William Haskell

Quotes

Physical Activity Pilot Trial

The Heart Disease and Stroke Control Program eventually was part of the Center for Disease Control in Washington and evolved out of the National Heart Institute [because] they didn’t have the kind of unit to do interventions and training. A lot of what had to be done early on was for the National Program for Closed Chest Cardio-Pulmonary Resuscitation. So they developed the films and had the contracts from the federal government with various people around the country to do that training. And then they took on the training of coronary care unit nurses. Those kinds of activities didn’t fit anywhere in the National Heart Institute at that time.

The meetings of the Physical Activity and Ischemic Heart Disease Planning Committee was my post-doctoral training in that my secretary was responsible for doing the minutes of all of those meetings and so I headed it and spent a fair amount of time following up with Henry Taylor. All of the people on that committee provided me with great training as I wrestled with how in the heck are you going to do a large trial of physical activity and coronary disease with clinical outcomes ….sample size and technique and response rate and then the faintness of heart period. I think that was the first study that was ever done in, wasn’t it, faintness of heart, washout? So the pilot studies got started at the University of Minnesota with Taylor and at Wisconsin with Bruno Balke and colleagues and then at Penn State with Jim Skinner who had then gone to Penn State with Elsworth Buskirk.

Graded exercise tests

For clinical testing the Bruce protocol got adopted on a relatively large scale. But I think if one looks around the country now at treadmill testing and what’s going on it is more like the Balke-taylor test… When that got adopted pretty rapidly the more physiologic protocols were used because of the low work capacity while the Bruce protocol started getting, you know, one half stage and all sorts of adoptions or adaptations for that.

HB: Yeah, okay. That’s life. Better salesmen win.

BH: So in the Heart Disease Control Program I really credit Sam Fox with pushing forward at the federal level the issue of physical activity, particularly with cardiovascular disease. I mean, he kept that on the agenda when a lot of people had absolutely no interest.

HB: What else did it accomplish?

BH: I think, you know, first of all the first solid review article that appeared on physical activity and particularly the epidemiologic studies and then some of the experimental studies looking at mechanisms, the review manuscript that Sam and Jim Skinner published in the American Journal of Cardiology, which was then still the journal of the College before that separation occurred. I think really at the national and international level the Heart Disease and Stroke Control Program was about the only unit in the federal government that was trying to push physical activity on the agenda and, therefore, in a sense, represented the U.S. at international meetings such as WHO, for this. .

HB: Well, that Finland meeting in ’64 very solidly supported that issue in its monograph. The publication tended to keep it as part of the general cardiovascular prevention agenda

Phase out

HB: How did it fade, the Heart Disease Control Program? I remember some trauma that Sam had under the Nixon Administration and how did physical activity get re-established in CDC later?

BH: The whole Center for Chronic Disease Control was phased out starting in 1967-68. It was phased out . . as there were general cut backs. At the same time CDC had been established and was growing there were a lot of questions about, again, duplicate entities. You know, within the Centers for Disease Control there was a Cancer Control Program, there was the original Smoking Program that was really the preparation for the original Surgeon General’s Report on Smoking and Health which came out of that unit. There was a Diabetes Program. Also there was a group that really pushed multi-phasic screening and kind of health risk appraisals – Robinson. I’m trying to remember his name. So there was a unit on medical screening and multi-phasic screening really was what it was up to, looking at multi-phasic screening. Smoking Program, Cancer, Diabetes, Cardiovascular Disease. And I think that with the economic downturn looking for constraining government programs the feeling was that duplication of effort at CDC and this unit, which was really relatively small.

Vietnam period

One of the other kind of major activities I had for a couple years was being the project officer for physicians who had military deferments to complete medical school and came into the Public Health Service. There were so many of them in the late sixties because of the Vietnam War that most of them typically were assigned to Indian Health Services. But basically Indian Health Services got filled up and so Sam took on a number of those individuals with the idea that this would be a great opportunity to seed them with established investigators looking at issues of physical activity.

