Coca-Cola and its partner the American College of Sports Medicine (ACSM) launched Exercise is Medicine (EIM) in 2007 to influence the medical establishment. On the surface, EIM encourages physicians to evaluate “physical activity as a vital sign” and then prescribe physical activity to their patients. The consequences of this scheme are greater and more pernicious than they initially seem. Annexing fitness training into health care via EIM means involving third-party payers, whether private insurance or government, and third-party payment means third-party control. Trainers who comply with the EIM scheme, therefore, will have to follow its rules regarding nutrition advice and exercise programs. This is tantamount to granting the ACSM and Coca-Cola regulatory authority over the parts of the fitness industry that accede to their scheme. And Coca-Cola’s interest is obviously to diminish or even negate the role of nutrition in physical health through an inappropriate and inaccurate emphasis on physical exercise alone, as they have done consistently in the past through various “energy balance” campaigns.
Both the ACSM and Coke reap benefits from EIM’s influence: It lacquers the ACSM with undeserved respectability and authority, and it fulfills Coca-Cola’s aim to downplay the importance of proper nutrition in chronic disease prevention. To substantiate Exercise is Medicine’s claims to legitimacy, the ACSM falsely claims it was launched in partnership with the American Medical Association (AMA) when it was actually founded in partnership with Coca-Cola.
If Coca-Cola’s role as a founding partner is one hurdle for EIM’s legitimacy, another is that its model does not work. A BMJ editorial delineated the problem in “Death by Effectiveness: Exercise as Medicine Caught in the Efficacy Trap!” The authors observed, “While we continue to be bombarded by original research and reviews extolling the efficacy of exercise, there is an apparent dearth of evidence of its effectiveness.” Exercise works, but getting people to stick to it long enough that they become healthier is another matter, especially when the intervention promoted is only marginally efficacious. This central defect throws cold water on EIM and related lobbying efforts: “While it is a mistake to confuse efficacy with effectiveness, in lobbying for exercise as a public health tool, we often do just that,” the authors explain. It does not matter how effective an exercise referral scheme is in theory or when conflicted researchers examine it in laboratory settings. What matters is the extent to which the intervention “achieves its intended effect in the usual clinical setting.”
And achieving results in clinical settings is exactly where EIM and related models have fallen short. One study from the BMJ examining the effectiveness of exercise referral schemes found:
There was no difference between exercise referral schemes and usual care in either the minutes of activity spent in at least moderate intensity per week or in the estimated energy expenditure from physical activity. … Harrison and colleagues reported no significant interaction between the effect of exercise referral schemes and prespecified baseline variables such as risk factors for coronary heart disease, sex, and age.
Finally, the paper concluded, “Overall there was no difference” between the exercise referral group and the control with regard to “body mass index or body fat.” Additionally, “There was also no between group difference in diastolic or systolic blood pressure, serum lipids, and respiratory function.”
It is one thing for doctors to refer patients to substandard trainers or recommend they engage in low-intensity exercise. It is quite another for those patients to adhere to the exercise recommendations or for doctors to have reliable indicators of their patients’ activity and fitness levels. In other words, EIM has not figured out how to convince large numbers of people to consistently, effectively exercise. If EIM fails to make people significantly healthier in the real world, what is it for, exactly? Whose interests is EIM advancing if not those of patients or clients?
In response to the failure of exercise referral schemes, EIM has resorted to a more intrusive measure: tracking devices. Felipe Lobelo, an MD and Ph.D. who directs the Exercise is Medicine Global Research and Collaboration Center and formerly served as chair of the American Heart Association’s (AHA) physical activity board, has partnered with the AHA and his longtime sponsors at Kaiser Permanente to promote wearable activity monitors such as Fitbits and Apple Watches. In 2015, Lobelo expounded on “the use of wearable devices to measure physical activity, [and] the use of apps and engagement technologies to get patients more active.” He added, “All that is coming and is heavily incorporated into the EIM model.”
If the hope was that wearables would make exercise referral schemes more effective, that hope may be misplaced. Wearable activity monitors, much like in-person exercise referral schemes, fail in study after study. They fail to measure or quantify simple functional movements. Researchers are therefore concerned that activity trackers may actually discourage people from sticking with effective exercise regimens. The authors of one study in Research Quarterly for Exercise and Sport note:
People may experience significant physiological benefits from HIFT (high intensity functional training), but if the activity trackers do not pick up on the potentially complex movements … they may think that they are not expending the proper amount of kilocalories and discontinue the exercise.
The authors did not mention the obvious implication: To the extent that health-care systems punish individuals for not meeting arbitrary wearable device goals, they are discouraging them from pursuing high-intensity and functional training, precisely the training that most benefits them.
The ACSM and Coca-Cola’s Exercise is Medicine scheme is a losing proposition for both the patients who will not see meaningful improvements in their health and the fitness trainers who will be effectively muzzled by restrictions on nutrition speech (and will lose clients discouraged by their inaccurate wearables and failure to improve). EIM serves a very specific set of interests: those of the ACSM, which benefits from a stranglehold on the trainers who would qualify for the medical referrals, and Coca-Cola, which benefits from the suppression of nutrition advice such as “don’t consume sugar-laden beverages.” EIM’s ineffective scheme thus works exactly as it was designed.