Injury data from the RWC 2011, 89.1 per 1000 player-hours2011 and the
earlier tournament of 2007, 83.9 per 1000 player-hours may have had an
effect on all teams.
But success could only be accorded to the winner in the final match.
The All Blacks had a long history of not even making the semi-finals.
However the RWC 2011 success was not due to the negative effect of injury
on the team but rath...
Injury data from the RWC 2011, 89.1 per 1000 player-hours2011 and the
earlier tournament of 2007, 83.9 per 1000 player-hours may have had an
effect on all teams.
But success could only be accorded to the winner in the final match.
The All Blacks had a long history of not even making the semi-finals.
However the RWC 2011 success was not due to the negative effect of injury
on the team but rather on the individual team members,for instance the
goal kicker. Other reasons may be due to the organisational arrangements
by the coach and support of its management and the infrastructure of the
national rugby.
At the RWC 2015 success was clearly a cognitive achievement by all teams
when they compare themselves with earlier RWC tournaments but did injury
have an effect? Or was success due to organisational arrangements?
We thank Dr. Bollen for his interest in our paper on knee arthroscopy
for the middle-aged and older patient with a painful knee (Thorlund et al.
2015a,b).
The consistent high-level evidence (Thorlund et al. 2015a,b; Khan et
al. 2015) questioning the benefit of arthroscopic surgery has so far had a
very limited effect on the practice of arthroscopic surgery in middle-aged
and older patients with a...
We thank Dr. Bollen for his interest in our paper on knee arthroscopy
for the middle-aged and older patient with a painful knee (Thorlund et al.
2015a,b).
The consistent high-level evidence (Thorlund et al. 2015a,b; Khan et
al. 2015) questioning the benefit of arthroscopic surgery has so far had a
very limited effect on the practice of arthroscopic surgery in middle-aged
and older patients with a painful knee and suspected meniscus or cartilage
lesion (Cullen et al. 2009, Bohensky et al. 2012, Dearing and Brenkel
2010, Lazic et al. 2014, Thorlund et al. 2014).
Yet, patients included in the randomized controlled trials analyzed
in the recent systematic reviews (Thorlund et al. 2015a,b; Khan et al.
2015) comprise the dominant patient group routinely treated with
arthroscopic knee surgery. Thus, 3 out of 4 patients arthroscopically
treated for suspected meniscus rupture, cartilage lesion or osteoarthritis
of the knee are reported to be older than 35 (Roos and Lohmander 2009,
Cullen et al. 2009, Bohensky et al. 2012, Dearing and Brenkel 2010,
Thorlund et al. 2014, Mattila et al. 2015). Further, a recent
characterization of patients treated with arthroscopic surgery found that
half had a diagnosis of old meniscus tear or osteoarthritis (Bergkvist et
al. 2015). These studies collectively show that a large proportion of
arthroscopic surgeries performed are done in patients where current high-
level evidence does not support the benefit of arthroscopic surgery over
non-surgical treatment.
Arguments that favor arthroscopy focus on patient subgroups among the
middle-aged and older with a painful knee, such as those with "mechanical
symptoms", where arthroscopic surgery is claimed to be effective. However,
criteria for such subgroups remain to be defined, and the benefit of
arthroscopic surgery over non-surgical intervention to be shown in well
designed studies. Indeed, the devil lives in the details.
Dr. Bollen fails to recognize that even extensive clinical
impressions can be very deceiving (Cobb et al. 1959, Wartolowska et al.
2014), and that multiple psychological mechanisms are activated when faith
in clinical experience is questioned by systematically collected evidence.
These mechanisms are inherently human, and are likely applicable also to
orthopaedic surgeons. When high level evidence speaks against clinical
experience and unquestioned routine, cognitive dissonance results.
Defenders of questioned treatments focus on potential scientific flaws in
the published trials to invalidate trial results to decrease their level
of cognitive dissonance, while at the same time they ignore the inherent
bias of clinical experience (Horton 1996, Miller & Kallmes 2010).
