Evidence shows that physical activity is highly beneficial for people living with and beyond cancer and is one of the most effective ways to manage the side effects of treatment and improve quality of life¹. Despite this, physical activity support is not routinely available within cancer care and most people diagnosed with cancer are not meeting the recommended levels of physical activity. This challenge has been recognized globally, leading to the establishment of the American College of Sports Medicine’s (ACSM) Moving Through Cancer initiative, with a mission to integrate exercise as standard practice in oncology by 2029². During the tenure of my Churchill Fellowship, I investigated exemplar exercise oncology programs in North America to gain insights into the cultural and contextual factors that have contributed to successful implementation. Exploring international perspectives can help us to overcome common barriers and make progress towards making physical activity ‘business as usual’ worldwide.

I hypothesized that the U.S. and UK’s differing healthcare models would influence the availability of funding and thus the culture of embedding physical activity into clinical care. However, I learned that how programs are funded had very little impact on their success, and the extent to which physical activity was normalised by the design of clinical environments and processes was far more influential. Design features can significantly affect people’s perceptions and behaviors. Health professionals are more likely to talk about physical activity and refer patients to support programs if it feels like a normal part of their work. Equally, patients will be more receptive to the conversation and adhere to the physical activity support if it feels like a normal part of their cancer treatment.

In some exemplar programs in the U.S., exercise facilities have been strategically placed next to a hospital reception and in close proximity to chemotherapy wards. This intentional design allows for a powerful message to be conveyed to all those who enter the hospital - that in the midst of cancer treatment, it is possible and encouraged to stay physically active. By being visible and easily accessible during treatment, the facilities also serve as regular prompts for both patients and clinicians to incorporate physical activity into their routine. This reduces stigma and creates the perception that exercise is an essential part of cancer care. In contrast, many exercise programs in the UK are delivered in community gyms without any visible connection to healthcare. This separation leads to the misconception that exercise is optional or only for those who are interested. Although there are advantages to offering physical activity support outside of hospital settings and closer to people’s homes, when a visual prompt for physical activity is provided within a clinical environment, it increases the likelihood that individuals will utilize these opportunities, even if they are not located within that facility. Successful programs recognize that the needs of people living with cancer can vary greatly and offer a range of options, including clinical exercise interventions, self-management advice, and community signposting. They also acknowledge that the success of any program relies on uptake and adherence by patients. Thus, it is crucial that the importance of physical activity is emphasized throughout the design of the clinical pathway to enable more people to access various forms of support.

In the physical activity sector, we often use the ambition of programs becoming funded by healthcare systems as a marker of success, and the importance of normalising physical activity through design features is often overlooked. Of course, funding is essential to deliver programs, but the most successful interventions had sustained the program for several decades without funding from healthcare systems. In some cases, funding from the system was viewed as a disadvantage due to its volatility, and using charitable and commercial funds instead allowed awareness and trust to be grown over a longer period of time. In these examples, the healthcare systems had still committed to the program by providing space within a hospital.  As healthcare space is a premium commodity, this provision creates the perception that physical activity is prioritized by the organization, further re-enforcing its importance. In contrast, if a health organization supports a programme purely through funding, the support is unlikely to create a normalizing effect, as clinicians and patients aren’t usually aware of how the programs are funded.

As we continue to advocate for physical activity to become part of standard care worldwide, the importance of making physical activity look and feel part of normal cancer treatment cannot be forgotten. Building new hospitals to accommodate exercise facilities is not feasible everywhere; nevertheless, there are simple and cost-effective design modifications that everyone working in cancer care could implement. For millions of people living with and beyond cancer, the benefits of physical activity could be truly life changing, and in some cases, lifesaving.

Whether you are a clinician, exercise professional, or researcher working with cancer patients, ask yourself, how can we work together to create a culture where physical activity is ‘business as usual’?

 

 

References

1. Patel, A. V., Friedenreich, C. M., Moore, S. C., Hayes, S. C., Silver, J. K., Campbell, K. L., ... & Matthews, C. E. (2019). American College of Sports Medicine roundtable report on physical activity, sedentary behavior, and cancer prevention and control. Medicine and science in sports and exercise, 51(11), 2391.

2. Schmitz, K. H., Stout, N. L., Maitin‐Shepard, M., Campbell, A., Schwartz, A. L., Grimmett, C., ... & Sokolof, J. M. (2021). Moving through cancer: Setting the agenda to make exercise standard in oncology practice. Cancer, 127(3), 476-484. 

