Translating exercise biology into the Venezuelan medical education and health care system.

Transcription

1 Invest Clin 48(3): , 2007 Translating exercise biology into the Venezuelan medical education and health care system. Pe dro Del Co rral. School of Pu blic Health, Johns Hop kins Uni ver sity, Bal ti mo re, MD, USA. Key words: Ex er cise bi ol ogy, ex er cise phys i ol ogy, phys i cal ac tiv ity, med i cal ed u ca - tion, his tory of med i cine, health pol icy. Abstract. In the ab sence of phar ma co log i cal agents, phys i cal ex er cise was widely used by phy si cians in the late 19 th cen tury to treat a num ber of mal a dies. In the 1950 s, ep i de mi o log i cal ev i dence sug gested an as so ci a tion be tween phys i cal ac tiv ity and health, and in creased in ter est in clin i cal ex er - cise bi ol ogy. By the 1990 s, suf fi cient re search data was ac cu mu lated on the ben e fits of ex er cise, such that North Amer i can med i cal as so ci a tions, gov ern - ment agen cies, and the World Health Or ga ni za tion have pub lished guide lines on ex er cise for pub lic and clin i cal pop u la tions. De spite this, lead ers in med i - cal ed u ca tion have re mained re luc tant to in cor po rate ex er cise bi ol ogy into the core med i cal cur ric u lum, or to sys tem at i cally im ple ment it in grad u ate med i cal ed u ca tion. This work re views Ven e zue lan ex er cise bi ol ogy lit er a ture, and its med i cal ap pli ca tions. Ven e zue lan sci en tists and cli ni cians have in - vested ef forts in cardiopulmonary ex er cise test ing, skel e tal mus cle ad ap ta - tions to train ing and ex er cise car dio vas cu lar phar ma col ogy in pa tients, sed en - tary sub jects and ath letes. It is sug gested here, that there is a need to de velop ed u ca tion and re search pro grams in ba sic and clin i cal ex er cise bi ol ogy in the for mal train ing of med i cal stu dents, phy si cians in res i dency pro grams, and al - lied health care pro fes sion als. Ten ta tive steps to ini ti ate this pro cess are pro - posed. Co rres ponding aut hor: Pe dro Del Co rral. De part ment of Nu tri tion Scien ces, 1675 Uni ver sity Blvd, 234 Webb bldg, Uni ver sity of Ala ba ma at Bir ming ham, Bir ming ham, AL 35294, USA. co rralp@uab.edu

2 378 Del Corral Tras la dan do la bio lo gía del ejercicio a la educación médica y al sis te ma de cui da do de salud venezolano. Invest Clin 2007: 48(4): Palabras clave: Biología del ejercicio, fisiología del ejercicio, actividad física, educación médica, historia de la medicina, política de salud. Abstract. En la au sen cia de agen tes far ma co ló gi cos, el ejer ci cio fí si co fue am plia men te usa do por mé di cos a fi na les del si glo 19 para tra tar nu me ro sas en fer me da des. Du ran te el si glo 20, en la dé ca da de los 50 s, la evi den cia epi - de mio ló gi ca ya su ge ría una aso cia ción en tre la ac ti vi dad fí si ca y la sa lud, y co - men za ba un in cre men to en el in te rés en la bio lo gía del ejer ci cio con apli ca - ción clí ni ca. Ya en la dé ca da de los 90 s, su fi cien te in ves ti ga ción fue acu mu la - da in di can do el be ne fi cio del ejer ci cio, en Nor te amé ri ca ya aso cia cio nes de me di ci na, en tes gu ber na men ta les y la Orga ni za ción Mun dial de la Sa lud pu bli - ca ron guías so bre ejer ci cio para po bla cio nes clí ni cas y pú bli co en ge ne ral. No obs tan te de esto, los di ri gen tes de edu ca ción mé di ca han per ma ne ci do re - nuen tes a in cor po rar la bio lo gía del ejer ci cio al pén sum mé di co cu rri cu lar, o a im ple men tar lo sis té ma ti ca men te en la edu ca ción mé di ca de post gra do. Este ma nus cri to re vi sa la tra yec to ria de la bio lo gía del ejer ci cio en Ve ne zue la y sus apli ca cio nes mé di cas. Cien tí fi cos y clí ni cos ve ne zo la nos han he cho con tri bu - cio nes en áreas ta les como prue bas de eva lua ción car dio pul mo nar, adap ta cio - nes de múscu lo es que lé ti co al en fren ta mien to fí si co y en far ma co lo gía car dio - vas cu lar en ejer ci cio