Another universal human trait is confirmation bias that makes us ignore,
or not want to be exposed to, information or opinions that challenge what
we already believe, while we readily accept information and beliefs that
confirm what we already believe. This leads to overconfidence in personal
beliefs and reinforces beliefs in the face of contrary evidence. The
effects are stronger for emotionally charged issues and deeply entrenched
views (Prasad et al. 2012, Aspenberg 2014, Lohmander and Roos 2015). A
further contributing factor to lacking implementation of high-level
evidence contrary to unquestioned routine is the organization of the care
pathway which can create perverse incentives to maintain procedure rates
(Hamilton and Howie 2015).
References
Aspenberg P. Mythbusting in orthopedics challenges our desire for meaning.
Acta Orthop 2014;85:547.
Bergkvist D, Dahlberg LE, Neuman P, et al. Knee arthroscopies:
who gets them, what does the radiologist report, and what does the surgeon
find? Acta Orthop 2015;in press.
Bohensky MA, Sundararajan V, Andrianopoulos N, et al. Trends in elective knee
arthroscopies in a population-based cohort, 2000-2009. Med J Aust.
2012;197:399-403.
Cobb LA, Thomas GI, Dillard DH, et al. An evaluation
of internal mammary artery ligation by a double-blind technic. N Engl J
Med 1959;260:1115-18.
Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United
States, 2006. Natl Health Stat Report 2009;11:1-25.
Dearing J, Brenkel IJ. Incidence of knee arthroscopy in patients over
60 years of age in Scotland. Surgeon 2010;8:144-50.
Hamilton DF, Howie CR. Knee arthroscopy: influence of systems for
delivering healthcare on procedure rates. BMJ 2015;351:h4720.
Horton R. Surgical research or comic opera: questions, but few
answers. Lancet 1996;347:984-5.
Khan M, Evaniew N, Bedi A, et al. Arthroscopic surgery for
degenerative tears of the meniscus: a systematic review and meta-analysis.
CMAJ 2014;186:1057-64.
Lazic S, Boughton O, Hing C, et al. Arthroscopic washout for the
knee: a procedure in decline. Knee 2014;21:631-4.
Lohmander LS, Roos EM. The evidence base for orthopaedics and sports
medicine. Scandalously poor in parts. BMJ 2015;350:g7835.
Mattila VM, Sihvonen R, Paloneva J, et al. Changes in
rates of arthroscopy due to degenerative knee disease and traumatic
meniscal tears in Finland and Sweden. Acta Orthop 2015;in press.
Miller FG, Kallmes DF. The case of vertebroplasty trials. Promoting a
culture of evidence-based procedural medicine. Spine 2010;35:2023-6.
Prasad V, Cifu A, Ioannidis JPA. Reversals of established medical
practices. Evidence to abandon ship. JAMA 2012;307:37-8.
Roos EM, Lohmander LS. Young patients--old knees. Knee problems in
the middle age often osteoarthritis. Lakartidningen 2009;106:1645-8.
Thorlund JB, Hare KB, Lohmander LS. Large increase in arthroscopic
meniscus surgery of middle-aged and older in Denmark from 2000 to 2011.
Acta Orthop 2014;85:287-92.
Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for
the degenerative knee: systematic review and meta-analysis of benefits and
harms. BMJ 2015a;350:h2747.
Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for
degenerative knee: systematic review and meta-analysis of benefits and
harms. Br J Sports Med 2015b;49:1229-35.
Wartolowska K, Judge A, Hopewell S, et al. Use of placebo controls in the evaluation of surgery: systematic
review. BMJ 2014;348:g3253.
The German physician Christopher William Hufeland (1762 - 1836) wrote
in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the
movements is the grand foundation on which health, uniformity of
restoration, and the duration of the body, depend; and these certainly
cannot take place if we merely sit and think. The propensity to bodily
movement is, in man, as great as the propensity to eating and drinking.