 

In the new year, fitness pros often see their facilities and schedules inundated with people looking to make a change. In the right conditions, and under proper supervision, a resolutioner really can shift the direction of their life. But under the wrong conditions, inexperienced (and even experienced) exercisers, athletes and recreational enthusiasts can get into serious trouble, especially if they’re overly motivated and willing to just “push through.”

Beyond the routine ways a novice can injure themselves, starting a new sport or fitness routine in the winter presents further complications. Cold can significantly affect performance, and according to the 2021 “ACSM Expert Consensus Statement: Injury Prevention and Exercise Performance during Cold-Weather Exercise,” “cold is a leading cause of death among people engaged in sports.”

Depending on the facility you work at and the nature of sport or activity you supervise, cold can be anything from an inconvenience to a serious danger. Let’s start this discussion with the way cold hampers our ability to exercise and perform, then move on to the ways it can actively harm us.

Exercise performance

According to the consensus statement authors, cooler muscle temperatures lower not only the amount of time we’re able to exercise but also power and even VO_2max, though most of these effects seem to be related to explosive or anaerobic exercise. A 1° C (~0.6° F) drop in muscle temperature can equate to a 4-6% decrease in these categories. An 8° C (14.4° F) drop can draw down muscles’ power output by 31% (though if the temperature of your muscles has fallen that far, exercise performance would probably be the last thing on your mind). Low muscle temperatures lead to higher levels of lactate in muscle tissue, and exercising in colder temperatures increases the amount of lactate in the blood relative to exercising in warmer temperatures.

Whether cold temperatures impact aerobic exercise in the way they do more explosive activities is up for debate. The consensus statement authors note that studies have reported results ranging from cold temps decreasing aerobic performance to actually increasing performance (or having no effect at all). And the extent to which insulated clothing may improve performance by keeping us warm versus impede performance by being bulky, heavy or ungainly is also an open question.

However, when it comes to injury, we have a little more information to work with. Let’s consider three common cold-weather dangers: frostbite, nonfreezing cold injury, and hypothermia.

Frostbite

Simply put, frostbite occurs when tissue freezes. The small ice crystals that form within the tissue physically damage the cells; then, thawing the area leads to reperfusion injury and inflammation.

Depending on outside conditions, frostbite can arise from a long period of exposure or in only seconds. It’s more likely to occur with increasing wind chill or if your skin has gotten wet, since evaporation leads to rapid cooling. Touching a cold material, like a metal streetlamp or fence, can also lead to frostbite via contact cooling. And in salt water, tissue may freeze at – 0.55°C / 31°F, even though the salt water itself will not freeze until it hits −1.9°C / 28.6°F.

Frostbite is also more likely to occur in areas of the body that are exposed to the elements and/or tend to receive less blood flow, like the hands, feet and head. Men seem to be more likely to get frostbite, though this might be due to sociological rather than physical differences between the sexes. Children and the elderly are also more affected, as are people of African ancestry. People with diabetes or multiple sclerosis may also be more susceptible.

As noted by the consensus statement authors, there are four degrees of frostbite, each with particular physical findings.

• First degree frostbite will present with numbness, and the central part of the affected area will be a waxy white or yellow color while the surrounding tissue will be red, swollen, and flakey or peeling. The surrounding tissue will itch or burn.
  
• In second degree frostbite, the central portion of the skin will develop surface blisters and the surrounding area will be red and swollen.
  
• Third degree frostbite mimicks the signs of second degree frostbite, but blood blisters form with 24 hours and the entire thinckness of the affected skin will be lost.
  
• In fourth degree frostbite, the damage includes not only all of the skin in the affected area but also extends into the tissue below, including muscle and bone.
  

Some ways to avoid frostbite include keeping an eye on the wind chill, keeping extremities covered and maintaining your core temperature. Frostbite is serious, so if you suspect you or a client may have developed it, it is important to seek medical attention.

Nonfreezing Cold Injury

Nonfreezing cold injury (NFCI) differs from frostbite in that, as the name suggests, the affected area doesn’t actually freeze. Typically occurring in cool and wet conditions, such injuries usually take a significant amount of time to develop. NCFI can begin to set in when the temperature of the tissue itself falls below 15°C / 59°F for an extended period, usually over the course of a number of days or even weeks — i.e., more likely on a backpacking trip or during military training than while pursuing discrete bouts of regular exercise. However, that isn’t always the case. NFCI can occur in less than a day depending on the individual affected and the conditions involved, and a mild form, chilblains, can form within one to five hours. A key factor in the development of NFCI during these shorter exposures is whether the tissue is adequately rewarmed.

