Exercise physiologist s role in clinical practice

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1 Exerise physiologist s role in linial pratie B Franklin, A Fern, A Fowler, T Spring, A dejong Department of Mediine, Division of Cardiology, Cardia Rehabilitation and Exerise Laboratories, William Beaumont Hospital, Mihigan, USA Correspondene to: Barry A Franklin, Diretor, Cardia Rehabilitation and Exerise Laboratories, William Beaumont Hospital, Preventive Cardiology/Cardia Rehabilitation Area C, 4949 Coolidge Highway, Royal Oak, Mihigan 48073, USA; bfranklin@ beaumont.edu Aepted 23 Otober 2008 Published Online First 28 November 2008 ABSTRACT The use of exerise testing has expanded greatly to help guide deisions about medial management and prognosis in a broad spetrum of patients. Numerous epidemiologial studies in people with and without doumented oronary artery disease have identified a low level of ardiorespiratory fitness as an independent risk fator for all-ause and ardiovasular mortality and that exerise apaity is inversely assoiated with healthare osts. Aordingly, unfit men and women should be ounselled to exerise in home-based or group preventative or rehabilitative programmes. In the era of managed are, the use of speialised exerise professionals for the supervision of exerise testing and training may represent a safe and ost-effetive alternative to many hospitals, linis and private physiian praties. Clinial exerise physiologists (CEPs) an play a ritial role in favourably modifying lients level of ardiorespiratory fitness and physial ativity habits. We detail the training of CEPs and outline the linial settings where they have ontributed substantially to healthare delivery. We also outline the role of registered linial exerise physiologists. It is important that exerise presription is not left to a few individuals or small groups. It needs a onerted programme with all those in a position to make a differene atively ontributing. The expansion of modern mediine has ontributed immensely to the early detetion and treatment of hroni diseases, espeially oronary heart disease (CHD). From , the age-adjusted death rate for CHD fell from 543 to 267 deaths per population among men (51%) and from 263 to 134 deaths per population among women (49%), resulting in nearly fewer deaths from CHD in Tehnologial, medial, preventive and rehabilitative advanes are largely responsible for these dereases. One of the most impressive gains in the management of patients with hroni disease has been the reognition of the benefits of strutured exerise and inreased lifestyle physial ativity 2 3 and their progressive inorporation into the mainstream of ontemporary medial treatment plans. Patients afflited with ardiovasular and pulmonary disease ommonly experiene a onstellation of hallenges, inluding a redued exerise tolerane, assoiated symptomatology, depression, 4 anxiety, esalating healthare and presription osts, and eonomi unertainty. A superimposed sedentary lifestyle an exaerbate many of the assoiated disease-speifi sequelae ausing seondary ompliations suh as redued ardiorespiratory fitness, musle atrophy, osteoporosis, overweight/obesity and impaired irulation to the lower extremities. Although there is muh room for improvement, some physiians have embraed the use of exerise in the prevention, diagnosis and treatment of these linial onditions and hroni health problems. 5 The emergene of the linial exerise speialist a professional who uses exerise testing and/ or training in the evaluation and management of a broad spetrum of healthy individuals and patients has reated the need for eduating and training healthare providers. Moreover, ost ontainment initiatives and time onstraints on physiians have enouraged more extensive use of speially trained healthare professionals (for example, nurses, physiian assistants, physial therapists, exerise physiologists) to diretly provide many of the diagnosti and treatment servies under the overall diretion of physiians. Although several professional organisations have responded by providing linially oriented exerise physiology ontinuing eduation workshops or ertifiations (for example, Amerian Counil on Exerise (ACE), Amerian Assoiation of Cardiovasular and Pulmonary Rehabilitation (AACVPR), Amerian Heart Assoiation (AHA), Amerian College of Cardiology (ACC), Preventive Cardiovasular Nurses Assoiation (PCNA)), perhaps the greatest reent emphasis on this area has been within the Amerian College of Sports Mediine (ACSM), espeially in regard to the training and ertifiation of linial exerise physiologists (CEPs). EDUCATIONAL REQUIREMENTS AND CERTIFICATIONS A pratiing CEP will have earned a bahelor s degree at minimum; however, students aiming to be CEPs are inreasingly pursuing advaned degrees in exerise siene, physiology or a losely related field. In most eduational urriula, a linial internship experiene is required. Loations of student internships are dependent on the hosen area of expertise (for example, ardiology, sports mediine, wellness). Clinially, there is ample opportunity for CEPs in ardiology praties, onduting stress tests, and working in preventive ardiology and ardia rehabilitation programmes. Clinial ertifiations are often required by many hospitals, medial entres and private physiian praties. Perhaps the most widely reognised and longstanding linially oriented exerise ertifiation is the ACSM s Certified Clinial Exerise Speialist (CES). This level of ertifiation requires a baalaureate degree in exerise or health-related studies, 600 hours of relevant linial experiene, urrent ardiopulmonary resusitation ertifiation (basi life support) and the suessful ompletion of a omprehensive examination now administered through omputer-based testing. In addition, students who have attained their masters degree may be ertified as registered linial exerise physiologists (RCEP), whih has a broader range Br J Sports Med 2009;43: doi: /bjsm

2 of expertise as ompared with the CES ertifiation that fouses primarily on ardiovasular testing and rehabilitation. 6 Goals of the RCEP are to improve visibility and aeptane of CEPs among the publi, physiian ommunity and other health professionals, preferably aross varied disease states and omorbid linial onditions, and to support the need for future liensure (that is, using nursing or physial therapy as models). Although other ertifying agenies are available worldwide, the ACSM is one of the few that offers linially oriented urriula, workshops and ertifiations. Inreasingly, many CEPs deide to pursue dotoral or advaned degrees in exerise siene, publi health, physiian assistant, nursing, business or ombinations thereof (table 1). The CES and RCEP titles are designated for exerise professionals who may work with high-risk or diseased individuals, as well as with apparently healthy people. The ACSM has published a list of the urrent knowledge, skills and abilities that omprise the foundations of these ertifiation examinations, as well as the minimum requirements for experiene, level of eduation and reommended ompetenies. 7 The ontent matter for these linial ertifiations is shown in box 1; a potential staffing plan for health/fitness and linial servies is depited in fig 1. Table 1 Levels of eduational experiene and assoiated linial roles and anillary responsibilities for the linial exerise physiologists (CEPs) Eduation Certifiation Clinial roles Bahelor of Health/Exerise Siene or related degree Masters in Exerise Physiology Dotorate in Exerise Physiology Amerian College of Sports Mediine (ACSM) Certified Clinial Exerise Speialist Certified Strength and Conditioning Speialist* ACSM Certified Health Fitness Speialist ACSM Registered Clinial Exerise Physiologist ACSM Registered Clinial Exerise Physiologist *National Strength and Conditioning Assoiation. Cardia Rehabilitation Diagnosti Stress Testing Clinial Weight Management Chroni Disease Exerise Presription Cardia Rehabilitation Anillary responsibilities Clinial oordinator or supervisor Personal fitness trainer Wellness speialist Corporate fitness speialist Researh oordinator/leader Manusript authorship College/university faulty Diagnosti Stress Testing Programme diretor Pulmonary Rehabilitation Researh oordinator/leader Metaboli Disease Manusript authorship Management Caner Reovery Support grant writing Clinial Programme Diretor Clinial Researh and Development Coordinator Medial Board of Diretors College/university professor Manusript authorship and oversight Grant writing PROFESSIONAL SCOPE AND RESPONSIBILITIES CEPs are required to have exeptional understanding and working knowledge of aute and hroni responses and adaptations to exerise in healthy and unhealthy individuals, as well as the influene of varied omorbid onditions and mediations. These professionals are often responsible for designing exerise programmes and formulating exerise presriptions for those with hroni disease suh as CHD and other ardiovasular onditions, diabetes mellitus, metaboli syndrome, obstrutive pulmonary disease, aners, arthriti disorders and obesity. CEPs often work with patients immediately following ardia interventions and/or events and are an integral part of the ardiovasular ontinuum of are. Aordingly, suh individuals should be highly trained in onduting diagnosti stress tests and adept at interpreting 12-lead eletroardiograms (ECGs) and ECG rhythm strips. Exerise training, risk fator modifiation, haemodynami and ECG telemetry monitoring, and patient eduation and ounselling are additional ompetenies in the physiologists linial armamentarium. Lifestyle modifiation and exerise training also serve as integral omponents of omprehensive linial interventions for overweight/obese patients. 