en pa cien tes, su je tos se den ta rios y at le tas. Se su gie re que hay la ne ce si dad de de sa rro llar pro gra mas de edu ca ción e in ves ti ga ción en bio lo gía del ejer ci cio con el fín de in cor po rar es tos co no ci mien tos en la for ma ción del es tu dian te de me di ci na, mé di cos re si den tes y pro fe sio na les alea dos al sis te ma de sa lud. Se pro po ne una se rie de pa sos ten ta ti vos para ini - ciar este pro ce so. Re ceived: Ac cepted: EXERCISE BIOLOGY AND HEALTH Ex er cise bi ol ogy stud ies the acute and chronic (i.e., train ing) ef fects of ex er cise on body systems, tissues, cellular and molecu - lar func tion. Its or i gins merged med i cine, phys i cal ed u ca tion and phys i ol ogy. By the late 19 th cen tury, manu scripts (1) and books (2) were writ ten on the sub ject. In this pe riod, phys i cal ex er cise was widely used by phy si cians to treat a num ber of mal a dies, per haps, be cause of the lack of phar ma co log i cal agents. How ever, the ad - vent of the lat ter, and the re forms in med i - cal ed u ca tion in duced by the Abra ham Flexner re port (3), may have blunted the prog ress in clin i cal ex er cise bi ol ogy. Mean - while, ba sic ex er cise bi ol ogy grad u ally flour - ished and, in 1921, No bel prizes were awarded to Eu ro pe ans Archibald Hill (Brit - ish phys i ol o gist) and Otto Meyerhoff (Ger - man bio chem ist) for their work in mus cle heat pro duc tion, energetics, and lac tic acid pro duc tion in con tract ing skel e tal mus cle. In the early 1950 s, in ter est in clin i cal ex er cise bi ol ogy grad u ally in creased with Investigación Clínica 48(3): 2007

3 The un trans lated sci ence of ex er cise bi ol ogy 379 the pub li ca tion of ep i de mi o log i cal ev i dence sug gest ing an as so ci a tion be tween phys i cal ac tiv ity and health (4). By the 1970 s, suf fi - cient re search data and clin i cal ex pe ri ence was gath ered on the car dio vas cu lar ben e fits of ex er cise for the Amer i can Heart As so ci a - tion (5) and the fed eral gov ern ment of the United States of Amer ica (6) to start pub - lish ing guide lines on ex er cise for the gen - eral pub lic and for pa tients with car dio vas - cu lar dis ease. By the early 1990 s, there was a grad ual shift of fo cus from or gan sys tems to mo lec u lar bi ol ogy tech niques (7), while the ben e fi cial ef fects of phys i cal train ing were be com ing ev i dent for many pa thol o - gies (see Fig 1). For in stance, there were pro spec tive data in di cat ing that cardio - respiratory fit ness is in versely re lated to mor tal ity rates (8). In the mid-90 s the Amer i can Col lege of Sports Med i cine, the Cen ters for Dis ease Con trol and Pre ven tion (CDC) (9), and the World Health Or ga ni za - tion (W.H.O) with the In ter na tional Fed er a - tion of Sports Med i cine (10) is sued joint state ments on Phys i cal Ac tiv ity and Pub lic Health and Ex er cise and Health, re spec - tively. These were closely fol lowed by the Na tional In sti tutes of Health (NIH) Con sen - sus (11), and by the re port of the Sur geon Gen eral (12) on phys i cal ac tiv ity. Given the po ten tial im pact on health care, one might ex pect that the sci en tific progress in exercise biology would have been trans lated into the med i cal ed u ca tion cur ric u lum. We shall next ex am ine this is - sue. EX ER CISE BI OL OGY TRAIN ING IN MED I CINE AND PUB LIC HEALTH Dur ing the 19th cen tury, the ben e fits of ex er cise were mostly in tu itive as there was in suf fi cient sci en tific data avail able to the cli ni cian. By ford (1) said It is sel dom Sarcopenia Cardiovascular disease Diabetes Mellitus Cancer Obesity Physical training Osteoporosis Cerebrovascular disease Chronic obstructive pulmonary disease Mood & Cognitive disorders Fig. 1. Chro nic di sea ses fa vo rably mo du la ted/trea ted by physi cal ac ti vity/physi cal trai ning (for re - view see 6, 8-12, 33). Vol. 48(3): , 2007

