Exercise Deficit Disorder Redux

It's the gift that keeps on giving.

A week ago our sports medicine group brought in Dr. Avery Faigenbaum to talk about his work on the safety and efficacy of resistance training in kids.  He's a world expert on the subject, and was just interviewed on CNN yesterday.

His talk here in Columbus covered issues related to resistance training, but Dr. Faigenbaum also delved into his work and research addressing the lack of basic activity in modern children, something he has dubbed 'exercise deficit disorder.'

During his visit, I had the chance to sit down with him and Dr. Michael Patrick, the host of Nationwide Children's Hospital Pediacast, to discuss issues related to exercise and resistance training in kids, as well as exercise deficit disorder.  Here is a recording of the broadcast.

At the end, I got to mention my kids, my inspiration. I talk about the importance of outdoor play, and their frolic in our magnolia tree, and their chickens.  Here's to you my darling Claire and Momo!  You may not stay forever young, but may you stay forever active in this beautiful world.

Exercise Deficit Disorder

It has been a very busy stretch, and I have been unable to find time to do any posting.  This entry itself will be brief, but I have to share some of the excitement I feel after our group of doctors hosted a visiting professor from the College of New Jersey.

Dr. Avery Faigenbaum is someone I met when I did my fellowship in Pediatric Sports Medicine at Children's Hospital, Boston.  He has published literally hundreds of studies, articles, chapters and books on the subject of pediatric resistance training.  Not only is he learned, but he is a dynamic speaker.  I carry fond memories of the last time I heard him speak in Boston, in 2007.  Imagine Rocky Balboa giving an erudite lecture at Harvard, and you will have a vision of Dr. Faigenbaum lecturing about his research.

Well, now I have a more recent memory.

Last night and this morning, we were able to host Dr. Faigenbaum here in Columbus, and it was quite a set of talks he gave.  Energized me and all my colleagues.

If you want to learn more about his work, go to his website.  It's difficult to be brief when describing his work.  I can only skim the surface in this blog.

I can still recall memories when growing up in the 70's of the myths that weight training in kids would stunt growth or cause injuries, specifically of the growth plates.   Dr. Faigenbaum has dedicated his professional life to, among other things,  researching the safety of resistance training in kids, and he has found that no prospective study of a supervised weight program in kids has ever revealed a growth plate injury.  When supervised, kids can lift weights safely.  He has gone further, and designed cost effective, age specific resistance training programs for kids which combine play and fitness.  He has demonstrated the need to focus on strength training as well as aerobics in kids (and that goes for adults too).

But his work is much deeper than this.  It is actually quite radical.  He is looking at the epidemic of childhood obesity from the angle of physical (in)activity.  He has coined the phrase "exercise deficit disorder," and he has begun to publish studies in the medical literature investigating this condition, which he postulates is a precursor to pediatric and adult pathology such as obesity.  It is an intriguing concept, a hypothesis which needs to be developed with more academic rigor, but as he spoke about this I couldn't help but think I was witnessing the elaboration of a new medical diagnosis.  Really, I felt as if I were witnessing the beginning of a revolution:  a new paradigm, one which would address the problem of a condition such as obesity long before it became manifest.

Certainly I see this condition on an almost daily basis:  the kids who have trouble doing a push up, or a squat; the kids who spend much more time in front of an iPad than on a playground, the toddlers who are put in the back of a bicycle trailer only to sit while their parents pedal.

Exercise Deficit Disorder, arguably one of the great public health crises of our generation.  I'll be returning to this issue often in this blog, I expect.

Once more on the bike

This is the fifth day in a row I've had some reason to go to Ohio State's campus, dangerous behavior for a boy from Michigan (who nevertheless is now faculty at OSU).

The three weekend days I was attending my monthly MPH classes.  Yesterday, I was teaching my class of 11 first year medical students.  Today, I was off to the Connor Senn symposium on sudden cardiac death in athletes.  The content of today's events is definitely worthy of a blog post, most especially because I need to get back to the topic of my April 28th post and revisit the pros and cons of screening athletes with EKGs.  That promises to be a lengthy post, and I'll have to wait until the weekend to find the time to do that.

It was a wet bike ride into town in the morning, followed by a cool and dry ride back home in the afternoon, after a day well spent.  The symposium was great.

On my mind tonight are once again issues of bike safety.  I discussed the importance of wearing bike helmets, especially for youth cyclists, in my last post.  I hope you have been able to visit the folks at Put a Lid on it, who do such a great job about helmet advocacy.

With rates of overweight and obesity increasing, and no end in sight, I have become a big fan of making our built environment more conducive to keeping people active.  It would be great if more kids could walk or bike commute to school.  It would be great, too, if more of us 'grown ups' could adopt an active commute.