Let us...
The German physician Christopher William Hufeland (1762 - 1836) wrote
in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the
movements is the grand foundation on which health, uniformity of
restoration, and the duration of the body, depend; and these certainly
cannot take place if we merely sit and think. The propensity to bodily
movement is, in man, as great as the propensity to eating and drinking.
Let us only look at a child. Sitting still is to it the greatest
punishment. And the faculty of sitting the whole day, and not feeling the
least desire for moving, is certainly an unnatural and diseased state. We
are taught by experience, that those men attained to the greatest age, who
accustomed themselves to strong and incessant exercise in the open air. I
consider it, therefore, as an indispensable law of longevity, that one
should exercise, at least, an hour every day, in the open air."
I would like to comment on the conclusions of the recent published
meta-analysis by Thorlund et al in the BMJ and the subsequent
sensationalist editorial. The conclusions are at odds with my own personal
experience and that of my peer group.
Although the methodology of the study is valid I would take issue
with the conclusions reached.
The meta-analysis on benefit started with nearly 1800 studies and wa...
I would like to comment on the conclusions of the recent published
meta-analysis by Thorlund et al in the BMJ and the subsequent
sensationalist editorial. The conclusions are at odds with my own personal
experience and that of my peer group.
Although the methodology of the study is valid I would take issue
with the conclusions reached.
The meta-analysis on benefit started with nearly 1800 studies and was
reduced to 10 (although in the text of the article, only 9 references are
cited after this statement). The meta-analysis on harm was on a separate
series starting with 2330 studies reduced to 9.
The devil is in the detail and I will address each study
individually. I review papers for journals and would certainly not have
allowed some of the conclusions reached in the papers, past the peer
review stage.
To start with, the 9 (or 10!) studies on benefit (or not) are a mixed
bunch dealing with degenerative change (3), degenerative meniscal tears (6
- 2 of which are the same study at different time intervals) or a
combination of the two (1). Two papers would never pass an ethics
committee in the UK and would not be considered for publication in the UK.
One of the papers on meniscal injury is related to depression and anxiety
and in an obscure journal. I have excluded this from my analysis as I
don't generally perform surgery to improve a patients psyche and
commenting on this is outside my sphere of competence.
Benefits (or lack of!)
Partial Meniscectomy
Yim et al - well conducted study but in common with other papers,
diagnosis had a large reliance on MRI findings and only 2/3 of eligible
patients entered the study. Patients who had any form of bony surgery were
excluded. This study was performed in South Korea in a population that is
very different, culturally and biomechanically from patients in the West
and its findings are only directly applicable to similar populations.
Gauffin et al - This paper states that patients having surgery had
significantly less pain than the non-surgery group at 12 months.
Sihvonen et al - this paper includes a sham surgery arm, which would
be regarded as unethical in the UK. Of 205 eligible patients 49 were
excluded. Interventions were carried out in 5 centres meaning only 30 in
each centre. The authors state only meniscal surgery was performed - "no
other surgical procedure was carried out". Tucked away in the
supplementary appendix is the "findings at arthroscopy" - only 20% of the
intervention group had no or mild degenerative change and 33% of the sham
surgery group. 54% of the intervention group had degenerative change and
40% of the sham surgery group and an equal number in each group were
osteoarthritic. This study only addresses intervention for one part of the
knee when the pathology is likely to be multifactorial and in particular
where there was no clear identification of symptoms directly attributable
to a meniscal tear.
Herrlins et al's 2 papers are also interesting, being a 2 and 5 year
follow up in the same cohort of patients. It is perhaps the most
disturbing, in that the authors of the meta-analysis neatly discard the
results and conclusions of the 5 year study "as the other outcomes are
only out to 2 years". Perhaps this is because the conclusions of the 5
year outcomes are very different from those of the 2 year outcomes.
