hypoxic training, physiological adaptations when exercise at altitude, are being translated to assist the critically ill to combat muscle wastage.

Roundtable discussion considering:

  • The use of exercise to manage osteoarthritis.
  • The Physical Activity Guidelines. They are not specific about exercise for specific conditions. It was argued that this kind of treatment plan needs to be individualised and supervised. Furthermore, patients often suffer from multiple conditions which need taking into consideration in the prescription of exercise.
  • The goal of the creation of the SEM speciality. They will facilitate education for exercise prescription.
  • Prescription of exercise by GPs. It was suggested that GPs do not know what to tell patients and are uncertain as to what exercise is safe. If this kind of advice was issued by NICE it was thought that GPs might be more inclined to prescribe exercise. It was argued that medical professionals are not consistently trained to prescribed exercise. SEM specialists will be trained, not to deliver these prescriptions each time, but to provide guidance and to develop the research base for it. It was suggested that SEM specialists and the NCSEM could demonstrate the benefits of exercise and provide the expertise to help further the delivery of exercise prescription.
  • PARQ (Physical Activity Readiness Questionnaire) Plus. This questionnaire aims to help certain patients self-assess whether they are well enough to exercise.
  • The need to embed exercise as treatment in the NHS in the same way as pharmacological interventions.
  • Advice notes for physical activities to help specific conditions being developed by a private company.
  • The envisaged work of the NCSEM to speed up the translation of SEM research to NHS services.
  • The lack of ongoing funding for the NCSEM. DH provided a capital grant to create facilities. Sponsorship was being explored. The Centre will bring research and clinical work together. Sheffield CCGs are already commissioning the SEM services. It was suggested that there is a need to create appetite in commissioning exercise. One way suggested was to create knowledge in the marketplace.
  • A previous NICE evaluation which found limited effectiveness amongst the 300 UK exercise referral schemes that exist. It was suggested that the structure for delivering exercise referral needs to be reconsidered.
  • An example of barriers to translation: a device for training respiratory muscles, to manage chronic obstructive pulmonary disease. It was suggested that if we understood the underpinning mechanism this treatment could be better applied and interventions modified.
  • Animal models.
  • Lack of integrated policy between health, physical activity, and other areas such as transport.
  • The success of a recent Macmillan campaign regarding the importance of exercise for cancer patients.
  • The value of exercise professionals forming part of multidisciplinary teams, in the same way that physiotherapists can do.
  • The lack of training for GPs. Developments such as teaching of sport science in special subject modules for undergraduate medical students and intercalated degrees in sport science were discussed. It was suggested that there might not be sufficient expertise within medical schools to deliver this training, but it was also suggested that SEM specialists could help with this provision.
  • The reduction in physical activity provision, such as sports areas, by local councils.
  • The barrier of health and safety to the delivery of strength training within the NHS.
  • The need to raise public awareness of benefits of physical activity, giving the public confidence and skills to do something about it, and addressing the cultural environment to make that acceptable. This would need support from the public, professionals, policy makers (both national and local) and the media.
  • It was suggested that the Research Councils and Higher Education funding councils are seeking to address the paucity of integrated physiology and whole systems approach research.
  • The similar difficulties in promoting exercise and healthy eating.
  • The need to explore underlying mechanisms so that interventions can be optimised and to replicate benefits through other means for those who cannot or will not exercise. It was suggested that this work 'falls between the cracks' in terms of funding.
  • Current NICE guidelines for illness. Over 30 of NICE's current guidelines say exercise has a role to play in treatment of specific conditions, but their advice is usually general, top-line comments. They do not discuss how or what specific type of exercise would be appropriate.
  • The importance of coaching. It was suggested that this is done well by teams supporting elite athletes and that the treatment of the wider public would benefit from this type of work.
  • The benefits of physical activity for businesses. These include better productivity from employees and increased speed in recovery from illness.
  • The mental health benefits from exercise being shown in the evidence base. For example, the evidence suggests that exercise can help reduce anxiety and depression.
  • The need to change the culture of research within institutions to promote the development of resources such as information for health professionals, for example, as well as publication in high-impact journals.
  • The work of UK Sport and Sport England. UK Sport conduct a survey with their clients each year about their satisfaction with their service. Sport England conduct the Active People Survey. DCMS do not have the scientific expertise to quality assure the use of science by its arm's length bodies.
  • How studying elite athletes can provide useful information to inform the treatment of the critically ill. For example, by characterising the mechanisms by which heart function improves with exercise in elite athletes and the military, we can tell how heart function is impaired in people with diabetes or with high blood pressure. Understanding the impact of training on metabolic efficiency helps understand inefficiency in cancer. By understanding the mechanism of growth in muscles by exercise, this can help combat muscle wasting in intensive care patients.
  • The value of SEM and SES. It was argued that they are not trivial, marginal, or elitist—they are of relevance to patients of every age, stage and disease.



 
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