“Before engaging in any type of physical activity please consult with your physician.”
Does that statement sound familiar? This little phrase is repeated on every fitness infomercial. You will find it written at least five times in the small print of your gym membership contract, it frequently rears its head after many fitness articles, and it is practically the mantra of every personal trainer who knows for liability purposes he/she better say this. Well my brother and I have some opinions about this little statement.
And if you don’t like controversy, you may want to stop reading right now. To us, this statement is completely ridiculous and makes absolutely no sense.
Just last month, my brother Keoni and I were at a prominent medical university giving a talk on natural medicine to the residents in the family medicine unit. As it is our custom in these talks, we asked for a show of hands of how many of the physicians in the room had any training in exercise during medical school. Not one hand went up. We then asked if any of these doctors received any education in nutrition while in medical school. Out of fifty or so physicians, 1 doctor raised his hand. And the results are the same every single time we visit a medical school like this one.
In case you have not realized it yet, the average medical physician knows next to nothing about exercise and even less about prescribing it. While it may be useful to have a client screened by a physician before beginning exercise, the “check with your physician” statement has two big problems.
- It makes the physician look like an expert in exercise, which they clearly are not.
- It gives the impression that exercise is somehow inherently dangerous.
While we are at it, why don’t we start putting “check with your physician” before eating a meal, walking across the street, or swimming across a pool as well? Sounds pretty ridiculous, doesn’t it?
The activities above are either common sense or have no bearing on what a doctor is trained in doing. Obviously, people can figure out just fine how to eat without choking despite the slight risk of it occurring. By the same token, a memory of our mother reminding us to look both ways when crossing the street usually suffices to keep us from getting run over. And if you are worried about drowning in a pool, we recommend you find a good lifeguard because little purple pills can’t cure water in the lungs. We know these scenarios sound absurd, but doctors are about as useful for exercise prescription as they would be in giving you swimming lessons. The faster you learn that, the quicker you can get in shape, be stronger, and live a happy more vital life without drugs.
The same goes for nutrition. If you have any doubts, just go to your local mall and see how effective doctors have been with their nutrition advice. What you will see is obese people every where you look. What medical doctors are good at is prescribing drugs and doing surgery. And let’s give credit where credit is due. Many of their efforts save lives, but imagine what could be accomplished if physicians had even a fraction of their total education steeped in diet and exercise training.
Here’s how bad it is: When my brother and I were deciding what medical schools to attend, we were shocked to find the curriculums of the average medical school in this country had zero courses in nutrition and zero courses in exercise. Already being well established in the fitness world, this fact immediately sent up red flags, so we set out on a different path.
Rather than choosing a more conventional medical school, we chose to attend one of the few medical universities in the country with a curriculum focused completely on natural health, diet, and exercise. But there is no need to seek out a doctor who specializes in lifestyle medicine, because just around the corner at your local gym you will find professionals who know vastly more about nutrition and exercise than most any doctor. They are called personal trainers.
How bad is it?
There are plenty of people with biased opinions. Rather than give you our honestly slanted view, and without only finding an expert who agrees with us, we do have some more objective data to support what we are saying.
As preventive and alternative medicine becomes more popular, and chronic disease less and less manageable, research has begun to focus on the exercise and nutrition problem. The 2001 May/June issue of Public Health Reports went straight to the source and asked the leaders of today’s medical schools how they themselves felt about the doctors they train. The researchers wanted to know how these directors and teachers of the country’s medical schools felt about the exercise education doctors received and those doctors’ ability to prescribe exercise programs. This study looked at 128 medical schools and had the deans and directors complete the 17-item Exercise and Physical Competence Questionnaire.
While 58% of the respondents believed their students could adequately perform a physical activity readiness screen, only 10% said that they thought their students could design a meaningful exercise prescription. Even less, 6% said their school had a course in educating doctors in the American College of Sports Medicine guidelines for exercise testing and prescription.
Another study in the Journal of Academic Medicine, volume 77, 2002, showed only 13% percent of all medical schools had any education in exercise. The authors stated in their conclusions,
“Providing our future physicians with the knowledge and skills to ask about physical activity, assess past and current activity patterns, and advise patients regarding implementation or maintenance of physical activity patterns will be one of the most significant changes we can make in medical education this decade.”
It appears that the medical students themselves are not that confident in their ability to deliver lifestyle medicine either. 2,316 medical students were tracked through their medical school experience in a study published in the American Journal of Clinical Nutrition in September 2006. What it found is that newly graduated doctors did not have a whole lot of confidence in their level of training.
Only 19% of the doctors felt they had adequate training in nutrition. And only 17% engaged in any kind of nutritional education when counseling patients. This is despite the evidence of the first Nutrition and Health Report by the Surgeon General in 1988. In this report, over 20 years ago, the Surgeon General C. Everett Koop detailed that 8 out of 10 of the top disease killers in America were directly related to nutrition. More than twenty years have passed, and it seems no great strides have been made in supplying physicians with the tools necessary to fight the major chronic diseases we all face.