HB: How would you approach developing the story of physical activity in this history of CVD epidemiology and preventive cardiology? Would you start with people, programs, the ideas, and if so, what would those people and ideas and programs be?

BH: In the U.S. I think the people that were pushing ahead, at least from the 1940s and ‘50s here and during that era were people like Tom Cureton at the University of Illinois who had a lot of the right ideas for the wrong reasons. And if you look back at what he was doing in the way of applied work, particularly with the YMCA, a lot of it is kind of what is going on today and I think that he got himself into trouble as more advanced understanding of potential mechanisms and when that came along he wasn’t willing to give up his old ideas. But his understanding of appropriate physical activity was important. And then in terms of cardiac disease really Herman Hellerstein’s early work in the 1950s in pushing exercise for cardiac patients was very forward thinking. So I think that particularly exercise, not so much for primary prevention, but for cardiovascular disease rehab. was really moving … Of course that was at the same era with Jerry Morris’s publications, which began to give a little bit of validity to the relationship between physical activity and cardiovascular disease, even though other people had addressed it to some degree before Jerry did. I think that his approach and consistency and kind of multiple publications was influential…

HB: The right ideas again for the wrong reasons.

BH: Yeah, somewhat for the wrong reasons.

HB: But he corrected himself.

BH: Yeah, Anyway, so I think that that work had a major impact.

HB: Seminal. And the cardiac rehab grew out of Hellerstein. Then the methodology, of course, that was all your old friends, Skinner and Montoye and Balke, Taylor and …..

BH: Yeah, so I think at kind of the same time Henry Montoye was a doctoral student with T.K. Cureton. So Henry’s start got, I mean if you look at the exercise physiology arena that moved to exercise and health and cardiovascular disease a fair number came out of the Cureton Lab early on. I mean there was the group in Michigan, Michigan State, Van Houge….

HB: Skinner…

BH: Montoye, Skinner, Paul Rebisol. There were a fair number there. A little bit later than that was, of course, out of then the Wisconsin group with Balke and there were a fair number of people coming out of there. And then there’s the in terms of just the exercise physiology beginning to relate to health was the Harvard Fatigue Lab group.

HB: Dill and Keys and Taylor…

BH: Dill and Robinson, yeah. But then Henry Taylor, his relationship to that coming out of there.

HB: Okay, great. Then Paffenbarger early.

BH: Yeah, early on then in the U.S. surely Ralph’s work, you know, his career of sticking with the same type of research, same message, obviously it had an impact. And Ken Cooper …From just a public standpoint is interesting. The first time I met Ken Cooper was back in probably 1966. One day Sam Fox called me in and said that if I had time he wanted me to go with him to visit the Surgeon General for the Air Force the next day, Richard Bohannon, because there was a young physician from Brooks School of Aerospace Medicine that was proposing a new exercise or conditioning program for the Air Force. So when Sam and I went and talked with Bohannon it was Ken Cooper and Ken was there and what we found out after the meeting was that it was a fait accompli the aerobics program for the Air Force. But also Ken had written his book on aerobics and so that…

HB: I forget what my polemic with him was, but it had to do with the design of his study that had no controls or something like that.

BH: Ken really didn’t do any research to document the essence…

HB: But he claimed he had a study.

BH: Well, the study was really done by Bruno Balke and the group when Bruno was at Oklahoma City before going to Wisconsin. And the concept of mets and points and that Ken and a writer basically modified, you know, much of that into the aerobic scheme of things. And then I met Ken… Oh, I became good friends with General Bohannon and Bohannon really liked the idea of pushing physical activity. I mean he was very prevention oriented and was interested in physical activity and somehow I continued to talk with him and then his daughter and then a lawyer and we ended up forming the National Jogging Association, which is now the National Running Association, which as been the major…

HB: I’ll be darned.

BH: In fact, I remember going home and drawing the first logo for the National Jogging Association. … I kind of remember meeting in Bohannon’s basement with these people that formed this National Jogging Association as it turned out. So that was kind of interesting.

