Much of the Flexner report at the beginning of this century dealt with validating medical procedures, and had a strong relationship with medicines that were tested on humans and animals. Much of the prescription medication in this country that undergoes controlled trials is done, in part, because of the early work by medical researchers after the report was published in 1910 (Payer).

At the same time, physical culture was becoming a driving force in the educational system. Students (both boys and girls), were participating in regular physical movement courses as part of their curriculums. However, this participation, as with most physical education programs throughout this century, have concentrated on sports and skill training. Although this type of exercise is important, it is transient from the standpoint that it is specific to a sport, and may not transcend itself into a lifetime activity to participate in for most.

*The Flexner report was commissioned in 1909 as a statement on the status of medical education in the US. It's contents inspired medical schools to standardize their curriculums, and opened the doors for philanthropists such as JD Rockefeller to donate large sums of money for medical research. This also opened the door for pharmaceuticals to work with medical schools in this research, and this aspect of medicine grew rapidly over the course of the next forty years.

In the 1950's the first epidemiological investigation of London bus drivers (Morris, Buskirk) showed an association between daily activity and heart disease (bus ticket-takers who walked up and down the buses had a lower incidence of health problems than the bus drivers). Since that investigation, many types of reports on exercise have shown strong evidence that regular moderate exercise may increase longevity, by lowering risk factors for premature morbidity and mortality, enhance physiology by lowering body fat, improving lipid and muscle metabolism, and bone density.

Since the late 1950's, sports medicine research has become intertwined with public health, medicine, general physiology, medical pathology, and gerontology research to attempt to answer basic questions about how acute and chronic exercise effects the human body, and what types of adaptations are made by its practice.

Current Tends In Health and Fitness
The 1970's marked a dramatic turn-around for the health and fitness world, as Frank Shorter won the 1972 marathon in Munich, and Dr. Ken Cooper coined the word "aerobics", and its system became wide spread through this decade. Nathan Pritikin came into notoriety for his program of low fat eating to help reduce the effects of "the typical American diet" on heart disease, cancer, and other lifestyle diseases. Nobel laureate Linus Pauling and colleague Ewan Cameron were performing investigations on large doses of Vitamin C and its effects on improving health with cancer patients. Governmental policies regarding health were implemented, and grant money for health issues was becoming more available. It seemed that more people were interested in health, and a new direction was about to occur within the movement (Fries, Weinstein).

But was it? According to publisher Marshall Ackerman (who founded Prevention Magazine with editor J.I. Rodale in 1954), the health movement in the US has seen relatively little change in the past 30 years. People move into its philosophy, and others move away, so the net effect is fairly stable. What are the reasons for such a small segment of the population being interested in health and fitness.

In her book, "Disease-Mongers" author Lynn Payer suggests that medicine is merely marketing people into sickness by diagnostic tests, and slick advertising campaigns. Indeed, in Dr. John MacDougall's book " The MacDougall Plan", the AMA, along with meat and dairy virtually created the four basic food groups as part of a sales program. The true health benefits of this way of eating has been debated and questioned by many alternative practitioners.

Has exercise been subject to the same type of segmentation as aspects of nutrition? Perhaps not, as the role of physical education was primarily to teach athletic skills. The aspect of activity and fitness as a lifetime endeavor, and to protect against certain diseases later in life was not introduced, and hence was not accepted as important. Medical practitioners actually advised against exercise for heart patients, pregnant women, and others with medical conditions because they felt that exercise had no substantial benefits (Fries, Ibrahim).

Any revolution that was suppose to happen in exercising for the general public never materialized during most of this century (Goldstein). There are many reasons, such as facilities available, type of instruction available on a mass scale (such as qualified health club workers), and suggestions made by doctors to patients. This brings us to perhaps the biggest reason for the lack of exercise "en masse". Fitness is not, and has never been, part of the health care system.

Although many aspects of rehabilitation include specific exercise routines, (physical therapy, occupational therapy, back to work services, recreation therapy, etc.), the concept of exercise for health has never been part of the physician's practice, or an aspect of major medical centers.

What if... exercise had been included in the Flexner Report? Would the demographics of health be different today? It is estimated by health club statistics that 82% of the American public is deconditioned, and they feel it represents a tremendous opportunity for the fitness profession to get them into regular exercise programs. How will this happen? What changes are necessary in order to create such a major change in our health care system, and health care thinking? This article explores the 10 paradigm shifts that will need to happen in order to dramatically change the way exercise and fitness programs are perceived by persons. These shifts will cause a tremendous increase in fitness participation by Americans, leading to an overall change in lifestyle, improvements in general health, and a cost savings in our health care dollars.

