Air University Review, July-August 1976

In the mid-sixties Dr. Kenneth Cooper and his aerobics program thrust the Air Force into the national limelight as a leader in the burgeoning field of cardiovascular fitness. The ensuing years have seen national interest and participation increase by almost logarithmical proportions. Quite naturally, the Air Force has continually been mentioned in this growth, since, in fact, its acceptance of aerobic fitness as a viable option helped set the stage for national enthusiasm. Likewise, the total concept of exercise as a form of preventive medicine (in limiting cardiovascular disease) has gained favorable exposure through the results of the Framingham Study¹ and other competent epidemiological studies. Now, almost ten years since Dr. Cooper's first article,² the Air Force has relinquished its prominent position in the field and appears to have fallen far behind in cardiovascular fitness administration.

In order to substantiate this claim, it is necessary to review the Air Force Aerobics Program, which annually evaluates the physical fitness of male personnel on the basis of a mile-and-a-half run. There are five fitness categories, but only individuals achieving Categories IV or V are considered to be conditioned. The program provides detailed charts, which allow beginning participants to progress to Category IV. Introductory information and specific instructions are contained in AFP 50-56. Unfortunately, most personnel do not understand the real basis of aerobics, and thus it has been treated as an end, a test, a square to be filled. In reality it is only a means of achieving an end: cardiovascular fitness.

Aerobic or cardiovascular fitness can be measured very precisely in the laboratory. This measurement, maximal oxygen consumption, is considered to be a valuable clinical index of cardiovascular function.³ However, this lengthy procedure is prohibitive in large groups, and therefore a field test (aerobics) was devised that makes it possible to estimate the laboratory results. Dr. Cooper's experimental data showed a strong relationship between running time and maximal oxygen consumption (r= 0.88), and thus the aerobics test was developed to enable individuals to assess their own cardiovascular fitness level.⁴ In summary, the aerobics program aspects of progressive conditioning, exercise points, and testing levels are all based on the physiological measurement of maximal oxygen consumption, a recognized clinical means of assessing cardiovascular sufficiency.

With this preview to understanding aerobics, let us analyze what I consider to be the Air Force's problem. The program can be considered suspect in three specific administrative areas. First, and certainly the most dismaying aspect for professionally concerned observers, is the designation of Category II as a "passing" level of physical fitness. Several cross-sectional studies⁵ have shown an oxygen consumption of 42 ml/kg-mm to be representative of a fair-to-good fitness level; however, Category II, as defined by Dr. Cooper, correlates to an oxygen uptake level of nearer 28 ml/kg-min is an abbreviation for milliliters of oxygen consumed for each kilogram of body weight per minute. The value of 28 ml/kg-min is poor by any standard, and any program that uses it as an index of satisfactory fitness is subject to real concern. In fact, many coronary--prevention programs would consider individuals at this level to be high risks and would place them in closely supervised classes.

Similarly disconcerting is the nature of the regulation (AFR 50-49) covering aerobics participation. The program gives too much control to the unit commander, thus limiting chances for a cohesive Air Force-wide program. Actually, the problem area of control is fundamental to my proposal for aerobics revision and will be discussed more thoroughly later.

Finally, sound educational material dealing with "why" aerobics instead of "how" aerobics has been missing. Aerobics presented a new fitness emphasis that needed explanation and validation. However, only the format was stressed by Air Force leaders, and the concept of aerobics as a form of preventive medicine deserved more attention than it received.

Conversely, the fitness boom (cardiovascular fitness) which the nation has experienced since the mid-sixties has benefited from mass media exposure and extensive educational programs within many facets of the private sector. The business world accepted leadership in the fitness arena and moved forward with great strides. An article in Nation's Business stated that more than 50,000 companies have developed physical fitness facilities, and some 300 of them have full-time directors.⁶ Why? Because business understands hard facts like " . . . premature deaths of young executives due to heart disease are estimated to cost American business $2.5 billion a year."⁷ Dun's Review reports that this emphasis is well controlled:

Some companies---Mobil Oil, American Can, and Jersey Standard to name a few--have in-house programs which include medical examinations and follow--up diet and exercise plans. A number of companies are sending their employees to outside institutes or clinics.⁸

