Sunday, December 16, 2012

Fitness and P4 Medicine


OK fitness professionals, have you heard of P4 medicine yet?  If you haven't, you need to get up to speed!  A quick Google search will tell you a lot.  P4 stands for Predictive, Preventive, Personalized and Participatory.  A fitness pro's groin should be quaking at this point. 

One web site states:
"Today's medicine is reactive: we wait until someone is sick before administering treatment. Medicine of the future will be predictive and preventive, examining the unique biology of an individual to assess their probability of developing various diseases and then designing appropriate treatments, even before the onset of a disease. Today's medicine is also myopic: we use only a few measurements to diagnose disease and are generally unable to make fine distinctions between individuals or between subtle variations of the same disease. Medicine of the future will use more sophisticated measurements, as well as more measurements overall, thereby yielding accurate health assessments for truly personalized treatments."
I know I'm preaching to the choir here, but lets review: 
"Regular physical activity, fitness, and exercise are critically important for the health and well being of people of all ages. Research has demonstrated that virtually all individuals can benefit from regular physical activity, whether they participate in vigorous exercise or some type of moderate health-enhancing physical activity. Even among frail and very old adults, mobility and functioning can be improved through physical activity. Therefore, physical fitness should be a priority for Americans of all ages. ...physical activity has been shown to reduce the risk of developing or dying from heart disease, diabetes, colon cancer, and high blood pressure."

I read a great book over the holidays, "What Got You Here Won't Get You There."  Keep that title in mind!  The opening chapter of the book starts with:
"You know those maps in shopping malls that say, "you are here"?  they exist to orient you in unfamiliar territory, to tell you where you are, (help show you) where you want to go, and how to get there.  A few people never need these maps.  They're blessed with an internal compass that orients them automatically. They always make the correct turn and end up where they intend via the most economical rout.   Some people actually go through life with this unerring sense of direction.  It guides them not only in shopping malls but in their school years, careers, marriages, and friendships.  When we meet people  like this, we say their grounded.  They know who they are and surprises will only be pleasant surprises.  The are our role models and heroes.  ... What all of these role models have in common is an exquisite sense of who they are, which translates into perfect pitch about how them come across to others.  A few people never seem to need any help in getting to where they want to go.  They have a built-in GPS mechanism."
We refer to these people with the "built in GPS" in the fitness world as "enthusiasts."  The fitness industry has done a great job of creating spaces for "enthusiasts"  to play.  We sell them a $19 a month membership and forget about them.  Some of them are so enthusiastic they invest a portion of their disposable income in us,  professionals,  in return for our guidance, leadership, but primarily in return for friendship and companionship.  The point is that the only successful fitness participants are the enthusiasts, those with the built in GPS. 

The evidence is that at least 80% of our population is so in-active that hypoactiviity is contributing to increased morbidity and mortality equivalent to smoking a pack of cigarettes a day.   And medicine has chosen to treat the diseases of chronic inactivity like diabetes, hyper-tension and arthritis with chemicals.  And who can blame them, the face of fitness is CrossFit, P90X, BowFlex, Treadclimbers, VO2 max tests, body fat assessments.   These tools of the enthusiasts,  frankly scare the not-yet-fit friends of ours.  When a non-enthusiast walks into our glass windowed, high-designed, over optioned, hundreds of choices fitness spaces, it's like a babe in the jungle experience for them.  They will order the P90X dvd's, but plugging them in, following them, they wind up drawing dust.  We have to offer our not-yet-fit brothers and sisters other avenues of entry into the fitness lifestyle and I believe P4 is one of those avenues.

Physicians, fitness is a behavior issue first, and a physiological marker second.  Approach the integration of fitness into your practice in that manner.  Great tools exist for the assessment of an individual's
stage-of-change relative to physical activity and healthy eating.  (  These can be integrated and completed outside the exam room with practical scores and counseling information ready when the physician enters the room.  This data will also be valuable in the treatment matching of your patients to programs.  Programs that your patients  will bond to immediately.(personalized)   The second recommendation I have is to measure and counsel what's important first.  (preventive)  As scientists, we get enchanted with all the extensive physiological assessment tools available.  But fitness, particularly in the non-enthusiast population begins with one simple metric, movement.  Move more, get healthier!  Unfortunately, movement  is difficult to measure to quantify in a single office based encounter.  You're going to have to connect with your patients in such a way that their willing to invest some daily effort creating a record.  The great thing is that we have "human gps" units that can hang on their waist that will collect, report and motivate the patient. (participatory).  Patients will value the information enough that they will endure the additional hassle of integrating the device into their life.

Next use in-office physiological tests that stand a chance of "connecting" to your patients and result in motivation and behavior change.  The information provided by the tests must be relevant to the goals and objectives of the patient.  VO2 only means something to freaks like us.  I can turn on CNBC or Bloomburg during the week and see a million terms and numbers that while important to someone, mean very little to me.  If I had to learn them to invest my money, I'd wind up keeping it all in a ball jar in the back yard.  That's the effect we have on everyone else with our current fitness assessments.  We have to offer "mutual fund" assessment and exercise.  I would suggest using the results of the stage-of-change assessment to direct your next steps in physiologic testing.  Graded exercise testing should be reserved for those in the Action or Maintenance stage.  For those who are in either pre-contemplation, contemplation, or early preparation, use simple heart rate variability test whose results will provide an opportunity to discuss activity volume and intensity.  If someone is symptomatic or risk qualified for a stress test, the stress test results will provide the same opportunity.  The other physiologic test that can be completed in a medical office environment and will be beneficial is the use of a 4 point BIA body composition assessment.  But how the results are presented to the patient are important!  I am going to write in an upcoming post about how the goal of weight loss is one of the biggest reasons fitness is failing.  But for now, report the results of the BIA in terms of volume of lean mass (how big is your motor) and the ratio of stored energy to lean mass.  These are terms that will motivate activity and behaviors that promote healthy patients.  At the end of the day, measure the success of your program by how much more your patients are moving!

If your a fitness professional, P4 medicine is one of the opportunities we've been waiting for that provides a real connection between medicine and fitness.  If you would like to learn more about systems that can help deliver the kinds of programs discussed here, feel free to contact us.  If your a physician, there are great exercise professionals that can help you deliver quality, integrated fitness as part of your practice.  If you would like some help doing so, let us know, we can help.

Thanks for your time and consideration,

Don Moxley

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