Fitness
February 12, 2012
Today’s blog post will be a guest-post from my friend and colleague, Anoop Balanchandran. For those who don’t know, Anoop is one of the most astute trainers around. In addition to being a top fitness pro, he is the founder of the excellent site, Exercise Biology, which provides cutting-edge articles and discussion about a wide range of fitness and nutritional topics. What I particularly admire about Anoop is his commitment to evidence-based practice. His article here shows his passion on the subject. I think you’ll find it to be highly informative. Hopefully it spurs thought and discussion. Feel free to chime in with your comments/feedback.
Why We Need an Evidence-Based Approach in the Fitness Field
By Anoop Balachandran, MS, CSCS
We have so many experts in the field who have been working in the trenches for years and getting results. So what is really the need for an evidence-based approach? Why do we spend millions of dollars on research? And why are people like myself, Brad Schoenfeld, Mark Young, Lyle McDonald, Alan Aragon and a few others so bent on scientific studies?
In this article, I am going to write about why evidence-based medicine evolved in the first place. Or what circumstances in the history of medicine led to the evolution of evidence-based medicine. These are the very same reasons evidence-based approach is used in other fields too, including fitness and strength conditioning.
I always felt that if you don’t understand why the evidence-based approach evolved, you will never really be bothered to look up studies or hear the science. You will of course say research is important, but will always be swayed by anecdotal evidences.
Almost everyone falls back to 3 types of evidences when they don’t have any scientific studies to support: Ancient wisdom, expert opinion, and common sense. What follows is a discussion of the problems with these approaches along with relevant examples of each:
Ancient wisdom
This is one of the most common arguments that are posed as “evidence” for why certain treatments should work or why it should get a pass from being tested scientifically. It is assumed that the longer the treatments existed, the stronger the evidence that it works.
Ancient Pharmacology: It is often quoted by medical historians that we used to use diuretics, purgatives, emetics, abortifacients and other drugs even before pharmacologic science evolved. And it is very true that they existed, but the effects of these drugs are grossly misleading.
Emetics work by making people vomit, but what conditions did vomiting help? Purgatives are useful for constipation, but nothing else; they only serve to dehydrate and weaken the people who were already dehydrated and weak. Diuretics were most commonly used for acute infections, but they only made the existing condition worse. Drugs were used to make people sweat thinking that it will get rid of toxins, but the only things they got rid of were essential fluids and salt from the body that was vital for an ill person. Crocodile dung was even placed in women’s vaginas for abortion and to prevent conception!
What about surgeries? Ancient Egyptians were skillful enough to remove a portion of the skull without killing the patient, but they didn’t have any clue what they were doing inside the skull in the first place. They performed these surgeries in people who had psychological problems yet all it did was cause pain and death for most. It is known that ancient Egyptians used moldy bread to treat infections. But even in the 19th century, even after we knew there was something in penicillin that could kill bacteria, the doctors struggled to get some practical benifits. Without the right species and chemical procedures to extract concentrated amounts of it, it was just useless. Now what chance does moldy bread stand in healing? The list can go on and on. There were some treatments that did do well such as mercury, antimony, and such. But the benefits were heavily outweighed by the harms that came with them.
Bloodletting: The practice of bloodletting was the standard medical treatment for almost 2500 years, lasting even till the 19th century. The most common form of bloodletting was cutting the vein, besides using cups and leeches.
It was based on the humoral theory of disease: all diseases and disabilities resulted from an excess or deficit of one of these four humors. The ancient Ayurvedic system in India, traditional Chinese medicine and Unani are very similar to the humoral theory. The four humors were black bile, yellow bile, phlegm, and blood.
Sick patients were thought to have an imbalance of their humors, which bloodletting was thought to restore. Doctors bled patients for every ailment imaginable. They bled for pneumonia and fevers, back pain and rheumatism, headaches and melancholia; even to treat bone fractures and other wounds.
Here is a quote from a historian on the subject: “The total quantity of blood taken amounted to 124-126 ounces or 3.75 liters, drawn over a period of nine to ten hours on Saturday, December 14, 1799.” The patient: George Washington – the first president of America – died that very same day. What do you think killed him – the infection or the “treatment”?
Now think about it for a second: Bloodletting endured for more than 2500 years and was considered as the major medical treatment for almost every disease. How can so many millions of people and thousands of experts go wrong for hundreds of years?