Specifically - in the 2007 paper (2 year follow up) the abstract states -
"arthroscopic partial medial meniscectomy alone, followed by exercise
therapy was not superior to supervised exercise alone". In the 2013 (5
year follow up) paper the authors make the same statement but add
"however, one third of patients from the exercise group, still had
disabling symptoms but improved to the same level after surgery".
Meniscal tear and Osteoarthritis.
There is only one, widely quoted, paper in this group by Katz et al.
Once again there is a large reliance on MRI diagnosis for degenerative
change and meniscal tearing. Enrollment was based on one symptom, of at
least 4 weeks duration, that might suggest a meniscal tear and a positive
MRI. There were 7 centres involved in the study with numbers per centre
ranging from119 to 17 patients. Of 1330 patients eligible for the study
only 351 were enrolled. Of the 150 patients in the physical therapy group
51 had crossed to the surgery group in the first 6 months and a further 8
did so between 6-12 months. After surgery these patients improved to the
level of the initially operated on patients. At 6 months 67% of surgical
patients improved by 8 points on the WOMAC scale compared with 43%
patients in the physical therapy group (bear in mind a third of these had
crossed over to the operated group).
In the UK it is very unusual to see a patient with symptoms of only 4
weeks duration and one must ask the reason why 2/3 of the patients
declined to enter the study (not defined by the authors). The most likely
reason in my experience is many patients will already have had
physiotherapy before referral and not surprisingly, wouldn't want to be
randomized to a group receiving treatment that had already failed them.
Osteoarthritis
Chang et al's paper is a small series, with 18 in one group and 14
in the lavage group ie both had an intervention. About half of each group
had significant improvement at 12 months, but the authors reach the
conclusion that "arthroscopic surgery may be beneficial in certain
subgroups". This study is smaller than a study by Hubbard and one has to
ask why Hubbards paper (see below), with a larger number of patients,
wasn't included despite being almost identical in design.
Kirkley et al, again compares conservative management with
conservative management + meniscal surgery. Once again 26% of those
eligible did not complete the trial. The authors excluded any patient with
grade 1 radiographic changes and 50% of the patients had grade 3 or 4
osteoarthritis. Generally in the UK there would be little indication for
surgical intervention in more advanced OA unless there are associated
mechanical symptoms.
Moseley et al's paper would again not be accepted by an English
orthopaedic journal as it includes a sham surgery arm. It has already had
a fairly robust rebuttal in an editorial in "Arthroscopy". Of the 324
patients eligible for the trial 144 declined to be enrolled. 25% of the
patients had "severe osteoarthritis" - a group that would generally not be
considered for surgery in the UK.
To quote Bob Jackson
"This study was seriously flawed, first by the selection of patients with
no clear indication as to how severe the arthritic state was in each case.
Second, patients in the Veterans Affairs system do not represent the
typical population, which consists of younger people and women (97% of
study patients were men). Moreover, VA patients have a vested interest in
getting continued benefits for a disability. Third, the statistics used in
the paper have been strongly criticized by independent statisticians, as
the authors changed their direction on 3 occasions, first using an
established device to show superiority of one group over another (which it
did not), then using another proven device to demonstrate "equivalence"
(which it did not), and then finally using an unvalidated measurement
device of their own making, which did prove equivalence of the 3 groups."
Adverse Events
The authors of the meta-analysis boldly state - "Arthroscopy is
associated with harms" without any qualification of this statement.
Professor Andy Carr has also recently stated in the BMJ that the
death rate from arthroscopic surgery is approximately 1/1000 and deep vein
thrombosis as 4 per 1000. Perhaps most worrying is this statement has been
published without being referenced and despite emailing him I have not had
a reply as to where these figures come from. This is, quite frankly,
irresponsible of the BMJ. In my immediate group we have performed
approximately 50,000 arthroscopies without a death.