4 380 Del Corral that any re me dial means re ceives the im - por tance due to it from the great body of the pro fes sion, un less its phys i o log i cal mo - dus ope randi is ra tio nal and well un der - stood. Al though the im por tance of vol un - tary ex er cise has been rec og nized by cen tu - ries and pre scribed to its most use ful ex tent by many of the pro fes sion, its great prac ti - cal ad van tages in a large num ber of dis - eases have not been ap pre ci ated to the full ex tent by all. ; call ing on the pro fes sion for more re search. By the end of the cen tury there was con cern that phy si cians were de - vot ing years of study to patho log i cal con di - tions and their re lief, but very few hours to keep ing a healthy body. Phys i cal train ing was mostly as so ci ated with ath letes, less to health. Brooks (13) stated that Phys i cal train ing has not yet ac quired the dig nity to be in cor po rated in the cur ric u lum of med i - cal study, but it is sup posed to lie within the prov ince of the gym na sium in struc tor or the pro fes sional ath lete (13). He won - dered why lit tle at ten tion was be ing paid to the sub ject of phys i cal train ing in med i cal schools. Eggleton (14) stressed the im por tance of med i cal grad u ates to mas ter phys i o log i - cal ther a peu tics, in clud ing med i cal gym - nas tics. It was stated Med i cal gym nas tics should be taught in med i cal schools by giv - ing the stu dent the phys i cal ex er cise he needs in the form of in struc tion in spe cial - ized gym nas tics, such as pro grams for pa - tients with heart dis ease In all prob a bil - ity noth ing will be done. Years will pass be - fore a change will come, be cause the lead - ers of the med i cal pro fes sion are not con - ver sant with these mea sures of treat ment. If they know lit tle or noth ing about these mea sures, how can they be ex pected to pro - vide ad e quately for them? (14). Un for tu - nately, more re cently, only 3% of phy si cians ad mit ted to ever tak ing a course re lated to ex er cise pre scrip tion dur ing their un der - grad u ate, or their med i cal school ed u ca tion (15). This is sur pris ing since vast amounts of knowl edge on ex er cise bi ol ogy and its ben e fi cial ef fects had been ac quired in the 20 th cen tury, par tic u larly in the lat ter half, with lit tle, if any im pact on med i cal ed u ca - tion. It has been over 150 years since By ford (1) called for re search into the ther a peu tic ef fects of ex er cise. Much has been dis cov - ered since then. Lead ing pro fes sional med i - cal or ga ni za tions, na tional and in ter na - tional health or ga ni za tions have en dorsed the ther a peu tic ef fects of ex er cise. Ex er cise bi ol ogy has kept up with other sci ences and now a days cap i tal izes on ad vanced tech nol o - gies such as gene ar rays, and plate read ers. To day, the ex er cise bi ol o gist is at the fore - front on the bi o log i cal mech a nisms by which ex er cise mod u lates gene ex pres sion in health, and in dis ease (16). De spite this, med i cal ed u ca tion lead er ship has re mained re luc tant to in cor po rate ex er cise bi ol ogy to the core med i cal cur ric u lum or to sys tem - at i cally im ple ment it in grad u ate med i cal ed u ca tion. VENEZUELAN EXERCISE BIOLOGY Miguel González-Guerra re viewed (1891 to 1990 s) the med i cal cur ric u lum of the old est med i cal school in the coun try, Universidad Cen tral de Ven e zuela (UCV). His re view in di cated that ex er cise bi ol ogy had not been part of med i cal ed u ca tion, at least in this lead ing med i cal in sti tu tion. In 1978, the med i cal ed u ca tion com mis sion of UCV ap proved sports med i cine as an elec - tive course (17), a step that has since been fol lowed by other med i cal schools (i.e., Universidad de Carabobo). Al though sports med i cine has some over lap with ex er cise bi - ol ogy, its ob jec tive is ath letic per for mance and the re ha bil i ta tion of in ju ries. Thus, med i cal stu dents do not re ceive core train - ing in ex er cise bi ol ogy to pre serve/re store health. In the 1930 s. Vic tor Delfino made Investigación Clínica 48(3): 2007