8 As exerise interventions have beome inreasingly adopted for the treatment and prevention of hroni diseases and disorders, CEPs are often employed as support staff for linial researh trials involving these patient subsets. CEPs play an important role in data olletion, programme design, treatment interventions, grant writing and subsequent publiation and presentation of the findings. Many international organisations (for example, AHA, ACC, ACSM, AACVPR) now onsider CEPs as valued multidisiplinary partiipants in annual sientifi meetings, symposiums and fous groups. Community organisations often invite CEPs as authoritative speakers on subjets related to exerise, weight management and lifestyle modifiation. Masters and dotorate prepared CEPs also serve on the faulty at ommunity olleges and universities, instruting undergraduate and graduate students in exerise physiology and related disiplines. CEPS SUPERVISE SAFE EXERCISE TESTS IN HIGH-RISK POPULATIONS A major role for the CEP is in the ondut and administration of exerise testing, with and without onomitant ardiopulmonary measures and/or myoardial perfusion imaging. CEPs are now widely reognised by the medial ommunity as being uniquely qualified to supervise exerise testing, inluding those patients at inreased risk for ardiovasular ompliations, if a physiian is within lose proximity and readily available to respond to an emergent situation. 9 This is in ontrast to exerise testing prior to 1980, whih was diretly supervised (.90% of the time) by physiians. 10 Sine then, linial pratie patterns have shifted due to ost-savings initiatives and esalating time onstraints on physiians, resulting in the use of speially trained allied health professionals, inluding CEPs, to supervise exerise tests. The safety of non-physiian supervision of exerise testing is now well-established. Knight and assoiates demonstrated an exemplary safety reord when using CEPs, inluding no fatalities, only four myoardial infartions and five episodes of ventriular fibrillation in over tests. 11 Franklin et al 12 reviewed 18 years ( ) of exerise testing experiene by non-physiians (highly trained CEPs and nurses, redentialed in basi ardiopulmonary resusitation and advaned ardia life support) who performed over tests, whih inluded a 94 Br J Sports Med 2009;43: doi: /bjsm

3 Box 1 Content matter for Amerian College of Sports Mediine ertifiations Exerise physiology and related exerise siene. Pathophysiology and risk fators. Health appraisal, fitness and linial exerise testing. Eletroardiography and diagnosti tehniques. Patient management and mediations. Medial and surgial management. Exerise presription and programming. Nutrition and weight management. Human behaviour and ounselling. Safety, injury prevention and emergeny proedures. Programme administration, quality assurane and outome assessment. Figure 1 Staffing plan for a preventive or exerise-based rehabilitation programme with speifi referene to onsulting professionals and the environment or setting signifiant subset of higher-risk patients (,15 20%). There were 14 ompliations (inluding 2 fatalities) for an event rate of 1 per 4146 exerise tests. Colletively, these data suggest that the overall inidene of ardiovasular ompliations appear to be no higher with experiened paramedial personnel than during exerise testing with diret physiian supervision. The role of the CEP during stress testing may inlude pre-test preparation and evaluation, test supervision, haemodynami monitoring and doumentation, ECG surveillane, and providing a preliminary test summary to guide the final physiian interpretation. Several reports now suggest that highly trained allied health professionals an provide an aurate preliminary assessment of the exerise ECG, in exellent agreement with internal mediine and/or ardiologist onsultant over-reads The CEP an also identify ontraindiations to exerise testing and appropriately summon the overseeing physiian if additional pre-test evaluations are warranted. In addition, CEPs an use test endpoints, as established by the ACSM, 7 to terminate an exerise test at an appropriate intensity level. If an exerise test is prematurely terminated due to adverse signs or symptoms, inluding a signifiant ishaemi ECG response, inreasing angina petoris or malignant ventriular arrhythmias, it is the CEP s responsibility to onvey this information in a timely manner to the attending or referring physiian. In situations where an emergeny arises, CEPs serve as part of the initial emergeny response team until the overing physiian arrives. CEP S ROLE IN DESIGN AND SUPERVISION OF MEDICAL EXERCISE PROGRAMMES CEPs also funtion in the design and supervision of strutured exerise programmes for apparently healthy individuals and those with hroni disease. Their role inludes restoring or enhaning the patient s funtional apaity, helping lients to redue body weight and fat stores, improving their ardiovasular risk profile and eduating them on the long-term benefits of a regular exerise programme, inreased lifestyle ativity 2 3 or both. Exerise presriptions are formulated based on knowledge obtained from formal eduational training, linial internship and on-the job eduation, and through workshops and ertifiation examinations. This