Physical fitness is lacking in medical professionals
Another big piece of this problem stems from the fact that doctors themselves are not models of physical fitness. It seems this trend starts in medical school. Not only does the medical school curriculum do an abysmal job of educating doctors in preventive medicine like diet and exercise, but the curriculum itself is extremely unhealthy for the doctors.
A study in the July 2004 issue of Military Medicine followed new doctors through their residency with the purpose of tracking changes in physical fitness. The study found that the curriculum significantly decreased the doctors’ level of fitness. This was true for even the most physically fit of the physicians. So not only does medical school not teach doctors about health and fitness, but it actually makes them less healthy and out of shape too.
This has profound consequences for several reasons. Research has shown that doctors, who are fit themselves, are more likely to counsel clients on physical fitness. In addition, physically fit physicians have more credibility among their patients, and this translates into greater patient adherence.
A recent study in the summer of 2006 in the journal Teaching and Learning in Medicine took a close look at several issues related to this. First they wanted to determine if physicians were healthier, less healthy, or just as healthy and physically fit as the rest of the population. What they found was that close to 2/3 of all doctors (60%) were of below average fitness when compared to the general population. Only 15% of physicians were considered above average. Obviously an overweight doctor is not going to inspire much confidence in an overweight patient.
What was most shocking about this study is the complete lack of competence among doctors in simple exercise concepts. Only 27% of doctors were able to list three ways for people to incorporate exercise into their daily life. 61% of doctors were unable to calculate an appropriate exercise heart rate for a patient, and 75% could not list the stages of change that a patient will go through in starting a new exercise lifestyle.
Are there any healthcare practitioners who can help?
If doctors don’t know anything about exercise and little to nothing about nutrition, then who are the experts in diet and exercise?
A doctor once told us that they don’t need nutrition training because they have staff dieticians who handle nutrition. There is no question a dietician is far better than a doctor when it comes to giving nutrition advice. But that still leaves a glaring gap in the exercise knowledge arena. We would also argue that the average dietician is very well trained in calculating calories, adjusting vitamin ratios, and generally very effective in feeding sick people what they need in the hospital. However, by our estimation, they certainly have not been much help in the area of obesity and weight loss. After all, these are the same people who brought us perhaps the biggest nutrition blunder of all time, the low fat diet.
This diet should have been called the “get fat diet”, because as soon as Americans took this advice people started to swell like hot helium balloons. Unfortunately, a great many dieticians still recommend this failed dietary practice to the vast majority of their clients. While not all dieticians are the same, it is buyer beware when taking nutrition advice from these folks.
Perhaps one of the main problems in the debate about who is most qualified to supply lifestyle advice is the fact that the vast majority of professionals and the schools that train them have not yet learned that diet and exercise are directly tied together. In other words, while proper nutritional habits and regular exercise may both provide some benefit on their own, they are most powerful when combined.
Other than a small minority of lifestyle-trained physicians, there is only one other group of individuals who has some education in both, and they are personal trainers. These individuals are the most qualified among healthcare professionals to deliver exercise advice, and they are also versed in the basics of nutrition. Maybe it is time we started to define personal trainers as primary care healthcare professionals.
Redefining healthcare provider
It is obvious that all personal trainers and personal trainer certifications are not nearly the same. However, there is no doubt that organizations like the American College of Sports Medicine and the National Strength and Conditioning Association certify highly qualified fitness instructors. There are other certifying bodies that are equally impressive. These trainers are not only the most knowledgeable health care practitioners as it relates to exercise, but they are fast becoming the go to professionals on topics involving diet as well. Personal training certifications, the good ones anyway, do provide a baseline of nutrition knowledge.
While this in no way makes personal trainers experts in nutrition, it does bring several major points to bear. First, doctors and dieticians see their clients over a desk and simply give advice and have very little follow-up. Personal trainers on the other hand meet with their clients several times weekly giving them a unique place in the healthcare continuum. Personal trainers are literally on the front lines of preventive medicine and are able to motivate, educate, and facilitate healthy lifestyle changes on a continual weekly basis. This alone makes for a powerful force in lifestyle medicine.
Another important point is that personal trainers are often the first and only people to be asked about nutrition advice. While the medical establishment has not yet caught on, the exercising public knows that exercise and diet are linked and will actively inquire about this relationship. This again sets up personal trainers as the gatekeepers in lifestyle medicine. The importance of this fact cannot be overstated. While a dietician or nutritionist may have workable knowledge in nutrition that exceeds the education of a trainer, the trainer is the one put in the position to dispense the advice more times than not. And because they work directly with their clients one-on-one, a level of trust is established that makes it more likely for the client to listen and adhere to the advice in the first place.
The final issue related to trainers is that they are in the best position to deliver true and meaningful results for their clients. Physicians and dieticians are missing at least one, if not both, of the two major determinants of effective body change and health promotion: diet and exercise.
