Sustainable Sports and Exercise Medicine
The climate emergency is a health emergency. Climate change is already leading to a vast change in our natural environment; more frequent flooding, deadly heat waves, rising inequality and worsening social injustice.
On the other side of the coin, healthcare is actively contributing to this crisis. High energy use, excessive non-recyclable material waste, over-prescription, and frequent travel for patients and staff all come at a cost. The NHS alone is responsible for around 5% of total carbon produced in the UK, and NHS England is responsible for 40% of the public sector’s carbon production. If global healthcare were a country, it would be the 5th largest carbon producer in the world.
To meet the 2040 Net Zero goal, our progress needs to ramp up. Unfortunately, it is starting to stall instead. Our healthcare system in its current form is not sustainable, and if we allow ourselves to continue on this path, we will struggle to maintain the level of quality care we provide today.
The good news is that change is possible. The better news is that many of these changes are simple, cost-effective, and often improve the quality of care rather than compromise it. Across healthcare systems globally, small and sustainable interventions are proving just that.
The introduction of the Sustainability in Quality Improvement framework has made it simple for organisations to address not just sustainability, but financial, social, and patient outcomes. If pockets of the medical community continue to adopt greener practices and share their success, they can inspire wider systemic change. We’ve already seen this happen in a myriad of other specialties through green team competitions, which you can read about in the SusQI Impact Reports.
One specialty that hasn’t yet received much attention in this context is Sports and Exercise Medicine (SEM). In many ways, there is no reason why SEM cannot adopt the same simple interventions proven effective in other specialties. In fact, SEM provides the perfect opportunity for a sustainable method and approach. The specialty already places emphasis on being active, getting outdoors, and overall well-being. Exercise has been shown to greatly reduce and prevent the number of serious health conditions, thus lessening the burden of these diseases on our healthcare system.
Embedding sustainability into SEM not only aligns with its values but also supports the growth and diversification of the specialty as a whole. It opens doors to collaboration with public health and environmental sectors and overall will help raise the profile of SEM.
This approach is well-aligned with the British Association of Sports and Exercise Medicine’s goals to make a measurable impact within the wider community in promoting sports and exercise, and investing in developments within SEM through partnerships and networks.
A healthier population equates to fewer resources, specifically a reduction in the distribution of pharmaceuticals, diagnostics, and surgery. This results in a greener, more carbon sustainable healthcare body. The connection seems obvious, but there is little in the way of literature and guidance to support SEM professionals in making this a reality.
Dr William Wynter Bee, a Sports and Exercise Medicine Consultant based in Oxford, highlighted himself that he had not seen sustainability as a core part of the conversation within his departmental planning or conversations. While quality improvement projects are continually ongoing, they have not had a focus on sustainability.
Explored in this blog is an identification of carbon emission sources in SEM, and recommendations for greener medical practice.
How Sports and Exercise Medicine causes climate change
While SEM promotes health and wellbeing, there is a hidden burden on the environment not readily addressed. For instance:
- The specialty places heavy reliance on single use medical devices such as bandaging, disposable ice packs, and tapes.
- Diagnostic imaging in the way of X-rays, CT scans, and MRI are also frequently used. Radiology departments are a significant contributor to greenhouse gas emissions, with MRI machines being the largest contributor. Though based in the US, an interesting article out of the New York Times has suggested that though MRIs are one of the most frequently used scans amongst SEM doctors, they are also largely unnecessary.
- Treatment and training facilities for sports players are energy intensive and expensive, requiring massive amounts of energy to maintain air conditioning, pool temperatures, and high tech equipment.
- Single use and limited use sports performance devices are on the rise. With technological advances happening everyday, older models are being scrapped prematurely. This cycle of constant ‘upgrading’ is contributing to large amounts of electronic waste (E-Waste). E-waste is any electronic equipment that has been discarded as products break or become obsolete. When not disposed of or recycled correctly, they become a threat to health and the environment. As of 2021, only 17.4% of E-waste is being properly disposed of.
- Specialist centres are few and far between, and being a relatively small specialty, there are few consultants in the UK. This may result in patients having to travel greater distance to their appointments than they would for a typical secondary care appointment. Conferences and sports events also require clinicians to travel. Dr Wynter Bee noted that travel to sporting events (specifically golf) formed a substantial part of his workload.
That said, SEM has a relatively low burden of medications involved in its care, and considering that the NHS’ number one source of carbon production is in primary care prescribing, this is a good thing. Dr Wynter Bee noted that the medications he typically prescribes and administers are steroid injections and anti-inflammatories, though most of his management involves other types of care. In this aspect, SEM is a pioneer in relying on holistic approaches to care, utilising a multidisciplinary approach through physiotherapy, psychosocial intervention, exercise programs, sleep, and diet.