training allows the CEP to safely and effetively address the individual needs of eah programme partiipant. Although the CEP an be employed in many settings, inluding fitness entres, ardia and/or pulmonary rehabilitation programmes, physial therapy linis and speialised fitness failities, their predominant role is in medially oriented diagnosti and treatment entres. Traditionally, this role has been in the rehabilitation of the ardia patient; however, reent pratie patterns have expanded their role to inlude working with patients with other hroni diseases and debilitating medial onditions, inluding pulmonary, metaboli, immunologial, inflammatory, orthopaedi and neuromusular disorders. Moreover, the ACSM RCEP has enhaned eduation and training to enable them to work with people with hroni diseases and medial onditions suh as musular dystrophy, Parkinson s disease and osteoporosis, for whom exerise may be benefiial. 7 CEPs work to reinfore health behaviours and trak progress of the exerise programme within a team of liensed healthare professionals, whih may inlude nurses, psyhologists and physiians. The sope of responsibilities for the CEP in the rehabilitative setting inludes diagnosti and funtional testing, exerise presription, exerise supervision, patient ounselling, eduation and outomes analysis. In addition, the CEP may address barriers to maintaining exerise ompliane, inluding psyhosoial fators, family or job responsibilities, orthopaedi or musuloskeletal limitations, or other deterrents to regular exerise. Box 2 highlights the role a CEP might play in a omprehensive rehabilitative exerise programme. INTERNSHIP MENTORING AND ANCILLARY ALLIED HEALTH PROGRAMMES Internship mentoring The role of the qualified CEP as an internship mentor is a noble one, serving as a teaher in the profession. A hands-on linial experiene under the guidane of a seasoned exerise physiologist an have a profound and favourable impat on the students areer diretion. It is ritially important that students are exposed to inpatient and outpatient ardia rehabilitation, exerise leadership (aerobi, resistane and funtional training), stress testing (dynami and pharmaologial), ounselling/ eduating patients and researh methodology so that they have appropriate experiene for employment. 18 Br J Sports Med 2009;43: doi: /bjsm

4 Box 2 Role of the exerise physiologist in the funtional assessment and exerise training of patients with ardiovasular disease (adapted from 17 ) Assess exerise tolerane: evaluate adverse signs/symptoms onsider medial history and health status assess barriers to exerise. Establish treatment goals: ollaborate with referring physiian and other liensed professionals assist in identifying patient short-term and long-term objetives. Individualise exerise-based interventions: determine readiness to hange promote safety and effetiveness ounsel patient on lapses or setbaks. Monitor progress: ondut outome evaluations provide updates to the patient and referring physiian enourage pleasurable ativities in a supportive environment. The CEP may also augment the undergraduate student s limited knowledge in researh methodology with assignments. For example, one projet ould fous on how to ondut a literature review and plan a mok researh trial with exeution of the statistial analysis. Alternatively, previously published studies may be reviewed and ritiqued with speifi referene to methodologial limitations (for example, lak of a ontrol group ). Providing tutorials and letures on topis of linial signifiane (for example, 12-lead ECG interpretation, speial populations, stress testing, ardia mediations) will help to integrate book knowledge with hands-on experiene. In addition, this presents an opportunity for the supervising CEP to mentor students in their partiular areas of profiieny or linial expertise. Written and pratial examinations for interns developed and/or administered by the CEP are key to identifying ompetenies in whih students exel or exhibit shortomings. These types of tests are an exellent preparation for the CES or RCEP ertifiation exams. The exerise physiologist an also introdue students to professional organisations suh as the ACSM or the AACPR, their regional affiliates, loal and national meetings, ommittees and eduational and researh missions. The qualified CEP an positively influene the student s interpersonal skills as well as his or her rapport with patients and support staff. 