Expert Opinion
Experts in every field have one thing in common – an unflinching self-confidence in their treatments and procedures.
Galen was the greatest physician of ancient Medicine after Hippocrates. Galen wrote about one his potions: “All who drink of this remedy recover in a short time, except those whom it does not help, who all die. Therefore, it is obvious that it fails only in incurable cases.” In short, if you got cured, it’s his medicine. If not, it is your fault.
In 1920, not all that long ago, William Osler, often called father of modern medicine and one of the most influential medical authorities in the world wrote: “To bleed at the very onset in robust, healthy individuals in whom the disease sets in with great intensity and high fever is good practice.”
Sleeping Babies: Dr. Benjamin Spock was one of the foremost experts in pediatrics. His book titled, Baby and Child Care, was the bible for both professionals and parents, especially in USA and UK for several decades. He wrote that a disadvantage of babies sleeping on their backs was that, if they vomited, they would be more likely to choke. Dr Spock therefore advised his millions of readers to encourage babies to sleep on their tummies. Sounds reasonable right?
Later scientific studies showed that babies sleeping on their stomachs increased the risk of sudden infant death syndrome. We now know that this advice, apparently rational in theory, led to the cot deaths of tens of thousands of infants.
Repressed Memories: Though we dumped most of the Freudian concepts of psychoanalysis, repressed memories still lingered. The subject of repressed memories has been one of the most controversial areas in psychology. Therapists claimed that anxiety, eating disorders, depression were due to memories of childhood sexual abuse that were repressed. And ‘therapy’ can unearth these buried memories.
The 1980’s began to see thousands and thousands of court cases being filed against parents, former neighbors, former teachers, former ministers and priests for sexual abuse based on newly discovered memories.
A few years later studies showed that suggestions and leading questions by therapists can implant false memories and that repressed memories have very little evidence. Imagine the pain of those fathers who went to grave bearing the burden of their own daughter falsely accusing them of sexual abuse. This is another example of how experts were unwilling to scientifically question their casual observations and beliefs that can lead to disastrous consequences. .
Lobotomy: The New York Times once wrote this about lobotomy: “…a groundbreaking medical procedure that promised hope to the most distressed mentally ill patients and their families”. The treatment was pretty simple: You surgically sever certain connections in the brain. Walter Freeman made it even simpler – he could do the procedure within 5 minutes without the need of a surgical room and anesthesia. Freeman’s “ice-pick” lobotomy involved inserting an ice pick like-instrument through the eye socket, tapping it with a hammer, and ‘wiggling’ it around to sever the frontal lobe. In 1949, the number of lobotomies conducted rose to 5000 per year. There were a few success stories, but for many patients the procedure resulted in a vegetative state, or reduced them to a childlike mental faculty.
Later this treatment was considered as one of the most barbaric mistakes of modern medicine. In his dying years, Walter Freedman travelled across the country to see his former patients to show the world that lobotomy “helped”. Just like most experts, he still couldn’t see where or what went wrong.
All these examples show how even well-meaning experts who have practiced their art for years in their field can go horribly wrong.
Common sense
This is another reason how treatments are justified in the absence of scientific studies. If the theory makes sense, why not use it.
Heart Rhythm Abnormalities: Heart rhythm abnormalities are associated with an increased risk of death after heart attack .So the theory was that a certain drug would prevent heart rhythm abnormalities and thus lower early deaths. The drug was licensed and the drug was prescribed in 1970. Most doctors were convinced of the drug from their excellent ‘results’. Just to convince the minority of unbelievers, a large scientific study was conducted in 1987.
As expected, the drugs stopped the abnormal heart beats in the study. It also stopped the heart. The five- year study was stopped in two years because people on these drugs were dying. At the peak of their use in the late 1980s, it is estimated that they may have been killing as many as 70,000 people every year in the United States alone – many more than the total number of Americans who died in the Vietnam War.
Hormone replacement Therapy (HRT): Hormone replacement therapy was based on the rationale that restoring estrogen levels in menopausal women would be helpful. This made sense since the female body stopped producing estrogen during menopause so replacing the estrogen could conceivably bring back the lost youth. HRT claimed to prevent heart attacks and strokes and millions of people, advised by their own doctors, started taking HRT.