Like frostbite, NFCI is more likely to occur in the extremities. Depending on severity, the aftereffects may last a matter of days to months. Significant damage can lead to symptoms lasting years, from pain and neuropathy to cold sensitivity and excess sweating.

Water can play a major role in the onset of NFCI. In nonfreezing temperatures, contact with water can increase cooling by directly conducting heat away from the body during submersion or via evaporation afterward. Consequently, waterproof boots, as well as gloves that can breathe to release moisture built up during activity, may help mitigate the risk of NFCI in certain conditions.

Hypothermia

Hypothermia occurs when core body temperature drops below 35° C / 95° F, meaning your body is losing heat faster than it can produce it. Exercise increases heat production, so staying moving is important, but so is wearing appropriate clothing. The authors describe a breathable base layer that wicks moisture away from the skin, an insulating layer, and an outer layer that protects from wind and water but allows moisture to escape via vents or other openings. Of importance, though, they note:

“The outer layer should typically not be worn during exercise (unless it is raining or very windy) but should be donned during subsequent rest periods. … A common problem is that people begin exercising while still wearing clothing layers appropriate for resting conditions, and thus are ‘overdressed’ after initiating exercise.”

If you’re overdressed, the excess moisture you build up in your clothing during exercise can then increase the rate of cooling you experience once you’re finished exercising.

Also of note, low blood sugar can prevent you from shivering. Since this is an important way to maintain body temperature as conditions get colder, make sure your body is adequately fueled.

Hypothermia can be divided into three categories. The first is “mild,” during which time the body’s core temperature ranges from 32 to 35° C / 89.6 to 95° F. According to the authors, signs and symptoms at this stage include “cold extremities, shivering, tachycardia, tachypnea, urinary urgency (and) mild incoordination.” (“Tachypnea” is abnormally quick breathing.)

The second category, “moderate” arises at body temperatures ranging from 28 to 31° C / 82.4 to 88° F. Those experiencing moderate hypothermia may exhibit “apathy, poor judgement, reduced shivering, weakness and drowsiness, slurred speech and amnesia, dehydration, decreased coordination or clumsiness (and) fatigue.”

The third category, “severe” sets in at core temperatures below 28° C / 82.4° F. Signs include “inappropriate behavior, total loss of shivering, cardiac arrhythmias, pulmonary edema, hypotension and bradycardia, reduced level of consciousness (and) muscle rigidity.” (“Bradycardia” is a slower-than-normal heart rate.)

As the body cools further, the affected person will lose consciousness. Without intervention, they will die.

The consensus authors recommend different courses of action depending on the stage and condition of the hypothermic individual. When out in the field, those with mild hypothermia and no other conditions should be given warm clothing and sugary drinks, encouraged to actively rewarm themselves, and be monitored.

Further, the authors write “In mild hypothermia cases that recover fully and risk factors are mitigated, there is no need to evacuate.” (Meaning the affected person doesn’t need to be brought to a medical facility.)

However, they continue: “For moderate and severe hypothermia and the critically ill, patients need to be handled very gently (as mechanical impact can trigger cardiac arrest), kept insulated, passively rewarmed slowly (0.75 to 1.0°C·h⁻¹) and evacuated.”

In sum

Cold weather presents its own unique set of obstacles and dangers, and it’s important to take into account the conditions that you and/or your clients will be exercising, performing or competing in — not only the ambient temperature but also windchill, dampness and the likelihood you’ll encounter standing water. Wearing the proper clothing and protective gear is important, as well as knowing the right amount of layers to wear when exercising vs. when resting. Proper precautions can go a long way to preventing injury and tragedy.

However, this piece is just an introductory blog post; if you are likely to face any of the conditions outlined above, I highly recommend reading “ACSM Expert Consensus Statement: Injury Prevention and Exercise Performance during Cold-Weather Exercise” and, more importantly, seeking out reliable continuing education and professional training. It never hurts to be prepared.

Related Content:

Blog | Exercising in the Cold: Chilled, not Shaking!

Resource | Exercising in Hot and Cold Environments

As we brush the dust of 2023 from our shoulders and look around, wondering what the heck we should be doing with ourselves in ’24, a beacon appears:

On Jan. 2, ACSM released the results of the 2024 Worldwide Fitness Trends: Future Directions of the Health and Fitness Industry survey, and we picked up on some interesting signals.

What do they suggest? We’ll get there in a sec. First, let’s go over what the survey is and does.