The authors of the meta-analysis have been disingenuous in that they
have taken a separate series of studies on complications and then applied
them to the separate series of surgical results they have analysed. This
cannot be logical or scientifically valid.
There are some large studies but these generally include all
arthroscopic surgery, including complex ligament surgery, arthroscopic
washout for septic arthritis etc, and not just meniscectomy and
debridement.
Maletis et al, analyzing some 21,800 cases , report only one
surgically attributable death.
Hetsroni et al quote a 2.8 /10,000 rate of pulmonary embolism but
this is strongly associated with increasing age, complexity of surgery and
operating time ie is not directly related to simple arthroscopic surgery.
Jameson's study included all arthroscopic surgery including ligament
reconstruction, with problems once again associated with more complex
surgery. Perhaps the most relevant point in this series is that a lower
rate of problems was associated with high volume units. The authors state
"Complications following arthroscopy of the knee are rare. It is a safe
procedure."
Hame et al's paper states "post operative complications are rare",
and this is in a series of patients who were all over 65 - a noted risk
factor.
The authors of the meta-analysis also include 2 papers from the
analysed "benefit" series in their analysis of adverse events.
Although they include the paper by Sihvonen et al the only adverse
event was a deep infection, which occurred 4 months after surgery
following a dental procedure and surely can't be directly attributed to
the operation.
Perhaps the most interesting paper in their series is the widely
quoted paper by Katz et al , which compared surgery against physical
therapy followed up for 12 months. They reported 2 deaths - however one
occurred in the physical therapy group! Adverse events of mild to moderate
severity occurred in 15 patients post surgery and 13 in the physical
therapy group. Ie physical therapy seems just as dangerous to the patient.
Discussion
I do not believe the stated conclusions of the meta-analysis can be
justified by the evidence provided, and the paper does not seem to have
been robustly reviewed or edited in appropriate detail. I hope I have
demonstrated this in the above commentary.
In my own experience, appropriate debridement in early osteoarthritis
can produce pain relief and improved function for anything up to 4 to 10
years. This has been shown in the literature in a prospective randomized,
single surgeon study on consecutive patients - Hubbard MJS JBJS 1996 (for
some reason not included in the meta-analysis) - which reports 50% of
patients with continued pain relief at 5 years. Aichcroth et al's paper in
1991 (large number with only a small number lost to follow up) showed 75%
of patients had minimal discomfort and improved function at 4 years post
surgery and only 14% of patients had had to progress to further surgery.
Although this study is not randomized, it was prospective and for a group
of patients who had significant symptoms of significant duration who had
already failed conservative management.
As far as meniscal tear goes, from the papers presented, this would
seem to be a valid intervention even in series where I would take issue
with some of the diagnostic criteria. It has been clearly demonstrated
that diagnosis of clinically relevant meniscal tears is more sensitive and
specific in the hands of an experienced knee clinician than MRI. - O'Shea
K.J., et al Am J Sports Med 1996, and Gelb et al Am J Sports Med 1996.
To make the diagnosis of meniscal tear based on joint line pain and a
positive MRI is clinical laziness at best. Posteromedial tenderness and
fullness (often associated with a small parameniscal cyst) which mimics
the patients pain, decreased flexion, pain on crouching and pain on
sleeping with the knees together, almost always results in immediate pain
relief flowing arthroscopic resection of the tear.
Even despite the poor clinical discrimination, 30% of patients failed
conservative management with "continuing disabling symptoms" and were
provided with pain relief on surgical intervention. An intervention which,
in skilled hands is quick, relatively painless, and has a very, very low
morbidity.
The authors state "these finding do not support the practice of
arthroscopic surgery for middle aged or older patients with knee pain with
or without signs of osteoarthritis" without defining the cause of the
pain. This statement is not supported by the evidence provided. A
summation of erroneous conclusions does not equate to a new "evidence
based" conclusion. To baldly state "arthroscopy is associated with harms"
with having looked at the complication rate specifically for simple
uncomplicated arthroscopic surgery is unacceptable and should not have
been allowed through by the editorial team.