Even if they are well educated in one, it is unlikely they will be adequately educated in both. This means more times than not the patient will fall short in their goals and be left frustrated through lack of progress. Trainers have skills that allow them to excel in both these gaps and also get to spend an appreciable amount of time with their clients, which addresses what some would argue is the major obstacle to body change. That is psychology. The only way to truly change psychology is through changing habits. This takes consistent practice through education and experience. Only personal trainers are in a position to provide adequate, consistent, and constant feedback about appropriate lifestyle choices making their interventions far more powerful.
Researchers McAuley and Courneya, in the journal Applied and Preventative Psychology, in one of the only studies on exercise trainers and exercise were able to show that personal trainers were able to address the 4 most important areas of exercise adherence:
- mastery experiences
- social modeling
- social persuasion
- physiological or emotional states.
This, they argued strongly, could potentially increase exercise adherence.
Finding the Best Personal Trainers
Despite the fact that trainers seem to be well suited to deliver exercise and nutrition advice, they are not without problems. There are many different certifying agencies, some, like the extremely rigorous ACSM Health and Fitness, are science based, involve significant coursework, and require a 4 day pre-exam course. This program along with the NSCA Certified Strength and Conditioning specialist require applicants have a bachelors degree to even sit for the exam. These are all a good example of the best personal trainer certification.
On the other end of the spectrum, there are organizations that literally require no prerequisites, can be obtained in ten minutes over the internet, and have curriculums completely based on their founding trainers. The industry is ripe with charlatans and bogus certifications.
There is currently a push being made to license personal trainers and in our opinion this would be a fantastic move towards delivering personal trainers the credibility they deserve. But until that time, how do you find the best personal trainers who can truly be a top notch primary healthcare provider for you and your patients?
There are a few rules and many of them come out of a recent study published by the Journal of Strength and Conditioning Research in May of 2008.
1. Go Straight to the Source. Your gym or wellness center is responsible for hiring qualified personal trainers. Find out if they have any criteria for hiring personal trainers. The research above shows that unfortunately many gyms and fitness centers do not require any specific certifications.
2. Look up Your Trainer’s Certification. The research above has also shown that the quality of the certification is directly related to the cost. In other words, the best certifications cost more. This is mainly due to the rigor of the programs and the time it takes for education. Many of the best personal trainer certifications require many hours of prep work and study.
3. Look at the Curriculum. Another easy way to tell if your trainer is qualified to deliver the nutrition and exercise guidance you need is to look at the curriculum of study they undertook. Most experts agree that a good certification will address the following levels of competence: basic science, biomechanics, anatomy, physiology, chronic disease education, exercise programming, program management, behavioral modification, and nutritional prescription. As you can see by the list, no 10 minute online certifying organization is likely to accomplish these goals.
4. Ask the Experts. Finally, the best way to know if your trainer is qualified is ask the experts in the field. Here is our list of the tops in personal training certifications:
- ACSM Health Fitness Instructor (ACSM HFI)
- NSCA Certified Strength and Conditioning Specialist (CSCS)
- ACSM CPT
- NSCA CPT
- Cooper Institute
Click here for a personal trainer certification comparison
While this list is not complete, it gives a good place to start in finding the best personal trainers in the industry. Just like with any other health care provider, it is up to you as a consumer to do your homework. Like all service industries, you usually get what you pay for. The cost of a top notch personal trainer is not only off set by the savings in healthcare from remaining healthy, but can save you from poor exercise and nutrition advice dispensed by your local physician.
There are no doubts that there are some very good doctors who not only understand nutrition well, but who also are well versed in exercise. However, these people are in the severe minority. By the same token, there may be nutritionists and dietitians who have spent time educating themselves in exercise and its prescription. These people too, are extremely hard to find. Since my brother and I have received a 6 year medical education that was focused on nutrition and exercise instruction as well as natural health, we are tempted to say just find one of these integrative physicians and problem is solved. However, that too is unrealistic given that personal trainers are far more abundant and affordable.
Which brings us to our final point. There is no doubt that the personal training field is currently in a state of flux. In the current environment you could end up with what we call “fast-food trainers”. These are those that have little to no training and have had their certifications squirted out off the internet, or true fitness professionals who have the correct training and clinical experience to deliver true quality healthcare and lifestyle medicine. Until the industry begins to understand the importance of regulation, it is important to find the best. Make sure the trainers you are after have some degree of education aside from being a past bodybuilding superstar. Most of the best certifications require a bachelor’s degree to even sit for the exam. It is best to always review the curriculum your trainer has gone through. A good personal trainer will be quick to know their limitations and be eager to refer to other healthcare practitioners.
The current environment in health care has left us with a sickness model that relies on drugs, which do nothing to truly bolster the health of the patient. While lifestyle medicine, like diet and exercise, has been shown conclusively to be the only true way to impact the health crisis we face, our family doctors and nutrition professionals are vastly under trained at delivering this advice.
At this rate, qualified personal trainers should be viewed as primary health care providers at the front lines of lifestyle medicine. And in the current environment, and in our opinion, personal trainers are better trained and equipped to deliver this advice than any other health professionals. If you are serious about staying healthy and fit (for you and your patients) then find yourself a good personal trainer. Some day, we may see warnings on drug bottles–“before taking this medication please seek the advice of a qualified personal trainer”.