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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