The worry is that symptomatic patients will be denied appropriate
treatment based on the findings of this "scientific study" which are in
reality not scientifically valid. As is so often the case, it is the
surgeon performing the procedure and not the procedure itself that is
critical in getting a good outcome.
At the age of 86, I am a strong believer in the virtues of moderate
physical activity for the elderly, walking some 5 km most mornings, and
tending a substantial garden. Moreover, I agree with the proposition that
for an elderly population, any physical activity is better than none, and
that controlled experiments can be devised to demonstrate some of the
short-term benefits of an increase in such activity. However, I w...
At the age of 86, I am a strong believer in the virtues of moderate
physical activity for the elderly, walking some 5 km most mornings, and
tending a substantial garden. Moreover, I agree with the proposition that
for an elderly population, any physical activity is better than none, and
that controlled experiments can be devised to demonstrate some of the
short-term benefits of an increase in such activity. However, I was a
little surprised that the normally eagle-eyed editors and reviewers of
BJSM allowed the current wording of the systematic review and meta-
analysis of low-level physical activity and death rates, as published in
the October issue. In this article, Hupin et al. [1] repeatedly make the
claim that "a dose of MVPA below current recommendations reduced mortality
by 22% in older adults." But it seems clear that the papers cited in
their well-conducted meta-analysis have demonstrated an association
between light physical activity and mortality rather than a causal
reduction in mortality. In most of the investigations considered, the
better initial health of some participants could account for both their
greater habitual activity and also their lower mortality, and the same
problem confounds the analysis of dose-response relationships. We cannot
determine how much physical activity is the cause, and how much it is a
consequence of good health. This is an important issue, and an unfortunate
limitation of much epidemiological research. Partial remedies are to
follow cohorts with differing levels of physical activity for some years
before beginning a study, and to examine the effects of a change in
physical activity over the course of observations.
References
1. Hupin D, Roche F, Gremeaux V. et al. (2015). Even a moderate-to-
vigorous physical activity reduces mortality by 22% in adults aged >60
years; a systematic review and meta-analysis. Br J Sports Med 2015; 49:
1262-1267.
It is common practice to refer lower limb injuries as non-contact, in
this paper the categories have been clearly defined. The term pressing
needs defining which may help the non soccer community.
All lower limb injuries in football ought to be categorised as contact or
in-direct contact with respect to the ground or an opponent. The
principles of the Laws of Motion from Newtonian mechanics and basic
physics might add fur...
It is common practice to refer lower limb injuries as non-contact, in
this paper the categories have been clearly defined. The term pressing
needs defining which may help the non soccer community.
All lower limb injuries in football ought to be categorised as contact or
in-direct contact with respect to the ground or an opponent. The
principles of the Laws of Motion from Newtonian mechanics and basic
physics might add further an understanding of patterns of movement and
relative contact with the ground and the opponent.
References:
Bunn, JW (1972) Scientific principles of coaching. Englewood Cliffs,New
Jersey.
Armenti,A (1992) The Physics of Sports. Springer-Verlag, New York.
Testosterone is one of the anabolic androgen steroids (AAS) that has
been abused to improve higher athletic performance by enhancing muscle
development and recovery. The purpose of this study was to assess basal
level of serum total testosterone in male athletes and to compare it with
physically active and sedentary males.
The study sample was composed of 40
males divided in four groups of different physical acti...
Testosterone is one of the anabolic androgen steroids (AAS) that has
been abused to improve higher athletic performance by enhancing muscle
development and recovery. The purpose of this study was to assess basal
level of serum total testosterone in male athletes and to compare it with
physically active and sedentary males.