One of the issues that folks frequently bring up is safety.  Many of us probably know, unfortunately, friends or family who may have been hit by cars while riding on their bikes.  All of us likely have at least read or heard such stories happening to strangers.  I can sympathize.  To date, I've never had a serious accident on the bike, but I'm not infrequently disturbed by drivers' behaviors as they pass me, or some times cut me off.  This is despite the fact that the roads are meant to be shared.

On some recent bike rides I've collected some photos of signage on the roads around town.

Well, that's a fine sentiment.  I'm surely happy to share the road with the cars, and really appreciate it when the courtesy is reciprocated.

This is more cryptic.  I wonder how many drivers, of cars or bikes, know what this means.  It translates to 'share the road,' and is more or less the equivalent of the sign above. It's yet another way of reminding cars to be aware that two-wheelers are on the road.

I particularly want to share this one, as it represents a sore spot in the life of bicyclists and pedestrians around Nationwide Children's Hospital, where I work.  It might be hard to read the sign; it says, 'yield to pedestrians in crosswalks.'  It's a traffic offense with a fine, but it's honored more in the breach than in the observance.  When I try to cross Parsons Ave. on foot or on bike, it is a rare car that yields.  Recently, there were two young women trying to cross and no car would yield to them their legal right until I biked into the cross walk and more or less sat in the middle of the road, forcing the issue.

I hope the police spend some time by this crosswalk, and ones like it throughout Columbus.  We have to make our roads safer for everyone, drivers, bikers, and pedestrians.  It is not only the right thing to do to reduce injury, but it can incentivize people to get out there and stay active.  The more we can commute to work and school, the healthier we will become.

There are medical studies aplenty to show that.  One recent such study will be the subject of the next post.

Sunday Morning, Biking Downtown

Sunday morning, coming down.


I was back on the bike, making my way to the OSU campus to complete the weekend with a heavy dose of linear regression, after an evening of slightly heavier socializing than I normally enjoy these days (friends of ours had a combined Kentucky Derby/Cinco de Mayo party; you  can imagine what combinations of mint juleps and maragaritas can do).  Or perhaps it was last night's 'super moon' that was making me feel a bit fuzzier than usual.  Biostatistics, bourbon, or big, big moon:  regardless of cause, the effect was to make me feel a bit like the character in Kris Kristofferson's song.


I wonder how the people on the cycle tavern are feeling this morning?  I biked by their contraption as I was going home yesterday, and they were already deep into their own celebrations.


It's a beautiful day here in Columbus.  It sure is easy to be outside and active when it's like this.  Even the urban down and out areas I bike thorough as I travel out of Bexley have some charm on a day like today.   The shuttered heavy industrial plants, the railroad tracks, the vacant lots, all are decorated with yellow dandelions, purple chickory, pink sweet peas (I think their sweet peas).


This is the kind of  weekend day I can only hope there are plenty of kids out on their bikes.  And I hope they are wearing helmets.  Safety is a big interest of mine, of course.  It's my occupational myopia as a physician and a public health practitioner.  I'm still surprised at how many people I encounter around town who are biking without helmets.  I wear a helmet for the same reason I get a flu shot:  I do it 'for the kids.'  When grown ups model behavior, the kids are likely to mimic it; so if it's good behavior we want to foster in our children, we have to be on our best behavior.  I alluded to as much in my recent blog post where I reviewed the data showing the strong association of parental encouragement and co-play and the amount of time their children will spend in outdoor activity.


Wearing a helmet is good for me, of course; but to be honest, I might try to get away without doing so if I didn't know how important it is for kids to wear helmets when biking, skateboarding, etc.  Our own Center for Research Injury and Policy at Nationwide Children's Hospital states that 10 000 children are hospitalized in the United States every year because of bicycle-related accidents, and a third of those events result in traumatic brain injuries.  The good news is that bicycle helmets are judged in some studies to be 88% effective at reducing traumatic brain injuries.


The book Moments in Leadership: Case Studies in Public Health Policy and Practice profiles a great example of a physician spearheading a local movement to increase use of helmets in young bicyclists, with a demonstrable decrease in traumatic brain injuries. In Seattle, Dr. Abraham Bergman began a campaign to increase bicycle helmet use in the 1980s.  Many local governments, including our city of Columbus, work through a punitive model to enforce bicycle helmet wear:  in 2008 Columbus made helmet wear mandatory for use in bicyclists under age 18. In neighboring Bexley, beginning in 2010, parents could be fined if their biking youngsters weren't wearing lids.


Dr. Bergman took a different approach, reasoning his best line of attack would come largely through motivating individuals to ‘do the right thing’   “I like to use motivation rather than education.  How do you get people to do things? The masters of that are advertising people," he is quoted as saying in the book.