19 This is refleted in teahing the linial omponents of ardia rehabilitation (phases I, II and III), whih inlude ECG telemetry monitoring for ishaemia and arrhythmia reognition, formulating individual exerise presriptions, ardia risk fator identifiation, patient eduation and ounselling, and responding appropriately to exerise-related untoward events. The positive influene of didati instrution during this eduational phase transforms textbook learning to the development and implementation of knowledge, skills and abilities. A group exerise setting an be an intimidating environment for the student intern. The CEP must manage to ensure that patients have full onfidene while they remain under the intern s diretion; this is paramount for the lient/instrutor relationship. Musi and props an provide a relaxed and enjoyable environment for both patients and novie exerise professionals. Using a variety of arm, leg or ombined arm-leg ergometers and exerise equipment (for example, free weights, resistane bands or tubing, body bars, basketballs, volleyballs, walking stiks) an also be helpful. Although stress testing represents a dynami and insightful linial rotation, the methodology has the potential to eliit threatening somati, haemodynami and ECG responses. In rare instanes, suh testing may provoke aute ardia events. This may be espeially disonerting to the student observer. Aordingly, the CEP should guide the student intern gradually (that is, inreasing performane expetations and ompetenies over time) while identifying and addressing his or her strengths and weaknesses during the designated rotation. Dynami and pharmaologial stress testing instrution to student interns inludes explaining the purpose and rationale for the evaluation, underlying methodology (for example, pereived exertion sale), potential adverse signs/symptoms, elements of 12-lead ECG and rhythm strip interpretation, obtaining aurate blood pressure readings, knowledge of indiations and ontraindiations, and the onfounding effets of mediations and/or underlying disease on the assoiated responses. Geriatri exerise programmes Although exerise physiologists are widely employed in ardia rehabilitation programmes, other staffing opportunities have beome inreasingly available for them in hroni disease management and allied health programmes. For example, hospital-based ommunity wellness exerise programmes an provide a medial setting for older adults who wish to exerise in a supervised and reassuring environment. 20 Providing physial onditioning lasses that are direted toward the senior population (that is, group low impat or aquati aerobis, resistane training, flexibility/agility ativities, tai hi) with pulse monitoring, blood pressure heks and instantaneous ECG rhythm strip surveillane 21 an reate a unique exerise experiene that is not offered at ommerial fitness failities. For example, a CEP an trak and provide pertinent haemodynami and ECG information to a patient s physiian, aiding in the treatment of hroni medial onditions and extending the ontinuum of are. A primary objetive of the CEP for wellness programmes is in improving or maintaining the ardiorespiratory and musuloskeletal fitness levels of apparently healthy older adults in a losely supervised setting. The CEP should identify ardia risk fators (for example, hypertension, diabetes, hyperholesterolaemia, igarette smoking, obesity) and musuloskeletal onditions (for example, previous injuries or surgeries), set short and long-term goals (for example, weight loss, and improving ardiorespiratory fitness) and then formulate an individual exerise plan. The programme s redibility is enhaned by the presene of a ertified or registered exerise professional that an oversee and monitor patient progress. EXTENDED CEP SERVICE ENHANCED EXTERNAL COUNTERPULSATION An alternative treatment for patients with ardiovasular disease in whih a CEP an extend servies inludes enhaned external ounterpulsation (EECP). EECP is a non-invasive therapy that an redue angina symptoms and improve exerise tolerane in symptomati patients with CHD who are no longer responsive to drug treatment or repeated revasularisations. 96 Br J Sports Med 2009;43: doi: /bjsm

5 Box 3 Enhaned external ounterpulsation (EECP) therapy methodologial onsiderations and treatment plan An EECP devie onsists of a series of modified blood pressure uffs wrapped around the alves, thighs and buttoks of the patient who is lying on a omfortably padded bed. The uffs are onneted by hoses to an inflation/deflation valve assembly and air ompressor, whih are synhronised to the ardia yle via the R wave obtained by ontinuous eletroardiogram (ECG) telemetry monitoring. The supervising staff member sets and adjusts treatment parameters on a touh sreen monitor, whih simultaneously displays heart rate and rhythm. The R-R interval is used to trigger sequential uff inflation in early diastole, beginning with the alves to the pelvis, with simultaneous deflation at end diastole. Cuff pressure is inreased in small inrements to a maximum pressure: usually mmhg. A typial outpatient treatment plan for EECP is daily 1-hour sessions, 5 days per week, for a total of 35 hours. Aspets of the methodology and treatment plan are summarised in box 3. Common ontraindiations to EECP therapy inlude ative thrombophlebitis (history of deep vein thrombosis requires urrent ultrasound learane), unstable angina, severe lower extremity vasular disease, doumented aorti aneurysm requiring surgial repair and pregnany. Although the exat physiologial mehanisms by