How climate change undermines Sports and Exercise Medicine
This is not a one-sided issue. We are already seeing the impacts of climate change, and with a specialty that relies heavily on the natural world, there are consequences for SEM as well. There has been an increase in sports related illness, such as exercise induced bronchoconstriction contributed to by air pollution, and increasing temperatures causing heat stroke and other temperature related disorders. Not to mention a destruction of our natural world, the sporting grounds for everyone, from complete beginners to elite athletes. There are countless examples:
- The Tokyo 2020 Olympics were the hottest on record, with multiple athletes suffering from heatstroke and heat exhaustion in outdoor events.
- In the UK, ageing sewage infrastructure combined with increasingly heavy rainfall and flooding has led to frequent discharges of untreated sewage into rivers and coastal waters, polluting ecosystems and forcing beach closures.
- Extreme weather, such as heavy rain, icy temperatures, and extreme heat have caused the cancellation of thousands of football matches at all levels in the UK.
- Extreme wind and hurricanes have caused major sporting teams in the US to postpone or cancel matches
- Storms and coastal erosion are increasingly problematic, putting historic golf courses such as St Andrews at risk
- Warmer and shorter ski seasons means ski resorts are unable to be operational at all, especially those at lower altitudes. Resorts in Europe and North America are already closing their doors.
“We are going to have to have a think about this. And maybe some of our endurance events, particularly the road, need to be staged at times of year where you are not putting athletes at risk.” – Lord Sebastian Coe, President of World Athletics.
There is certainly room for improvement within this field. Quality improvement projects are already being done. Why not include sustainability? Being sustainable in practice does not and should not impact quality of care. When thinking about sustainable healthcare, think about the triple bottom line – is it beneficial financially, for patients and staff, and for the environment?
Prevention is key!
Looking at the Centre for Sustainable Healthcare’s 4 pillars of sustainable healthcare, prevention is what we should be looking to first. This aligns nicely with a SEM approach, which places a major focus on injury prevention as a first step, as well as exercise as a prevention for disease. SEM professionals are already working closely with other clinicians to promote exercise.
Physical activity champions from ‘Moving Medicine’ is an initiative that offers free clinician to clinician training, to help educate healthcare professionals, so that they can share best practice with their patients. Initiatives such as this are great examples of an interdisciplinary approach to promoting exercise amongst the public.
Preventing sports related injury in elite athletes is well described, but how do clinicians go about injury prevention in the general population? We are encouraging the population to exercise and get involved in sport after all, but what advice are we giving to reduce the number of very common sports related injuries? SEM needs to continue to work closely with schools and national sporting associations, to promote up-to-date evidence based injury prevention methods, beyond ‘stretching before exercise’. In reducing injury occurrence, there is a reduced need for hospital visits, diagnostics, referral, medication, and surgery.
Collaboration between SEM organisations (such as BASEM and FSEM) and national bodies are needed and enhancing partnerships brings an opportunity to implement a sustainability lens to exercise promotion and injury management.
Consider implementing other pillars of sustainable healthcare (patient self care, lean service delivery, low carbon alternatives) through these 10 recommendations:
- Empower SEM practitioners to take on SusQi projects to enhance sustainability at your practice – the Centre for Sustainable Healthcare SusQi website is a good place to start with this. Here are a couple of case studies of SusQi projects for inspiration: Reducing PPE use and Green Walking for mental health care
- Urge your department to take part in a ‘Green Team Competition’.
- Lead collaboration between SEM organisations and GPs, schools, and sports organisations to spread awareness of sustainability in health care.
- Use telemedicine in monitoring rehab to reduce unnecessary travel where possible.
- Switch to reusable/ recyclable taping materials, and reusable ice packs.
- Limit use of single use wearable tech, and highlight correct disposal and recycling of E-waste on websites and in clinics.
- Implement green surgery practices.
- Challenge SEM bodies to consider sustainability when event planning for conferences and sporting events, such as plant based catering, carbon off-setting etc.
- Engage athletes in sustainability practices and lifestyles – reduction in meat and dairy, travel to reduce their carbon footprint. Inspire patients by adopting these lifestyle habits.
- Initiate point of care diagnostics – for instance use of ultrasound in clinic vs MRI.
By making small but intentional changes in how clinicians prevent and treat injuries, the SEM community can become the perfect example of how medicine and sustainability are so closely intertwined. Embedding sustainability into SEM practice also aligns strongly with the specialties long term goals of growth, diversification, and wider community impact. Now is the time to act – consider if your organisation could implement some of these recommendations and get things moving!
National Sporting Heritage Day celebrates the impact sport has on our culture and society. To inspire future generations to enjoy and benefit from sport, we must also protect the environments and systems that make it possible. As clinicians, let’s start with making sports healthcare more sustainable.
Sustainable Sports and Exercise Medicine: summary
1. SEM already encourages movement, outdoor activity and wellbeing, but sustainability is not integrated into recommendations for practioners + there is very limited literature/ no evidence of SusQI in SEM
2. Current methods of injury management are carbon intensive (tech heavy, travel intensive, single use materials)
3. Injury prevention is the most effective way to reduce emissions