The study sample was composed of 40
males divided in four groups of different physical activity level: two
athlete groups (basketball and football), one physically active and one
sedentary group. The subjects were assessed for the level of total
testosterone by Chemiluminescent Immunoassay, controlling for biological
parameters including age, body mass index (BMI), lean body mass (LBM),
diurnal variations. LBM of basketball players (70.2 ? 1.9 kg) was higher
(p < 0.05) than other groups.
Basketball players showed a lower
testosterone level (10.8 ? 1.0) compared with other groups (p < 0.05).
The highest significant difference (p < 0.05) according to basal level
of total testosterone was between basketball players and sedentary (16.7 ?
1.5). Decreased basal level of total testosterone of basketball players
correlates with high LBM in respect to other physically active groups (p
< 0.05). Future suggestion for WADA is to review the upper reference
limit of basal level of total testosterone after the vigorous training
periods for Basketball players
Recent editorials have renewed the debate on the role of physical
inactivity in the current obesity epidemic. [1, 2] Malhotra and colleagues
cite an opinion piece suggesting "little change of physical activity
levels in the past 30 years," while Blair counters that U.S. Dept. of
Labor statistics show "mining, agriculture and agricultural jobs declined
substantially."
Recent editorials have renewed the debate on the role of physical
inactivity in the current obesity epidemic. [1, 2] Malhotra and colleagues
cite an opinion piece suggesting "little change of physical activity
levels in the past 30 years," while Blair counters that U.S. Dept. of
Labor statistics show "mining, agriculture and agricultural jobs declined
substantially."
Both statements have some truth, but they neglect the degree of
energy imbalance needed to make a person obese. In moving from an
acceptable body mass to obesity (BMI > 30 kg/m2), an adult accumulates
about 15 kg of fat, and a child 5 kg. If spread over 10 years, this
equates to 10-30 g/week, or a daily energy imbalance of about 50-150 kJ.
Current statistics lack the accuracy to detect such an imbalance.
Many of the obese are children, unaffected by changes in mining.
However, walking or cycling 1-2 km to and from school is now widely
replaced by transportation in their parents' cars. This could easily
reduce daily energy expenditure by 50-150 kJ.
References
1. Malhotra A, Noakes T, Phinney S. It is time to bust the myth of
physical inactivity and obesity: you cannot outrun a bad diet. Br J Sports
Med 2015; 49: 907-8.
2. Blair SN. Physical inactivity and obesity is not a myth: Dr. Steven
Blair comments on Dr. Aseem Malhotra's editorial. Br J Sports Med 2015;
49: 908-9.
Roy J. Shephard,
PO Box 521,
Brackendale,
BC V0N 1H0,
Canada.
It is like saying Coca-Cola is the favorite drink of many athletes.
The truth is much more complex.
Research in this field that is funded by the beverages industry tends to
be biased.
There will always be people in any field, including scientific research,
who will do almost anything to make a buck.
I can understand the necessity of balancing the views on any public health
issue, but here the balance is tipped over by an ev...
It is like saying Coca-Cola is the favorite drink of many athletes.
The truth is much more complex.
Research in this field that is funded by the beverages industry tends to
be biased.
There will always be people in any field, including scientific research,
who will do almost anything to make a buck.
I can understand the necessity of balancing the views on any public health
issue, but here the balance is tipped over by an evident conflict of
interest.
We thank Prof Cooper for his comments (15th June 2015) on our Letter to the Editor, and in particular his critique of our Point 3. We stated in our original letter that "we invite discussion and criticism of our review, and will gladly amend any sections that can...
We thank Prof Cooper for his comments (15th June 2015) on our Letter to the Editor, and in particular his critique of our Point 3. We stated in our original letter that "we invite discussion and criticism of our review, and will gladly amend any sections that can be shown to be incorrect." In that spirit we will modify our Point 3 accordingly to better reflect the evidence, but we would also like to discuss further the issue that Prof Cooper has raised.