Begun in 2006, the survey polls members of the fitness community from around the world to predict the trends that will characterize the industry for the next year — useful intel for studios, facilities, and individual fitness professionals looking to make timely investments in equipment, training and certifications.

For the 2024 edition, just shy of 2,000 people completed the survey; more than one-fifth of the respondents were personal trainers, and the majority had from one to nine years’ experience working in the health and fitness space.

This year, the survey provided respondents with 45 possible trends organized into eight thematic categories: “exercise setting,” “fitness business model,” “medical fitness,” “special populations,” “training modalities,” “digital technology,” “programming” and “recovery based therapies.” Respondents then chose the top 20 trends, the top ten of which are listed below:

1. Wearable Technology
2. Worksite Health Promotion
3. Fitness Programs for Older Adults
4. Exercise for Weight Loss
5. Reimbursement for Qualified Exercise Professionals (QEPs)
6. Employing Certified Exercise Professionals
7. Mobile Exercise Apps
8. Exercise for Mental Health
9. Youth Athletic Development
10. Personal Training

But what, practically speaking, can we take away from these results? Let’s talk top three.

No. 1: Wearable Technology

First, barring some massive, grid-destroying disaster, Wearable Technology will likely only continue in its popularity. In fact, Wearable Technology has taken the No. 1 spot nearly every year since 2016 (in 2018 it was No. 3, and in 2021 it was No. 2). This staying power probably reflects, on the one hand, the ever-increasing sophistication of these devices — smartwatches, heartrate monitors, sleep trackers, fitness trackers, etc. — and on the other the medical and fitness community’s increasing ingenuity when it comes to determining what to do with the data they provide.

Which is to say, it can take a while for people to realize the full impact of a new technology, and for new modes of thinking to develop in order to best make use of it. Taking the time to study first the tech itself and second the way other people are using it will give you a better picture of how to implement wearables in your practice, whether that’s tracking a client’s heart rate over time or logging the total steps in each of their workouts. Be careful, though, not to tread into the territory of a medical professional (unless you are one). The thorough monitoring power of these devices might be tempting, so be cautious about how in-depth you get when it comes to tying their data to exercise prescription and progress. And of course it goes without saying that the client must be on board with all of this tracking.

Last, your milage may vary depending on the region you’re in and the age of your clientele. Tech tends to percolate into wealthier areas first, and the younger generation is more likely to use it — though this may not remain the case as older people begin to see the potential benefit of tracking their health in real time.

If you want to explore further, this 1 CEC course based on the 2023 Annual Meeting lecture sing Wearable Sensors and Big Data to Identify Digital Biomarkers in Sleep, Health, and Exercise Performance can provide some intriguing insights into the possibilities wearable tech opens up.

No. 2: Worksite Health Promotion

For its part, Worksite Health Promotion came in at No. 2 this year, which may perk up the ears of those interested in offering their services to businesses or other entities. It’s possible that this up-ranking of worksite health is in some way a reaction to the COVID-19 years and the remote working environment; whether it’s merely a renewed focus on health in all aspects of life after many of us were stranded at home cultivating bad habits, a reaction to mass illness, or an attempt to make a return to in-office expectations a little less bitter, it’s hard to say. Regardless, partnering with a corporation or association to provide its employees with fitness and wellness programming will have advantages and disadvantages, and these will of course depend on each individual org. That said, gaining in one fell swoop a set of clients who are all in one place and are likely going to be available at relatively predictable times could be a great opportunity and a source of stability in your business.

To drive the point home — the CDC claims that the average full-time American worker is going to spend about one-third of their life in the workplace. Fitness always competes for time with other obligations, so getting a foot in the door in this otherwise off-limits 33.33% of your clients’ lives could be a huge win.

If you want to learn more about the world of Worksite Health Promotion, check out this 3 CEC ACSM course featuring the experiences of five worksite wellness professionals.

No. 3: Fitness Programs for Older Adults

The placement of Fitness Programs for Older Adults in the No. 3 slot probably comes as no surprise. The aging population in the U.S. continues to grow; according to the 2021 Profile of Older Adults, the time period from 2010 to 2021 saw a 38% increase in the cohort of people age 65 and older. Further, the Trends authors note that this increase is likely to continue through 2040. To put it simply, more and more of your potential clients are going to be older people rather than younger people, so specializing in the unique needs of this group is probably a good bet. As we age, we see our risk of developing numerous illnesses increase apace — so too the incidence of cognitive impairment and the chance of having a fall. This, of course, is where fitness professionals come in. Aerobic and strength training keep some of the impacts of disease at bay, help people remain independent, and improve their quality of life.