Paradigm 1: EXERCISE AND HEALTH PROMOTION SERVICES WILL BE REIMBURSABLE THROUGH INSURERS.
This may be the single biggest reason that most people do not participate in health-related exercise programs. Although most of us know that even a moderate amount of exercise is beneficial, we don't participate because of costs. In 1994, Dr. C. Everett Koop, speaking to a fitness conference in Reno, NV, stated that one of the reasons we may never achieve true health care reform is that patients have come to expect too much from their health care system for too little a price.

What Dr. Koop meant was that insurance reimbursement had cut the cost of the medical service to the patient, so they did not know in many instances what the price actually cost, but that most of the inflated cost was passed on to other insurance subscribers.

The elements of health care reform suggest that HMO's may lead the way for "capitated health subsidies" for health club memberships, and health promotion programs in a medical setting.

California's PacifiCare HMO has a program called Senior Fit, whereby senior citizens may participate in a health club exercise program at a pre-determined cost, to improve their health. The program is capitated through the insurer, and a specific contract is reached with individual health clubs. It is a trend that is growing very fast.

Arizona and Colorado Fitness Networks have negotiated with regional HMO's for health promotion packages that include traditional services (stress reduction, smoking cessation), along with therapeutic exercise, physical therapy, pre natal exercise, and yoga and meditation as part of a package that was purchased by the insurers. They feel that this unique concept in "one stop shopping" for health services is comparable to a medical clinic where many types of services are performed. Many health clubs are following this lead, and within the next two to three years, it will not be uncommon for seniors, diabetics, and those with high blood pressure to receive a physician's referral to their local health club for a six month membership to work on their specific medical need.

Future Implications:
If managed care embraces wellness and health promotion programs in the coming 1-3 years, we will expect millions of Americans to take advantage of certain health program within their place of employment, or from their insurance agent. This may lead to a dramatic utilization decrease in clams, as a percentage of subscribers avert a disease or its complications through exercise and education. Like the Steelcase report, showing a decrease of over 50% of medical claims over an 8 year period through wellness participation. There may be a substantial savings seen through engaging in regular exercise by large numbers of people.

Paradigm 2: CREATE RELATIONSHIPS BETWEEN PHYSICANS AND EXERCISE PROFESSIONALS
Many physicians have a general knowledge of the benefits of exercise, but many are reluctant to refer patients to exercise programs because they do not understand the specific elements of exercise prescription, or the qualifications of the staff. In almost all instances, they do not understand how these services can be profitable.

The concept of education of health professionals is touched on below, but the concept of educating physicians is an important one. In many areas of the country, they are gatekeepers, and their referral is important for the success for many allied health practitioners. The way for exercise to be an important part of the health care system is to convey specific research on the effects of exercise in medical conditions to the general public, and be able to convince physicians that this program will be beneficial for their patients.

A prime example is the concept of exercise during pregnancy for improved labor and delivery. Although there are hundreds of medical publications in the area of exercise, it is not routinely part of the advise given as part of an obstetricians pre-natal health visits (Clapp). However, the effects of poor health are known (gestational diabetes, neural tube defects, fetal alcohol syndrome, premature birth). If one can extrapolate that exercise as part of a health promotion package is effective on birth outcomes, then it may be universally accepted as part of a regular obstetrical visit.

The concept of profitability is touchy, because many do not believe that the only reason to create a relationship with medicine is to create profits. However, fitness professionals can generate money for the medical practice. By seeing patients 2-3 times per week for a regular exercise program, the practice increases profits based on the fee for service for therapeutic exercise, or capitated rate negotiated at with the HMO. Thus, fitness becomes as essential to the practice as the nurse educator, or the physician's assistant.

Paradigm 3: IMPROVING THE CONTINUING EDUCATION REQUIREMENTS OF EXERCISE PROFESSIONALS
As consumers, we expect that professionals who work for us have a minimum level of competency in their field of expertise. In health care, most professionals receive their initial education, and must sit for a state board exam that has set the minimal level of competencies for their particular job. They must on a yearly basis receive continuing education credit so they can keep up in their field.

At present, there are no requirements to become a personal fitness instructor. The fastest growing aspect in fitness, it has no minimum entry level requirements, and no mandatory continuing education. Trainers are for the most part business owners who work with clients in a fee for service mode, and are not required to receive any education in order to perform their jobs. They may have experience in terms of being an athlete, or have spent a lot of time training in a gym.