5 The un trans lated sci ence of ex er cise bi ol ogy 381 ref er ence, in the med i cal jour nal Gaceta Médica de Ca ra cas, to Eu ro pean stud ies point ing at the sci en tific ba sis of kinesiotherapy and the nu mer ous med i - cal in di ca tions for move ment ther apy (18). In 1952, the Ven e zue lan Na tional In - sti tute for Sports founded the Cen tral Med i - cal De part ment in the cap i tal, Ca ra cas. Among its du ties was re search and ed u ca - tion in hu man per for mance and sports med - i cine (19). This group would later col lab o - rate on a re search pro ject on work phys i ol - ogy with a group at the UCV s Uni ver sity Hos pi tal (20). But, a re view of the lit er a - ture sug gests that few Ven e zue lan lab o ra to - ries have worked and pub lished (in ter na - tion ally in dexed peered-re viewed jour nals) in ex er cise bi ol ogy. The first doc u mented Ven e zue lan stud - ies of ex er cise bi ol ogy were on work phys i ol - ogy, and date to the early 60 s, by the In sti - tute of Work Med i cine and In dus trial Hy - giene at Uni ver sity of Zulia. These se ries of stud ies were per formed by Joachim Meyer-Delius and his as so ci ates on man ual la bor work ers em ployed at a ma jor for eign oil re fin ery, and on the Na tional Guards Troops, both at Zulia state. They de scribed body ef fi ciency, us ing a cy cle ergometer, at dif fer ent work loads, un der dif fer ent heat and thermoneutral en vi ron men tal con di - tions (21-25). Their find ings in di cate that work ing body ef fi ciency was 25% lower, un der heat, com pared to thermoneutral en - vi ron ments (23), which was at ten u ated by phys i cal train ing (24). In their re ports, they pointed out that: 1) phys i o log i cal stud ies, dur ing pro fes sional ac tiv i ties (ex er cise), are the base for un der stand ing pre ven tive med i cine (24), a con cept that re mains valid to day; 2) the lack of phys i cal ex er cise is a fun da men tal fac tor in the de vel op ment of car dio vas cu lar dis ease in the coun try. It was rec om mended to train more phy si cians in work med i cine, ad vo cate for sports in schools and com pa nies, and cre ate climatized gym na si ums (23, 25). Have these rec om men da tions been fol lowed? In 1962, the Sec tion for Func tional Cardiopulmonary Ex plo ra tion, Di vi sion of Car dio vas cu lar Dis eases, of the Min is try of Health and So cial As sis tance, was founded at the Ca ra cas Uni ver sity Hos pi tal. This Sec tion de liv ered ser vices to pa tients re - ferred to them from phy si cians from neumonology, car di ol ogy, an es the si ol ogy, med i cine, and other in sti tu tions such as the Na tional In sti tute of Sports (19). This was the first group in the coun try to study work ca pac ity, by di rectly mea sur ing whole-body ox y gen up take (via pul mo nary gas ex change), in a group of Ven e zue lans (i.e., sed en tary sub jects and ath letes). Their find ings in di cate that, com pared to nor ma - tive Eu ro pean and North Amer i can data, the work ca pac ity of ven e zue lan ath letes was sim i lar, but sed en tary ven e zue lans were less fit (20). The au thors hoped that their study would serve as a ref er ence point for fu ture stud ies in work ca pac ity of cardia - pulmonary re ha bil i ta tion pa tients, sports med i cine and mil i tary med i cine. Nearly 40 years have passed, it is un clear to what ex - tent oth ers have val ued their ini tial work. By the 1970 s a third group, headed by Sonia Hecker-Torres, of the De part ment of Phys i o log i cal Sci ences, Luis Razetti School of Med i cine, UCV, be gan stud ies. Her lab o - ra tory worked on skel e tal mus cle phys i ol - ogy, in clud ing ad ap ta tions to phys i cal train - ing (26). Her group showed that phys i cal train ing in creases mi to chon drial num bers and size (27), and en zy matic ac tiv ity (26, 28) on fe line gas troc ne mius; a fa vor able ad - ap ta tion for ox i da tive me tab o lism. In the early 1980 s she took a sab bat i cal with Bengt Saltin in Co pen ha gen, Den mark. Upon her re turn she used the Bergström s nee dle mus cle bi opsy tech nique, and char - ac ter ized the en zy matic ac tiv ity, fi ber type and capillarization of Ven e zue lan ath letes (29-31). These stud ies (29-31) were help ful Vol. 48(3): , 2007