Practically speaking, the ACSM Exercise is Medicine^® Credential might be a good option to pursue if you’re looking to demonstrate relevant skills for this population. From the ACSM website: “Exercise professionals who earn the Exercise is Medicine^® (EIM) Credential demonstrate their ability to help individuals with common chronic diseases lead healthier, more active lives. They are also more likely to be seen as a trusted referral resource by health care providers.” This combination will be of the utmost utility when working with older adults.

Bits and Bobs

Though we’ve focused on the top three takeaways from the 2024 results, there’s still a lot to learn from the remaining seven.

No. 4, Exercise for Weight Loss, reminds us why the majority of clients seek out fitness pros’ services. Though the concept of wellness is growing in its cultural impact, plenty of people still just want to lose weight. It’s good to keep that perspective in mind — when the rubber meets the road, people probably remain more interested in shedding pounds than adopting a whole new lifestyle. Give the people what they want.

No. 5, Reimbursement for Qualified Exercise Professionals (QEPs), represents the tip of the iceberg in an interesting ACSM story. For some time, ACSM and its partner organizations have been pushing for the expansion of “current procedural terminology” or “CPT” codes to include fitness-related services as well as the recognition of fitness pros as “qualified exercise professionals,” or “QEPs.” Health care providers use CPT codes, maintained by the American Medical Association, to characterize the services they provide and more easily bill insurance, and getting qualifying fitness professionals classed as QEPs increases the likelihood that they’ll be allowed to use such codes. This two-pronged approach, then, is intended to make it easier for fitness professionals to get paid for their services. Given the importance of physical activity to overall health, this is a crucial step both for fitness pros and patients. (More about current physical activity CPT codes.)

No. 6, Employing Certified Fitness Professionals, goes hand in hand with No. 5. Ensuring that the fitness professionals we hire adhere to the highest standards of care and practice makes sense both for businesses and for the clients they serve.

No. 7, Mobile Exercise Apps — this trend seems closely aligned with Wearable Tech. Fitness trackers and other phone- or watch-based applications may help people get the most out of their workouts, allowing them to better plan their activity, give them reminders to keep after a program, or offer other features to streamline the fitness experience. Take a look at this study on the efficacy of mobile apps in weight loss.

No. 8, Exercise for Mental Health — no surprise here. People aren’t doing well in the world we’ve created and exercise can help reregulate our emotions. This trend reminds us that the clients who seek us out might be looking to treat injuries we can’t see. Kindness, and checking in to see how people are doing, can go a long, long way. You can explore more of the connections between exercise and mental health in this 1 CEC course based on the 2023 ACSM Annual Meeting lecture “The Mental Health Crisis: The Impact of Exercise and the Environment on Psychobiological Function.”

No. 9, Youth Athletic Development. Though the aging population is growing, we can’t forget young people. Childhood and adolescence are critically important times for developing fitness habits and overall physical health and strength. Fortunately, the National Youth Sports Health & Safety Institute (NYSHSI), a partnership between ACSM and Sanford, recently launched a podcast focused on healthy youth sports. Check it out! ACSM and NYSHSI are also launching the Youth Fitness Specialist Certificate. Stay tuned.

No. 10, Personal Training. When it comes to keeping people healthy and getting them to progress, you really can’t beat one-on-one coaching. Personal training still has an important role to play, no matter what trends or technologies come and go.

Wrapping It Up

The 2024 trends present an interesting glimpse into the future of the fitness industry. In the main, keep an eye on Wearable Tech, Workplace Health Promotion, and Fitness Programs for Older Adults. These are the trifecta at the top for the coming year, and making business decisions around them could have a real impact over the next few quarters. But also look out for updates on Reimbursement for Qualified Exercise Professionals (QEPs); this one is already at No. 5, and I suspect it will only become more important as time goes on. Whether that’s in 2024 or in later years, it’s a good trend to keep pace with. Its impact on this space, as it builds up steam, will probably be significant.

Learn more by visiting the 2024 Worldwide Fitness Trends: Future Directions of the Health and Fitness Industry on the ACSM website.