In 1993, Women’s health initiative study was embarked to confirm the belief that HRT was saving lives. The study was stopped early because the number of deaths from breast cancer was higher in the hormone treated group. This study was later confirmed by other two large trials. It is estimated that in the UK alone the use of HRT was causing an extra 2000 cases breast cancer cases a year.
The thalidomide disaster, diethylstilboestrol (DES) disaster and many other tragic stories from the past have reminded us again and again to be very skeptical of our casual conclusions. There are even more not-so tragic stories of treatments that were claimed to be effective for specific conditions, but later proved to be ineffective. In the fitness and strength and conditioning field, there are a lot of programs just based on grandiose theories, expert opinion and testimonials but yet to be scientifically tested.
Conclusion
I can keep going on and on, but hopefully it’s clear that an evidence-based approach was born because experts, ancient medicine, and theories were getting it wrong – so wrong that people were dying in thousands. Most of these experts were the foremost experts in their field and had mastered the so-called art of medicine or treatment.
I hope this article serves to show why treatments, workout programs, diets, and theories should be scientifically tested or simply why we need an evidence-based approach.
Bloodletting and Lobotomy maybe long gone, but experts, theories and uncertainties still remain.
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Sounds like we’re all on the same page!
Evidence-Based Coaching!
http://samleahey.com/evidence-based-coaching/
Well said, Anoop!
Comment by Sam Leahey — February 12, 2012 @ 10:48 pm
Nice article Anoop!!!
Comment by Bret Contreras — February 13, 2012 @ 12:38 am
Well done Anoop.
Comment by Randy — February 13, 2012 @ 1:24 am
Great article! I am definitely linking to that on Saturday!
Comment by Ines Subashka — February 13, 2012 @ 1:25 am
Thanks Sam, Bret, Randy and Ines!! That one nice article, Sam. I have read it before.
I hope people would think beyond the fitness realm. This article is important for anyone who cares about their health, and not just getting fit. I have seen a lot of people in my country making life changing decisions based on above three “non-evidence” based methods. I hope this article will make those people think twice.
Thanks Brad for giving me an opportunity to write for our blog.
Comment by Anoop — February 13, 2012 @ 6:40 am
Hey Sam:
Great job on your article. Well thought out and articulated. Kudos 🙂
Brad
Comment by Brad — February 13, 2012 @ 7:15 am
Nice one, Anoop.
I keep telling my organization that our approaches, especially pertinent to weight loss is “Catabolic weight loss”, if remain undetected can increase susceptibility to diseases, premature aging and even death, so we are not giving justice to our customers. In the name of providing health and wellness, for so many years various fitness professionals (?) have been giving only sickness to their clientele. If i organize an exercise system, i will keep these major goals for my clients (a) Survival fitness (b) Healthy life span.
Comment by Vinodh Rajkumar — February 13, 2012 @ 8:36 am
Excellent article! I like the detailed examples of all these instances where even the medical community gets wrong, I’ve never seen a list of so many of them in one place.
Let me toss a pair of other calls for evidence based fitness article links here:
Brad Schoenfield’s other pieces: http://bretcontreras.com/2011/08/a-scientific-approach-to-fitness/
Brent Rushall (a sports scientist/psychologist), making a deft connection between the 2nd law of thermodynamics and why “tradition” isn’t so great, in the context of swim coaching.
http://coachsci.sdsu.edu/csa/thermo/thermo.htm
Thanks for guest posting, I will be adding your blog to my weekly reading list!
Comment by Cam — February 13, 2012 @ 5:23 pm
Thanks Vinodh. I am not sure what you mean by catabolic weight loss. But when say ‘even death’, we need some solid evidence to back it. Too many instances in our history of unnecessary fear mongering.
Thanks Cam!
I just feel the only way to convince people to take an evidence based approach seriously is to show them why it evolved in the first place. All these articles and endless facebook debates about science vs experience vs results are just completely unaware of our “eventful” history of medicine. If people had the slightest clue, we could have shifted the focus from why to do science to how to do science.
Comment by Anoop — February 13, 2012 @ 7:01 pm
Fantastic article Anoop. I feel many seek to simplify physiology into simple systems or cause-effect relationships, not fully understanding the complexity behind the biology.