6 382 Del Corral in con firm ing and rec om mend ing pos si ble changes in phys i cal ac tiv ity pat terns con sis - tent with the skel e tal mus cle fi ber phe no - type of the ath lete. Torres and her as so ci - ates have col lab o rated with the car di ol ogy and neumonology ser vice of the Uni ver sity Hos pi tal to ex am ine the ef fects of phys i cal train ing on the skel e tal mus cle of pa tients with cor o nary dis ease (32) and chronic ob - struc tive pul mo nary dis ease (33); and the links be tween ex er cise per for mance and skel e tal mus cle char ac ter is tics in pa tients with Cha gas s dis ease (34). Both stud ies (32, 33) trained the pa tients on cy cle ergometers and tread mills at 70% to 80% of their peak ox y gen up take, 3 times a week for 6 weeks. Mus cle bi op sies and cardiopulmonary test ing were per formed be fore and af ter train ing. These stud ies show im prove ments in ox y gen up take, skel - e tal mus cle histological and histochemical changes, sim i lar to those ob served in healthy sub jects. The pa tients also re ported an im prove ment on their health re lated qual ity of life. Taken to gether, these stud ies dem on strate that mod er ately in tense ex er - cise may serve as a valu able ther a peu tic tool in pa tients with cor o nary and, mod er - ately, to se vere chronic ob struc tive pul mo - nary dis ease. In the 1980 s a fourth group emerged, headed by Manuel Velasco and as so ci ates at the Clin i cal Phar ma col ogy Unit, Vargas School of Med i cine, UCV. Their work has been mostly pa tient-ori ented re search, con - duct ing sev eral stud ies ex am in ing car dio - vas cu lar re sponse to ex er cise in hy per ten - sive pa tients, sed en tary sub jects, and ath - letes. They have stud ied the mod u lat ing ef - fect of dopaminergic agents (35, 36), clonidine and minoxidil (37, 38) and indoramin and propranolol (39). For in - stance, they have pro vided ev i dence that the blood pres sure and heart rate re sponse to ex er cise is mod u lated by the dopaminergic sys tem and this ef fect in turn, may be al tered in hy per ten sive com - pared to normotensive in di vid u als (35, 36). The fifth and most re cently es tab lished group op er ates out of the De part ment of Neumonology at the Uni ver sity Hos pi tal, UCV. Their ini tial work was geared to wards cardiopulmonary ex er cise test ing in pa - tients with chronic ob struc tive pul mo nary disease (40). Since then, they have stud ied respiratory muscle recruitment and exercise per for mance in eucapnic and hypercapnic patients; reporting that exercise capacity and ventilatory mus cle re cruit ment are sim i - larly im paired in both types of pa tients (41). They have sug gested that a stair climb ing test is a sim ple way to de ter mine max i mum func tional ca pac ity, whereas the 6 Min ute Walk test was more suit able to as sess ex er - cise tol er ance (42). More re cently, they have col lab o rated with Torres and as so ci - ates to ex am ine the re la tion ship be tween ex er cise per for mance and skel e tal mus cle char ac ter is tics in pa tients with ad vanced Cha gas s dis ease (34). They have also ex - am ined the ef fects of phys i cal train ing on the skel e tal mus cle of pa tients with chronic ob struc tive pul mo nary dis ease (33). Many other groups have used ex er cise par a digms to ex am ine var i ous clin i cal ques - tions. For in stance, the ef fects of ex er cise on asth mat ics (43), dysthmia (44), ma jor de pres sion (45), the car dio vas cu lar re - sponse to amlodipine (46), the Valsalva ma - neu ver (47), lipid, lipoproteins, li pases, and ste roids (48). There have also been stud ies de scrib ing the ef fects of ex er cise on ni tric ox ide pro duc tion (49), uri nary cy clic guanosine monophosphate ex cre tion (50), his ta mine lev els (51) proteinuria (52), rhabdomyolysis (53), platelet func tion and he ma tol ogy (54), and cat a lepsy (55). Most of the lit er a ture dis cussed to this point has been in adults and a few an i mal stud ies. There have been sev eral in ves ti ga tors ex am - in ing ques tions in pe di at ric ex er cise bi ol ogy (56-58), which has been a field of in ter est Investigación Clínica 48(3): 2007