Additional Resources: 
Course | Annual Meeting 2023: The Mental Health Crisis (1 CEC)
ACSM Fitness Trends Page
Course | 2021 Summit - 5 on 5: Five Worksite Wellness Pros

 

Participation in ultra-endurance events often pits human physiology against the earth’s unruly elements. Generally, the term "endurance sports" refers to athletic events that occur for prolonged durations and it’s clear that participation in endurance racing has increased exponentially over the last half century. Some of the most challenging and awe-inspiring events include ultra-marathon races such as the Western States 100, The Ultra Trail Mont Blanc (UTMB), The Hard Rock 100 and the Moab 240. Full-distance triathlon events such as the Ironman have become very popular since its inception in 1978. Long distance swims like the English Channel swim and the 55km Birkebeiner cross-country skiing event are also classic endurance events. As participation grows, and more endurance events are held, the safety of all athletes must become a greater priority.

Research and online reports have made the world increasingly aware of the tragedies in endurance sports. Many people remember the tragic story of Fran Crippen, a team USA swimmer who died in 2010 competing at a 10k world cup event in the United Arab Emirates. Recently, USA triathlon released the Fatalities Incident Study, reporting 45 deaths from 2003 to 2011. Another report cited at least 135 deaths in triathlon from 1985 to 2016, and online tracking has reported 22 deaths in 2023 alone. Furthermore, 35 fatal events happened in ultra-distance marathon races between 2008 and 2019 in Western Europe. These reports and others show the risks of such competition, as well as the critical need for optimal prevention and treatment plans. 

Best practice recommendations for prevention, recognition and treatment for numerous exercise-related illnesses and fatalities has been drafted by several organizations, including the National Athletic Trainers Association. While these documents represent best practices in sports medicine, the reality is that ultra-endurance sports pose unique challenges for athlete care. Ultra-endurance sports often span multiple locations and townships, vast amounts of terrain, and different environments, making the treatment and emergency care protocols particularly complex. Gathering experts from each endurance discipline to generate recommendations for injury prevention and care at these events is critical. Distributing this information to medical volunteers, athletes, coaches and greater public is equally important, either by governing organizations or by researchers, as recently done for ultra-endurance running and triathlon events. 

The final challenge is the effective implementation of the developed best practices and guidelines at the race venue. Policies and procedures devised by the race organizations are often different from local country EMS protocols and this leads to confusion regarding which protocols are followed. This puts athletes’ lives at risk. We emphasize the need for endurance event organizations to work within communities that support best practices when it comes to the treatment of exercise related illnesses. Just as important is intentional preplanning and proper communication of race administrators with the medical team to make sure policies are being adopted and staff/volunteers are trained accordingly. Specific emergency action plans (EAP) should be created for each race and then shared and practiced with the local county medical providers and race day volunteers as part of preplanning. Important aspects of best practices guidelines for ultra-endurance racing often include active environmental monitoring, cold-water immersion tubs and defibrillators, sufficient numbers of spotters and volunteers on course, and that the EAP has been practiced and reviewed prior to the event start. Several organizations, including the Korey Stringer Institute, have developed such policies and a templates for generating an EAP.

There is great value in a post-event review and systematic follow-up to learn from ongoing race experiences. Thus, the recent call to systematically record and report medical encounters, race parameters, and environmental conditions at all community-based endurance sporting events.  Race organizations can and should mandate this action for all events so as to heighten global understanding of athlete risks and treatment of injuries. We suggest race organizations and research teams create large repositories for such data to be stored, aggregated and analyzed on a regular basis. 

The need for race organizations to develop and implement data-driven guidelines for athlete safety has never been more important. We must ensure that events have these guidelines, create race-specific EAPs and train race personnel accordingly so that all athletes compete in safe environments. We emphatically state that doing so will quite literally save lives. 

David Martin, M.S., is the co-director of athlete performance and safety at the Korey Stringer Institute. He is a PhD candidate at the University of Connecticut studying the effects of creatine supplementation on heat acclimation. David is a 3-time USA triathlon All American, a USA triathlon certified coach, and has been competing in endurance events for the past 10 years. His athletic achievements include competing at the 2019 ITU World championships, breaking the fastest known time on Connecticut’s 51-mile section of the Appalachian trail, and holding the 50km course record at the Jack Bristol Ultramarathon. 

Christopher P. Connolly, Ph.D., FACSM, is an Associate Professor of Kinesiology at Washington State University, where he directs the Kinesiology Graduate Program and the Exercise Physiology & Performance Laboratory. His work centers on ultra-endurance safety and performance optimization, particularly as it relates to preventing and treating adverse health occurrences during triathlon training and competition. He is the co-director of the Global Triathlon Safety Database.

Viewpoints presented in ACSM Bulletin commentaries reflect opinions of the authors and do not necessarily represent positions or policies of ACSM. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for the ACSM Bulletin.