 Time to link Sport and Health in a positive way Click to read the .pdf version As physical activity levels in our society continue to fall, the ‘science’ of obesity prevention has evolved from suggestions on how to fix the problem into attempting to explain why the suggestions of 5-10 years ago haven’t worked. Hopefully the major focus areas of the Journal of Science and Medicine in Sport (which currently include sports injury epidemiology and prevention and physical activity promotion) can help illustrate a natural link that needs further exploitation. For example, an opinion piece in the MJA has listed 18 different factors as potentially contributing to the obesity epidemic (1). It did not mention inadequate prevention or management of sports injury, despite that it has been shown that injury is a barrier to greater physical activity for approximately 20% of the population (2). By contrast, a recent letter to the BMJ has made mention of both the obesity crisis and sports injuries, but unfortunately in the opposite context to that in which the discipline of sports medicine would like to position itself (3). Nicholas Finer, a consultant in obesity medicine, wrote to complain about the East Suffolk primary care trusts’ decision to not fund joint replacements unless the patient has a body mass index (BMI) below 30. He correctly pointed out that this policy is based on a perception that obese people are to blame for their predicament and could voluntarily do/have done something to reverse it. This dilemma is one for another editorial. Here I would like to draw attention to the final line of Dr Finer’s letter, in which he states (in order to further defend overweight patients’ right to be funded for joint replacement), “Logically extended, such a policy would deny treatment to, among others, smokers, most patients with HIV infection, and those who sustain sports injury” (3). Sports injury seems to be a paradox on the landscape of obesity prevention. On the one hand, exercise and sport are vital components in maintaining energy balance (and therefore protecting against weight gain, in addition to other health benefits) (4). On the other hand, superficially a sports injury can appear to be a self-inflicted problem, as Dr Finer points out, in the same fashion that lung cancer in a smoker appears to have been self-inflicted. This comparison can, for the most part, be immediately declared an unfair analogy when it is shown that those who are active actually cost the health system less than those who are not (5). There are no studies showing cost savings associated with being obese, being a smoker, being a promiscuous male homosexual or being an intravenous drug user. Yet ironically, in Australia, there is far more (albeit still less than optimal) government funding and infrastructure devoted to the problems of smoking, HIV sufferers and obesity management, than there is to either promoting physical activity or preventing or managing sports injuries. The discrimination against sports injury in Australia (in that it is not viewed as a problem worthy of any government attention (6,7)) is probably based solely on the public perception of the professional football codes. For nine months of the year, the Australian media constantly promotes the subliminal message that “all” professional footballers are earning thousands of dollars per week, having physiotherapy five times a day, surgery every couple of months, and thereby retiring as 30-year-old millionaires in urgent need of joint replacements. In this context, the average person on the street (which politicians pander to) thinks to him or herself, “why should the government pay for physiotherapy for sports injuries?”, “why should there be a national sports injury insurance scheme?” and “why should the doctors who look after pro football teams be considered specialists?” The “problem” of sports injury needs to be approached from many angles (better prevention, better management of injuries) but not the angle of discouraging people to play sport. It would be a welcome initiative for our Federal and state governments to sign some sort of physical activity version of the Kyoto protocol, such as a pledge that by 2012, 75% of Australians should be meeting recommended physical activity levels. In such an environment, sports injury might be seen as a barrier to achieving the proposed goal, and our governments might start to take the issue seriously. With respect to those sports injuries which are already occurring, funding is inadequate at many levels. The worst and saddest example of this is the insurance payments for anyone suffering quadriplegia as a result of sports injury (8). The maximum payment currently available from insurers is a lump sum (only) of $300,000, which is grossly inadequate for someone young who will be permanently and totally