Comment by Andrew — February 13, 2012 @ 7:27 pm
“Hormone replacement Therapy (HRT): Hormone replacement therapy was based on the rationale that restoring estrogen levels in menopausal women would be helpful. This made sense since the female body stopped producing estrogen during menopause so replacing the estrogen could conceivably bring back the lost youth. HRT claimed to prevent heart attacks and strokes and millions of people, advised by their own doctors, started taking HRT.
In 1993, Women’s health initiative study was embarked to confirm the belief that HRT was saving lives. The study was stopped early because the number of deaths from breast cancer was higher in the hormone treated group. This study was later confirmed by other two large trials. It is estimated that in the UK alone the use of HRT was causing an extra 2000 cases breast cancer cases a year. ”
Ok so this is a ten year old study…using FDA-approved HRT rather than a custom-made preparation…. of compounded BHRT… misleading to say the least…
So now you have a personal trainer who is mis-lead with a ten year old study… and applying it to clients???
Yes i agree the how to do and how it was done and who done it all apply to science…
Comment by Spartan Training — February 13, 2012 @ 7:51 pm
Hi Anoop,
(1) I meant ‘Catabolic weight loss’ indicating the loss of fat free mass. But I see loss of fat free mass as whole disturbance in homeostasis. In fitness field, even basic tests like RHR, BP are not done religiously. To endorse disturbance in homeostasis, thorough reliable lab investigations are required.
(2) “Related to death”, i have once come across a reference from your website that related “few deaths related to cardiac muscle loss”. As I had mentioned in my previous post, if I establish an authentic exercise system, I will try also to maintain a statistical report of my clientele’s life span and the cause of their expiry.
Comment by Vinodh Rajkumar — February 14, 2012 @ 2:21 am
Thanks Andrew. I completely agree. And most of these come from medical “experts”.
Hi SpartanTraining,
Thanks for the comment.
The Women’s Health Initiative (WHI) study was supposed to run for 8.5 years. The study was a multi -center trial recruiting thousands of people from 40 different centers in US. One group had almost 17,000 while the other group had around 10000 subjects. The study started in 1998 (after recruiting since 93) and one arm was stopped in 2002 after just 5 years. The other arm was stopped in 7 years. This was later confirmed b the HER and HERS 2 clinical trials. The HERS study was another huge multi center trial which confirmed the results. So I hope you understand that we are not talking about a “16 week study” on a “20-30 subjects” here.
http://www.ncbi.nlm.nih.gov/pubmed/12117397
The WHI is one study which again showed the validity of an RCT and is often quoted to show the pitfalls of theory and expert opinion. These studies are ones which changed the course of medical history
And what is this “custom- based” preparation you are talking about? Or this another one of those conspiracy theories involving the FDA.
Comment by Anoop — February 14, 2012 @ 7:53 am
Hi Vinodh,
I would say maintaining muscle mass is important. But I wouldn’t go as far to talk about death and such. But your concern for our client’s health is appreciated.
It is good to be concerned about the clients health, but we don’t want to get excited and make such bold claims. This is how many alternative practioners sell their products – by raising unnecessary fear in the minds of people without enough evidence.
Comment by Anoop — February 14, 2012 @ 8:04 am
Fantastic article, Anoop!
Very well done.
-J
Comment by Jordan Syatt — February 14, 2012 @ 8:31 am
Alternative practitioners just go behind money and take the advantage of their clients looking for short term unrealistic goals. But evidence based practitioners should be noble and motivate their clients also to fix realistic long term goals. For example, some fitness clubs sell “Super slimmer package” in which most of the clients lose weight excessively in a very short span of time. In various fitness centers, there is no concept of fitness test to ensure the health status of consumers. The recent audit which I did for my organization finally projected ‘Pathetic state’ of service. Perhaps, fitness status of ‘Super slimmer consumers’ when compared with before & after “Super slimmer package” may reveal decline in aerobic capacity and muscular strength. If these negative effects are diagnosed early, it is possible to regain the homeostasis. But this is not happening, so conditions of disturbed homeostasis go chronic and invite health problems. First of all, we also need conducive work set up to practice evidence based and also for developing evidences.
Comment by Vinodh Rajkumar — February 14, 2012 @ 8:32 am
Thanks Jordan for comment!
H Vinodh,
Not all, a few of them. Most of them means well, but like the examples I showed above they just can’t see through their confirmation bias. This happens to the best of us. The only way too go around is to take a scientific approach. Keep up your good work.