Dr. Bergman applied a systems approach to achieve his goal of increasing bicycle helmet usage in children.  He collaborated with his partner Dr. Frederick Rivara and other health care practitioners.  He identified several key ‘players’ who would need to participate for his vision to bear fruit:  local news agencies; local and international manufacturers and distributors; and local retailers.  Then he went to work.

He needed  to get out the message to motivate parents and children, and he did this by having local news crews interview the families of injured children.  He needed to address the barrier of cost:  for many families, the contemporaneous cost of $80 (1980's dollars)  for a helmet was far too expensive.  He worked with a local company, Mountain Safety Research, as well as international manufacturing units in Taiwan to produce a low cost helmet.  He then worked with a local retailer, Fred Meyer, as well as a national one, Toys ‘r Us, to ensure that these helmets would be sold.  Using this systems approach, Dr. Bergman achieved a cost-effective intervention, locally available:  the end price of $15 for a helmet was within reach for most families.

Bergman and Rivara then set out to measure the success of their campaign.  They took advantage of a ‘natural experiment,’ in which a similar community of Portland, Oregon could be compared with their community of Seattle:  in Portland, there was no such campaign at the time to induce families and children to use helmets.  The case study reports that the baseline rate of helmet use was 3% in both communities, and over the time the researchers conducted their evaluation that proportion rose to 65% in Seattle and only 12% in Portland.  This dramatic increase was achieved without legislation; one can infer that the change was attributable to the Bergman campaign.

Dr. Bergman’s modeling of exemplary public health practices did not end there, however.  The gold standard for a primary prevention intervention is to prove that you have reduced morbidity and mortality of a disease.  In other words, one might prove that more children were wearing bicycle helmets, but does this result in the outcome one was hoping for:  the reduction of head injuries in children?  

Indeed, Bergman and Rivara went on to conduct just such an epidemiologic study. (Rivara et al., 1994)  From 1987 to 1992 they and their team monitored helmet use and head injury admissions rates for children in a large health maintenance organization in Seattle.  During the five years of this study they saw helmet use rates rise in school aged children from 5.5% to 40.2%.  During this same period, they observed admission rates for bicycle-related head injuries decrease by 66.6% in 5- to 9-year olds and by 67.6% in 10- to 14-year olds.

This case, the "Seattle Children's Bicycle Helmet Campaign,"  inspires me.    A clinician, like me, observed negative health outcomes in patients, and he was not willing to accept the status quo.  Certainly, he could have continued caring for these children one by one:  treating a concussion here, sewing a laceration there, and possibly even seeing a family through the grief of a death.  Dr. Bergman did not stop there.  He became a leader in public health and helped bring a product to production and motivate people to use it.  He went on to assemble a team to assess the results of his intervention.  In applying principles of good public health practice, leadership, and systems analysis, Dr. Bergman went far beyond the boundaries of clinical medicine and impacted literally hundreds to thousands of individuals.  I can only hope I could achieve a small portion of this in my career.

So, if you're inspired, first:  get outside and have fun.  Second, if you're going to your bicycle, put on your helmet!  And third, make a small public health promotional gesture and visit my friends at the Ohio chapter of the American Academy of Pediatrics, who run a fantastic campaign called 'put a lid on it'.  'Like' their Facebook page, and learn how you, too, can promote safe activity for the kids in your life whom you love.

Bicycle Musings

I was biking cross town this a.m. making my way to my monthly public health classes, and it got me to thinking.  I love biking, or running, or swimming for the thinking it allows me to do.  I find I have some of my most productive insights while I'm active.  As the author of Spark, John Ratey, has noted, exercise is as good for the brain as it is for the body.

Among my many motivations for bike commuting is exercise certainly, but I also enjoy the ease of parking and the cost (essentially free) when compared with the alternatives.  This morning, especially, I was motivated to bike, as the POTUS  is visiting Ohio State's campus today to kick off his re-election campaign.  Unfortunately, I can't be in attendance for the speech, as I'll be taking a biostatistics exam.  I'm fortunate, however, as I biked in, and will bike out, of campus with ease, while my classmates have suffered today's special event traffic.

Which brings me to this graphic I came across on line a week or so ago:

This cartoon reminds me of the famous saying inscribed on Woody Guthries' guitar, "This Machine Kills Fascists."



Even a climate change skeptic (I'm surprised by how many people I still encounter who count themselves in that camp) would be hard put to argue against this sentiment. Let's do something patriotic and get rid of our addiction to 'foreign oil.'  We can depend on the Middle East less by drilling more, sure; but we can also do so more simply by getting on those bikes sitting in the garage. By choosing to move on our own feet, or on wheels we propel ourselves, we are making a choice for our health, for our environment, and for our country.

My bike:  the weapon to wield in the fight against middle age gut, brain decline, climate change, and foreign oil dependency.  .

I'm heading back for more classes tomorrow a.m., so there will be more bike musings to come.