7 The un trans lated sci ence of ex er cise bi ol ogy 383 to the au thor (59-62). Their work (56-58) per tained to the use of ex er cise test ing as a physiological model of stress to assess cardio vas cu lar hyperreactivity, po ten tial risks of pre ma ture hy per ten sion and car dio vas cu - lar dis ease in ad o les cents (56-58). This line of work should be ex tended, as early de tec - tion of cardiosvascular dis ease and prompt phys i cal ac tiv ity in ter ven tions should soon be come a na tional health pri or ity. The au thor is aware of a small group of Venezuelans in ex er cise bi ol ogy over seas, par tic u larly in the United States of Amer - ica. Rafael Reyes, re ceived his doc tor ate from Lou i si ana State Uni ver sity in 2004, were he worked on the car dio vas cu lar and hemo dynamic re sponse to re sis tance train - ing in young and older in di vid u als (63). Otto A. Sánchez, re ceived his doc tor ate at Uni ver sity of Min ne sota in 2004, were he worked on the ef fects of ex er cise train ing on sin gle-fi ber con trac tile prop er ties of di a - betic rats (64). Jazmir M. Hernández, re - ceived her doc tor ate from The Penn syl va nia State Uni ver sity in 1999, were she used a ro dent model to work on pro tein syn the sis and glu cose up take in mixed gas troc ne mius mus cle af ter re sis tance ex er cise (65). The au thor of the pres ent pa per re ceived his doc tor ate from The Uni ver sity of Ten nes see in 1997 were he worked on the met a bolic ef fects of low cortisol dur ing pro longed ex - er cise in adults (66). The sci en tific ba sis of kinesiotherapy and move ment ther apy date back at least to Ex er cise bi ol - ogy/phys i ol ogy was ini tially stud ied in the 1960 s as work phys i ol ogy. There were warn ings against the lack of ex er cise and its ef fects on car dio vas cu lar dis ease, the un - der stand ing of the phys i ol ogy of phys i cal ac tiv ity was pos tu lated as the base for pre - ven tive med i cine. Ven e zue lan sci en tists and cli ni cians have ex plored some ar eas of ex er - cise bi ol ogy, such as cardiopulmonary ex er - cise test ing, skel e tal mus cle ad ap ta tions to train ing and ex er cise car dio vas cu lar phar - ma col ogy, in pa tients, sed en tary sub jects and ath letes. I find it deeply con cern ing that the in ter na tional and na tional lit er a - ture on ex er cise bi ol ogy has had lit tle no - tice able ef fect on Ven e zue lan med i cal ed u - ca tion. There is a need to or ches trate di - dac tic and re search pro grams in ex er cise bi ol ogy to for mally train phy si cians and non-phy si cians in the ba sic and clin i cal ap - pli ca tions of ex er cise bi ol ogy. In par tic u lar, a na tional ini tia tive pool ing to gether re - sources from the med i cal schools, schools of pub lic health, phys i cal ed u ca tion schools and the Na tional In sti tute of Sports, is sug - gested. TRANSLATION OF EXERCISE BIOLOGY: SUGGESTED TENTATIVE STEPS Step 1. Identification of Training Pro grams There is a mas ter s de gree in ex er cise phys i ol ogy in the School of Phys i cal Ed u ca - tion at The Instituto Pedagógico, Ca ra cas. In 2006 the na tional gov ern ment in au gu - rated the Universidad del Deporte, in San Carlos, Cojedes State, where a 4 year phys i - cal ed u ca tion de gree with a track spe cial - iza tion in Phys i cal ac tiv ity and health is avail able. The Universidad Rómulo Gallegos, in San Juan de Los Morros, Guárico State, has an nounced a Sports Med i cine res i dency train ing pro gram for The Na tional In sti tute of Sports has in au gu rated sev eral na tional cen ters for ap - plied sci ence and med i cine in sports (CENACADE) in sev eral states (see www. ind.gov.ve). Taken to gether, these re - sources are meant to launch a ro bust na - tional sports pol icy. If taken to its full length it will be a step for ward as, pre vi - ously, it was sug gested that the na tion had no clear na tional sports and phys i cal fit ness pol icy (67). These ini tia tives could ben e fit from join ing forces with the ex ist ing re - search groups ex plor ing ex er cise bi ol ogy at Vol. 48(3): , 2007