In our letter we pointed to the "Physical Activity Guidelines Advisory Committee Report" in relation to studies showing that physical activity (PA) has an effect on body weight and to challenge the (unreferenced and un-evidenced) claim by Malhotra et al., that "...physical activity does not promote weight loss". The text on page G4-5 to G4-6 of the report clearly describes that from 20 identified RCTs, 4 had appropriate designs and sufficient statistical power to assess weight loss. They showed weight loss of 1-3 kg for 13-26 MET.hours per week, with greater losses at greater doses of PA (1). Presumably Prof Cooper does not dispute this interpretation of the evidence.
We believe the discussion here should focus on the selection of included studies, critique of exposure and outcome measures, and assessment of risk of bias within each study. Debate should also focus on whether 1-3 kg has population level public health relevance as only very large doses of PA resulted in losses greater than the 5% suggested by the report as having clinical relevance.
Perhaps of greatest importance is whether the PA regimens used in these studies could ever be implemented at a population level. On this point we suspect not, and we would highlight again we are sceptical that PA alone is an answer to obesity. It was not our intention to give this impression but to show that the claims of Malhotra et al., did not represent the available evidence. We agree that the evidence suggests diet has a substantially greater effect than PA, and in our original letter we went on to cite further evidence stating that diet plus PA appears to have the greatest effect (2).
Prof Cooper is quite right to say that Figure G4.2 shows that diet has a greater effect than exercise (PA). To directly quote the original study from which the figure was adapted "Randomized trials consistently show benefits of exercise for weight loss, but the effects are often modest" (3). Again we invite debate on the included studies, control conditions used, definition of "modest", and whether these findings have public health relevance - but they clearly contradict the Malhotra claim.
Prof Cooper requests "In the spirit of rigor and honesty I think they should revise their criticism # 3. Even more importantly, they should provide evidence that exercise alone prevents or reduces obesity or they should acknowledge - as the NIH document does - that exercise alone is ineffective."
We have clarified above how the cited report (1) and the 1999 paper it references (3) show that PA (exercise) reduces body weight. We have also submitted an addendum to our Point 3 accordingly to acknowledge that there is debate over the magnitude and clinical relevance of effect, and to emphasise that diet appears to be more effective than PA for reducing obesity. Further, we welcome continued debate on effect, effect size, clinical relevance, study quality, scalability and generalizability. To suggest that the debate on the usefulness of PA is finished is misleading and should be questioned - as Prof Cooper correctly pointed out the Physical Activity Guidelines Advisory Committee Report is equivocal in its interpretation of the evidence. More importantly we also caution against PA only approaches and recommend multi-component approaches combining diet and PA (4).
Finally, we note Prof Cooper refers to "curbing the obesity epidemic". We would point out that this inherently refers to the relative merits of PA and diet in weight maintenance, which is different to weight reduction and has not been the focus of this discussion.
1. Committee PAGA. Physical activity guidelines advisory committee report, 2008. Washington, DC: US Department of Health and Human Services. 2008;2008:A1-H14.
2. Johns DJ, Hartmann-Boyce J, Jebb SA, Aveyard P. Diet or exercise interventions vs combined behavioral weight management programs: a systematic review and meta-analysis of direct comparisons. J AcadNutr Diet. 2014;114(10):1557-68.
3. Wing RR. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues. Medicine and science in sports and exercise. 1999;31(11 Suppl):S547-52.
4. Hunt K, Wyke S, Gray CM, Anderson AS, Brady A, Bunn C, et al. A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. Lancet (London, England). 2014;383(9924):1211-21.
Conflict of Interest:
We receive funding from a number of national and international research councils, and companies that make devices for physical activity and sedentary behaviour research. We do not receive funding from the food industry.
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In response to Professor Cooper:
We thank Prof Cooper for his comments (15th June 2015) on our Letter to the Editor, and in particular his critique of our Point 3. We stated in our original letter that "we invite discussion and criticism of our review, and will gladly amend any sections that can...
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