HB: Maybe you can help me on this little point. Somehow I must have reviewed somewhere an application of a study that Cooper was proposing with Air Force personnel and I just couldn’t accept it as a design so I got into this unpleasant polemic with him. I don’t remember.

BH: He had I know several studies proposed, but I mean, the concept of aerobic points and the idea that aerobic exercise was the critical issue relative to physical activity, which at that point, in a sense, kind of counter the Vic Tanney and other kind of, you know, resistance or weight training type of thing.

HB: I think I remember now. He said it was impossible for him to have any non-trained Air Force personnel as controls

BH: Yeah, yeah. That sounds right.

HB: “I can’t have half trained people.” He said. And I replied, “Well, then you’ll have a half-assed study.”

BH: Yeah. Wow!

HB: He finally got Steve Blair aboard and made some good science out of that stuff. I give him credit for that.

BH: Yeah, Steve had done two years of sabbatical with us and then went down there. So here’s where Steve got really a lot of his epidemiology training and worked with Paff while he was here and other people. In fact, Steve was very much involved in developing the physical activity assessments for the Five City Project. He was here right during the planning stage and kind of Stanford or whatever Seven Day Physical Activity Recall Questionnaire was developed during that time when Steve was here _____________.

HB: But he also hasn’t got much credit for the major contributions of the first exercise test based epidemiology in prediction and the findings about women and cancer.

BH: Oh yeah, I know. He’s very, very effectively utilized that database.

HB: What was the nature of your work?

BH: We actually had the publication that preceded his on exercise testing and relation to coronary disease from the LRC Prevalence Survey. Lars Eklund is the first author on that. So that actually preceded Steve’s publication on that.

HB: Good, I’m glad to get that straight.

BH: But still, he’s the one that pushed ahead.

HB: Did it have women, too?

BH: We had women in the LRC, but we didn’t have enough so it didn’t get into the publication. There weren’t enough events in the women.

HB: Would you like to say a word about the European contributions?

BH: Yeah, The European contributions, I think, primarily came early on in terms of basic exercise physiology, methodology, particularly the group out of Stockholm, both the Central Gymnastica Institute with primarily Astrand and Benkt Saltin and that group and then out of Karolinska with Leonard Kieser and Torny Sjostrand.

HB: Denolin and Messin,, did they make a contribution?

BH: Of course at that same time and even preceding some of that was the work done in Finland by Martti Karvonen. So I think the Finnish group really contributed a lot to some of the initial work physiology that overlapped beginning to understand…

HB: Then in cardiac rehab they are pretty strong.

BH: Actually cardiac rehab, they had some rehabilitation services, particularly in Finland, that were related to the devastation caused in the male population during the Second World War.

HB: Russo- Finnish war.

BH: So it was really kind of a … all of the regional rehabilitation centers set up in Finland were really set up to provide, justified for rehabilitation of war veterans and then later on they became more chronic disease facilities in terms of chronic obstructive lung disease and then cardiac.

HB: Then all the German system of health care involves active rehab centers.

The Black Forest group and the Bavarian group and all their friends.

BH: Yeah, the group in Freiberg and the group near Munich and Hohenrude. Yeah, I mean their whole approach of activity, baths, modern altitude. Very interesting, however, you know, is the lack of any real scientific data that they ever produced in terms of documenting the benefits of those. I remember Martti Karvonen telling the story about his doing electrocardiograms after somewhat older Finnish men went into the sauna then into the cold water and came out again. Somebody said, “Well, what happened?” He said, “You wouldn’t believe the abnormalities in the electrocardiogram.” “Well, what did you do about it?” He said, “Stopped recording the electrocardiogram.”

HB: I love it.

BH: So that’s kind of the way the Germans were about the spas whenever Sam Fox sent an investigative team to Germany to try to assess what evidence there were for the benefits in what they were doing. And Herman Hellerstein was actually a member of that group and couldn’t come away with any data. They would ask, “Where’s the data?” “People get better.”