8 384 Del Corral other na tional in sti tu tions. The sci en tific ex change would fa vor both sides and would fa cil i tate a first step to de velop pro grams for phys i cal ac tiv ity in health and dis ease. The next ten ta tive step is ed u ca tion. Step 2. Education A) Ex er cise Bi ol ogy would be a valu - able course for al lied health care work ers. Phys io ther a pist, cardio pulmonary tech nol o - gist, oc cu pa tional ther a pists, and health in - for ma tion tech nol o gists would ben e fit from a course in ex er cise bi ol ogy. B) Exercise biol o gist should be trained and in cor po rated in the med i cal team. The Min is try of Health, Min is try of Ed u ca tion and Sports, and the Min is try of Higher Ed u ca tion could fa cil i - tate a di a logue among med i cal, pub lic health and nu tri tion schools along with the in sti tu tions iden ti fied in Step 1, to train the new doc toral-level health pro fes sional, the ex er cise bi ol o gist. C) Exercise Biology should be in cor po rated into un der grad u ate and grad u ate med i cal ed u ca tion. The course would be taught to med i cal stu dents af ter most of the ba sic sci ences (3 rd year), at the clin i cal level (4 th or 5 th year), and to phy si - cians in train ing (i.e., phys i cal med i cine, com mu nity med i cine, fam ily med i cine). Step 3. Ser vice The pur pose of this step is to pro vide a ser vice to the com mu nity, where: a) the in - di vid u als would be eval u ated clin i cally by qual i fied staff trained in ex er cise bi ol ogy; b) in di vid u al ized ex er cise pre scrip tions would be gen er ated; c) par tic i pants would be fol - lowed up at med i cal and sports fa cil i ties (ap pro pri ately equipped); and d) lab o ra tory and clin i cal eval u a tions would be per formed pe ri od i cally. Who would be the tar get? Ini - tially, the most in need; those with chronic dis eases, the el derly, dis abled, pris on ers or those with drug ad dic tion. Even tu ally, all adults at risk/with chronic dis ease (Fig. 1) would be tar geted. Step 4. Re search Al though Step 1 calls for re search col - lab o ra tion as a link be tween de vel oped and de vel op ing groups, Step 4 calls for or ga - nized re search within the com mu nity pro - gram. The data col lec tion gen er ated from the hos pi tal/com mu nity-based pro grams would pro vide valu able ep i de mi o log i cal data for the na tion which could be use ful to op ti mize ser vice. Ad di tion ally, clin i cal/ba - sic re search pro to cols should be gen er ated from this ini tia tive with the end of gen er at - ing pub li ca tions for peer-re viewed, in ter na - tion ally in dexed jour nals. THE MIS SION OF THE EXERCISE-BIOLOGIST The grad u ates would be ready to join gov ern ment ini tia tives geared to the main - te nance of health and re ha bil i ta tion of dis - ease (Fig. 1). To this end, the pro gram would likely im prove the qual ity of life, de - crease in take of pharmaceuticals and even - tu ally re duce fi nan cial health-care costs. The growth of this pro gram would be, at least ini tially, dic tated by de mands of the Na tional Gov ern ment. PER SPEC TIVES The dan gers of the 20 th and 21 st cen - tury life style have plagued our mod ern civ i - li za tion, lead ing to phys i cal de cay and mul - ti ple chronic dis eases. The sci en tific ev i - dence of di rected ex er cise train ing on health has been en dorsed by the CDC, the Sur geon Gen eral, the NIH, and the WHO. Ven e zue lan cli ni cians and sci en tists have ex plored some ar eas in ex er cise bi ol ogy such as cardiopulmonary ex er cise test ing, skel e tal mus cle ad ap ta tions to train ing and ex er cise car dio vas cu lar-phar ma col ogy. De - spite this, the med i cal ed u ca tion lead er ship has re mained re luc tant to in cor po rate ex er - cise bi ol ogy to the core med i cal cur ric u lum Investigación Clínica 48(3): 2007