whih EECP provides linial benefits to patients remains unlear, there is evidene that the benefits are multifatorial and involve augmented blood flow to ishaemi myoardium, enhaned vasomotor funtion, improvements in left ventriular diastoli performane, inreased somati oxygen onsumption at rest or ombinations thereof. The responsibilities of the CEP inlude prepping and monitoring the patient during EECP therapy sessions, pre and posttherapy evaluations of lung sounds to assess for fluid retention, oxygen saturation levels, blood pressure and ECG rhythms, as well as weighing the patient at eah session to monitor for ongestive heart failure. Exerise professionals an also provide the referring physiian with periodi updates about the patients linial and physiologial responses to the treatment plan, espeially if adverse signs and/or symptoms are noted. COUNSELLING AND COMMUNITY EDUCATION Inreasingly, the demands plaed on physiians time may limit their ability to effetively ounsel patients on the benefits of exerise, exerise presription and omprehensive lifestyle risk fator modifiation. Physial inativity is the only major risk fator ommon to obesity, diabetes, ardiovasular disease and metaboli syndrome. Studies show that physiians onsistently disuss exerise with less than a third of their patients 5 and that exerise ounselling is more often employed as a seondary prevention measure The aging US population and predited future physiian shortages will only serve to augment these hallenges. Aordingly, CEPs are in a unique position to omplement the physiian and his or her support staff through the exerise and risk fator redution ounselling of their patients in a variety of settings. CEPs play an integral role in linial pratie by assisting with global risk fator redution for patients with CHD, diabetes, metaboli syndrome and obesity. Counselling partiipants with hroni diseases and disabilities on the lifestyle behaviours that ontributed to these onditions (that is, physial inativity and unhealthy eating patterns) through group letures, one-on-one onsultations and regular interations an failitate substantive behaviour hanges. In addition, providing serial surveillane about their risk fator redution to referring physiians, physiian assistants and nurse liniians may serve to improve partiipant outomes. Within the settings of employee and ommunity health programmes, suh as heart and vasular sreenings, CEPs are also poised to deliver health, wellness and fitness oahing. Inluded in the risks for most hroni diseases and medial onditions is an overriding behavioural omponent that ontributes to either positive or negative outomes. Behaviour patterns have the single greatest impat on premature death and disability, surpassing geneti predisposition, soial irumstanes, healthare availability and environmental exposure. 28 Health and wellness oahing improves self-effiay that is, the individual s ability to formulate and implement a suessful plan while addressing ompliane barriers. CEPs are also trained to identify a partiipant s readiness to make lifestyle hanges and determine the likelihood that they will maintain ompliane to a presribed programme. The strategies (that is, goal setting, motivational interviewing, reward systems) used by the CEP to favourably alter lifestyle behaviours are dependent on both of these modulating variables. Community involvement is another essential funtion of CEPs that aids in the dissemination of valuable exerise and health information. Knowledge is the first step in preparing an individual to make long-term behaviour hanges. Well-written artiles in lay publiations (for example, newspapers, magazines, patient newsletters) an be helpful. Presentations to gender-speifi groups, weight ontrol entres, organisationsponsored events (for example, Amerian Heart Assoiation Start! Heart Walk ) and assoiation onferenes are ideal opportunities to ommuniate with other allied health professionals and the publi at large. Media interviews, often fousing on reent studies, also help to larify the impliations for patients and providers on various health issues. SUMMARY AND PRACTICAL IMPLICATIONS Traditionally, CEPs have been viewed as personal trainers or ardiopulmonary speialists. As the medial ommunity begins to at on the evidene that exerise is mediine 29 for both prevention and treatment, CEPs will beome inreasingly embraed and employed as health professionals. Colletively, their linial knowledge, skills and abilities allow exerise physiologists to assist physiians in the diagnosti and funtional evaluation, eduation and behaviour modifiation of their patients. As rehabilitation speialists, researhers, employee health programme oordinators, health and wellness oahes, and ommunity and professional eduators, CEPs are invaluable resoures in interventions designed to ombat virtually all hroni diseases, not just CHD, diabetes and obesity. Competing interests: None. REFERENCES 1. 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