HB: What was the nature of your Wolf lecture?

BH: Wolf lecture put together information that I had gotten interested in back when I was in the Public Health Service related to the discrepancy between what was being recommended by the American College of Sport Medicine Guidelines, exercise guidelines coming from those in the exercise and performance background versus the epidemiologic data. Whenever I look at the epidemologic data and try to ferret out amount and intensity and type of exercise, I would see one thing and then when I looked at what the Exercise Training Studies were – recommending higher intensity, short durations kind of things, there was a mismatch here. They were both being used to promote the idea of physical activity in chronic disease prevention.

HB: So you tried to resolve that.

BH: So my goal of the Wolf Lecture was not so much to resolve it, but to bring what I thought was this discrepancy to peoples’ attention. In some ways that led to the CDC meeting, the 1995 meeting and the 1996 report where they said, “Yeah, there is something going on here.”

HB: How would you encapsulate that?

BH: I think the main issue was that the epidemiologic data really supported the notion that moderate intensity activities, such things as brisk walking carried out intermittently throughout the day was associated with reduced cardiovascular and all-cause mortality and that we really needed to understand that and see whether there were profiles of activity other than a single bout carried out at the gym three times a week was going to provide benefit. And that was the stimulation.

HB: So you are defining new questions?

BH: Kind of new questions, but also I try to answer questions that I felt frequently were getting asked about health benefits of exercise and the profile of activity. People say, “Well, I don’t do 30 or 40 minutes at a time, but I ride my bike back and forth to work, I do things at noon, does any of that count?”

HB: And you say that’s led to new studies?

BH: Yeah, that’s led to a whole series of studies of which we did one of the earlier to look at whether if you do 30 or 40 minutes at a time versus breaking that up to multiple bouts of exercise throughout the day do you see similar changes in risk factors…

HB: Not risk, but risk factors.

BH: Risk factors, that’s correct. Those studies will never get at clinical outcomes, but this has stimulated the epidemiologists, people particularly like I-Min Lee who has really tried to analyze existing data and also tried to ensure that with questionnaires being used in newer data that you can begin to get at some of these questions.

HB: Intensity, frequency…

BH: Intensity, frequency, and short bursts versus long bouts and some of Imin’s recent publications are very helpful So I think that those questions have stimulated a fair amount of evolution of thinking about the difference between physical activity really to promote health, particularly through weight and metabolic function, rather than exercise to increase aerobic capacity. So that has evolved into concepts of metabolic fitness compared to cardiovascular.

HB: Very good.

Though you are not at the age really, I note that as one approaches dotage one begins to think more out-of-the-box and I notice you more than dabbling in alternative medicine issues. So what can you tell me about this?

BH: Oh, that’s fun, yeah. I have a good friend who is on the faculty at Harvard, David Eisenberg. When a medical student at Harvard he spent a year in China learning things about Chinese medicine, this type of thing, the Chinese language. David is the author of the 1993 NEJM article that really pointed up, based on a national survey, pointed up the broad use of various complementary or alternative therapies in the U.S. So David and I always talked…

BH:. I thought the way to do it is to begin to get some very good scientists to use their technologies to look at it.

HB: How are you proceeding with, for example, the composition of these supplements and their purity and their dosage? I’ve sat on the FDA committees the last few years and it’s been a disaster.

BH: Absolutely. I mean that’s going to be one of the major issues…

BH: And then we’ve had a couple fun projects on mindfulness meditation for patients with congestive heart failure showing improvements in quality of life, but physical functioning we’ve been trying to do things like autonomic balance with baroreceptor sensitivity and heart rate variability in those studies. We have a post-doc who is doing work in that area. So anyway, I figured when I started that if nothing else I’d learn a helluva lot, you know, by getting immersed in it.

HB: I think that would be great fun and it also makes good cocktail conversation.

BH: Yeah, it does.