disabled (8). The comparative payment for someone similarly injured in a traffic accident would be $7-$9 million (8). Obviously the contact sports are far from free of obligation in this regard, with the ongoing heavy contesting of scrums at adult level in rugby union being particularly indefensible (as it has long been cited as an obvious way that quadriplegia can be prevented (9)). Governments in Australia perceive a strong need to legislate to protect the rights of injured workers and victims of traffic accidents, yet there is no similar will to protect those injured playing sport (6). I propose that the Federal government in Australia legislate to prevent anyone playing a contact sport without a minimum adequate level of catastrophic insurance. To provide adequate funding of such insurance (with a view that $2 million may need to be the ball park figure for an ‘average’ case of quadriplegia), premiums for the football codes may need to rise to a level of (by my estimate) approximately $50-100 per participant per year (soccer football, Australian football) and $200-300 per year (rugby league and union respectively). Bridging finance may need to be provided by the government to avoid a massive drop in participation from such a rise in insurance premiums. Perhaps a ten year phasing-in period is needed in which the government works towards a national sports injury insurance scheme and the football codes work towards improvements in safety, all in the background of a commitment to maintain current levels of sports participation. Yes, there may be safer sports to play that the rugby codes, but in addition to the health benefits of exercise, isn’t it better to have our young, testosterone-fuelled males battling it out on the football fields than on the beaches in Cronulla? The biggest problem with all of the above proposals is that there is no one in Australia to suggest them to. If I sent a copy to the Health Minister and a copy to the Sports Minister, the two article manuscripts would be both stamped “not this department” by the bureaucrats who screen them. They may even have a head-on collision whilst being forwarded to the ‘other’ department (sadly, shortly before being permanently filed in the rubbish bin). I particularly like the recent suggestion that governments should appoint ministers for Public Health (10). If there was a government minister with a portfolio of actually trying to preserve the health of the public (rather than to treat illness), then he or she would be responsible for both making Australia more active and for improving prevention and management of sports injuries, which are synergistic aims. The Howard government has been in power for ten years and has overseen unprecedented growth in the Australian economy over this time period. Unfortunately it has also overseen unprecedented growth in the size of Australian waistlines in the same decade (1,11). The Howard years will therefore be seen as golden years by most economists, but time is running out for this government to prove that it has not wasted its chance to make a difference in preventive health. (1) Catford JC, Caterson ID. Snowballing obesity: Australians will get run over if they just sit there. MJA 2003; 179 (11/12): 577-579. Available at: http://www.mja.com.au/public/issues/179_11_011203/cat10664_fm.html (2) Finch C, Owen N, Price R. Current injury or disability as a barrier to being more physically active. Med Sci Sports Exerc. 2001 May;33(5):778-82.
(3)Finer,
N. Rationing joint replacements: Trusts’s decision seems to be based on
prejudice or attributing blame
(4)Brukner PD, Brown W. Is exercise good for you? MJA 2005; 183 (10): 538-541. Available at: http://www.mja.com.au/public/issues/183_10_211105/bru10410_fm.html (5) Pratt, M, Macera, CA, Wang, G. Higher Direct Medical Costs Associated With Physical Inactivity. Physician Sportsmed 2000; 28(10). Available at: http://www.physsportsmed.com/issues/2000/10_00/pratt.htm
(6)
Orchard JW, Finch CF. Australia needs to follow New Zealand’s lead on
sports injuries
(7)
Orchard J. Health insurance rebates in sports medicine should consider
scientific evidence
(8) Carmody DJ, Taylor TKF, Parker DA, Coolican MRJ. Spinal cord injuries in Australian footballers 1997–2002. MJA 2005; 182 (11): 561-564. Available at: http://www.mja.com.au/public/issues/182_11_060605/car10658_fm.html (9) Taylor TK, Coolican MR. Rugby must be safer: preventive programmes and rule changes. Med J Aust. 1988;149(4):224.
(10)
Corbett SJ. A Ministry for the Public's Health: an imperative for disease
prevention in the 21st century?
(11) Stubbs CO, Lee AJ. The obesity epidemic: both energy intake and physical activity contribute. MJA 2004; 181 (9): 489-491. Available at: http://www.mja.com.au/public/issues/181_09_011104/stu10428_fm.html
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