9 The un trans lated sci ence of ex er cise bi ol ogy 385 or to sys tem at i cally im ple ment it in grad u - ate med i cal ed u ca tion. This phe nom e non is not unique to Ven e zuela. This how ever, does not ne gate or weaken the pri or ity to or ches trate a na tional ini tia tive to for mally train phy si cians and non-phy si cians in the ba sic and clin i cal ap pli ca tions of ex er cise biology. Al though the Na tional Gov ern ment has taken some steps re gard ing na tional sports pol icy Deporte Para Todos (Sports For All), most of its ef forts are aimed to raise the qual ity of com pet i tive ath letes and less so to serve the health/med i cal phys i cal ac tiv ity needs of the adult and el derly pop u - la tion. There fore, there is a need to bridge the gap be tween ini tia tives in ex er cise bi ol - ogy for hu man per for mance and the few ex ist ing in ex er cise bi ol ogy for health care. Pool ing to gether re sources from the med i cal schools, schools of pub lic health, phys i cal ed u ca tion schools and the Na tional In sti tute of Sports would be an up hill en - deavor with out an or ches trated na tional lead er ship. The WHO called on gov ern - ments around the world to con sider the re - la tion ship be tween phys i cal ac tiv ity and health pro mo tion. To make prog ress, it is vi tal that trans la tion and dis sem i na tion oc - cur. The cru cial ques tion is whether we have the will to take the nec es sary steps. ACKNOWLEDGEMENTS The au thor would like to thank Gra - ham Moo ney, Juan F. Del Cor ral, Margot Corvaia, Sonia H. Torres and Jacinto Convit, for their ed i to rial com ments of an ear lier draft of this manu script. REFERENCES 1. By ford WH. On the phys i ol ogy of ex er cise. Am J Med Sci 1855; 30: LaGrange F. Phys i ol ogy of Bodily Ex er cise. Lon don. Kegan Paul In ter na tional Flexner A. Med i cal ed u ca tion in the United States and Can ada. A re port to the Car ne gie Foun da tion for the Ad vance ment of teach ing, Bul le tin num ber 4, Mor ris JN, Heady JA, Raf fle PA, Rob erts CG, Parks JW. Cor o nary heart-dis ease and phys i cal ac tiv ity of work. Lan cet 1953; 265:1053-7; ; concl. 5. Amer i can Heart As so ci a tion Com mit tee on Ex er cise: ex er cise test ing of in di vid u als with heart dis ease or at risk for its de vel op - ment: A hand book for phy si cians, Dal las, Healthy Peo ple. The Sur geon Gen eral s Re port on Health Pro mo tion and Dis ease Pre ven tion. U.S De part ment of Health, Ed - u ca tion and Wel fare. Wash ing ton, DC. Publication number , Booth FW. Ap pli ca tion of mo lec u lar bi ol - ogy in ex er cise phys i ol ogy. Exerc Sport Sci Rev 1989; 17: Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, Clark DG, Coo per KH, Gib bons LW. Phys i cal fit ness and all-cause mor tal ity. A pro spec tive study of healthy men and women. JAMA 1989; 262: Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC. Phys i cal ac tiv ity and pub lic health. A rec om men da - tion from the Cen ters for Dis ease Con trol and Pre ven tion and the Amer i can Col lege of Sports Med i cine. JAMA 1995; 273: World Health Organiazation-FIMS. Ex er - cise for Health. Bull. World Health Or ga ni - za tion 1995; 73: NIH Con sen sus De vel op ment Panel on Phys i cal Ac tiv ity and Car dio vas cu lar Health. JAMA 1996; 276: U.S. De part ment of Health and Hu man Services. Phys i cal Ac tiv ity and Health: A Re port of the Sur geon Gen eral. At lanta, GA: Cen ters for Dis ease Con trol and Pre - ven tion (CDC), Na tional Cen ter for Chronic Dis ease Pre ven tion and Health Promotion, Brooks WA. The ed u ca tional as pects of phys i cal train ing. Boston Med & Surg J 1895; 132: Vol. 48(3): , 2007

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