Comment by Anoop — February 14, 2012 @ 9:04 pm
Thanks Anoop.
I hope you will agree that it is also in some cases we have the ability to rationalize scientific things without even having solid evidence. Many times it happened to me also. For example, I hypothesized and started a pilot study with 30 adolescent girls ” Pelvic floor exercises to control the extent of endometrial necrosis”. At the start of the study, I didn’t have any clue, no relevant evidence as base. But based on various positive outcomes, I had to change my topic ” To explore the cryptic benefits of pelvic floor exercises in relation to menstruation”. In the same study, I could find out 15 different types of menstrual pain (based on onset of mentrual pain, duration of pain, intensity of pain, palliative measures etc) and confirmed with another 200 subjects. I projected the evidence so that further researches can be done using my findings, but seldom the study was appreciated. The editorial panel of journals also should consider the limitations that a researcher encounters and give a chance for such studies to come to limelight with strong recommendations of further research.
Comment by Vinodh Rajkumar — February 14, 2012 @ 11:58 pm
Interesting read, Anoop!
Are there any disadvantages to scientific evidence as well? Are there cases when experience and logic are superior to scientific evidence?
Comment by Risto Uuk — February 15, 2012 @ 12:41 pm
Hi Risto,
Thanks for the comment! And good question too.
There are a lot of disadvantages with scientific evidence, but we don’t have a better alternative. Do we?
If you are asking is there a place for experience and clinical intuition in evidence based approach. Sure there is. No client or patient will be the exact same as the study population. Each client or patient will have their own unique needs, expectation, risk factors and such. So evidence-based approach uses both studies, trainer/clinical expertise and experience, and client preferences. So you need both the science and the art. It becomes a problem when you solely rely on either one of them.
If you read some of Brad’s published articles, you will see what I am talking about.
Comment by Anoop — February 15, 2012 @ 6:50 pm
Couldn’t agree more – the amount of myths (and the steadfastness of its proponents refusing to let go, even in the face of overwhelming evidence) is just startling.
Hopefully bit by bit collectively we can make a difference.
Comment by Sol Orwell — February 17, 2012 @ 12:31 pm
Evidence based practice (EBP), expert opinion, and common sense need to be all inter-connected. One cannot stand alone over the other. EBP is there to be critiqued…Of course a Random Controlled Trial or a Systematic Review are going to be hard to argue against but most scientific studies have lower levels of evidence and therefore need to be critically evaluated by those that are an expert in their respected field and a decision made to implement those techniques into his/her practice.
Another factor often overlooked is patient/client input…Due to the complexies of human physiology no one person will react the same to a specific treatment or exericse as another; therefore it is important to value the individual and apply EBP, expert opinion and common sense to that specific patient/clients case. Their opinion matters, this will go along way in helping with compliance also!!!
Comment by Shawn Valentine — February 17, 2012 @ 4:55 pm
Hey Shawn:
Thanks for the feedback. What is often misunderstood is that the EBP is not solely focused on peer-reviewed studies. Rather, it involves making decisions based on a combination of current research, practical experience, and the needs of the individual. Thus, they are all interconnected in the EBP model.
Brad
Comment by Brad — February 17, 2012 @ 5:10 pm
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There is “evidence based practice” and evidence directed practice. You can not always find the exact study to support and intervention. But, you may be able to find several articles that suggest a direction.
Comment by Herb Silver — February 19, 2012 @ 11:49 am
Thanks Sol. I agree. Thanks to people like Brad we are moving in the right direction.
Thanks Shawn. What Brad wrote and my reply to Risto. Even RCT’s and reviews need to be critically analysed. In the fitness field, the evidence comes mainly from expert opinion.
Thanks Herb.
If you don’t have a study, you just go down the ladder of the evidence to expert opinion or basic science. And that’s what you see in the fitness field. But what is missing is the frank acknowledgement that the reliability and validity of the results to be pretty low. You just simply cannot be sure of your results or what caused it.
As they say there is always ‘evidence”. The question is what kind of evidence.
Comment by Anoop — February 19, 2012 @ 8:37 pm
Great post Anoop! It’s really nice to have people like you and Brad who break down fitness with scientific evidence. It seems like every day there is a new guru promoting some fad without any solid reasoning. Just wanted to say thanks for the work you do!
Comment by Dale C — June 4, 2012 @ 9:25 pm
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