New York Life is cited as a good example of careful exercise monitoring. Here every employee is given a coronary profile annually, including an exercise electrocardiogram (ECG), to determine if his or her heart is capable of handling a normal activity plan. Fortune also highlights some very successful programs thriving in several large corporations.⁹

Dr. Alexander Rush, of the Benjamin Franklin Clinic in Philadelphia, comments that, "Clinics catering to businessmen have been swamped with a surge of examinations in the past two years."¹⁰ Business Week carried an article listing top clinics catering to businessmen.¹¹ An article in Government Executive points up the lack of governmental agency interest in fitness even though the efforts of one sister group (the President's Council on Physical Fitness and Sports) have successfully assisted businesses in developing group activity programs.¹²

As was expected, the rapid escalation of interest in exercise has brought forth critics and skeptics. Although many skeptics have been convinced, a more important outcome has been the number of improvements and controls fostered by valid criticism. Perhaps most important has been the demand for a thorough medical exam, including an exercise stress test, prior to beginning an activity program. The American College of Sports Medicine believes these tests should be required for any person over age 35. The College feels so strongly about the importance of proper screening prior to beginning an exercise program that it has published a book containing guidelines for exercise testing and prescription.¹³ The Reader’s Digest published an article¹⁴ in which several prominent cardiologists advocated the use of stress testing in predicting future heart problems. The article emphasized that stress testing not only helps predict problems but helps control or minimize them Dr. Sam Fox, past president of the American College of Cardiology, states, "The evidence is very strong that exercise stress testing is a powerful predictor of future coronary disease."¹⁵

As shown earlier, industry has attempted to insure the best medical safety for its programs. The country has witnessed a concomitant interest in exercise stress testing. Ironically, a recent publication highlighting fatalities related to jogging admitted that exercise stress testing might have prevented those deaths.¹⁶ Dr. Loring Brock, director of a cardiac rehabilitation center in Denver, states that stress testing is "probably the most dependable predictor of the potential heart attack of all tests we have available to us."¹⁷ In summary, the nation's response to emphasis on cardiovascular fitness has brought about a profitable merger of medical personnel, professional researchers, and the business world.

Unfortunately, the Air Force has neglected to cultivate this relationship. Additionally, aerobics has slowly eroded into another annual requirement. I would suggest that the reason for this declining interest is more a subtle case of misplaced emphasis than a matter of inadequate administration.

The lesson to be learned from successful programs in the business community is that medical supervision and interest must be closely tied to cardiovascular fitness programs. The remainder of this article will be dedicated to applying this lesson to the Air Force environment. Its thrust will be to show why control of the Air Force Aerobics Program should be shifted from the unit commander to the Office of the Air Force Surgeon General. This management change would provide improvements in testing, monitoring, and education. These three areas of concern are not without their present problems.

Perhaps testing is the most maligned aspect of the current aerobics program. One major criticism is the danger of testing personnel without proper medical screening or on--site medical supervision. This disagreement with Air Force testing procedures is not simply a complaint from the ranks but was also voiced by Dr. Herman K. Hellerstein at a national conference on exercise and heart disease.¹⁸

A second criticism of testing is the unrealistic passing level of Category II. Dr. Cooper's original plan delineated Category IV as a desired minimum-fitness level (a level in consonance with several other sets of norms), but the present acceptable level, as previously shown, is far below the desired minimum and therefore is meaningless as a fitness standard. For example, it seems implausible that any 35-year-old man running a mile and a half in 17 minutes and 30 seconds could really believe himself to be physically fit.

Quite naturally, the problems in monitoring are related to the ones in testing. All personnel testing Category II or III are considered fit, and thus their susceptibility to coronary heart disease does not receive the attention it deserves. Or, more precisely, the aerobics screening tool is not being used to advantage in searching for prospective heart attack victims. Finally, as mentioned earlier, educational programs designed to include cardiovascular fitness (aerobic fitness) in the total health picture have not been developed. Such education must come from a source the majority of individuals consider knowledgeable and reliable.

Medical control of aerobics would certainly not constitute an instant panacea, but it could go a long way toward solving some of these problems. Ancillary to this in-house improvement would be the opportunity to return to a position of leadership and innovation in this national concern.

Testing. Specifically, Surgeon General control could improve the testing problem in two related ways. First, medical adequacy of the program could be facilitated by having medical specialists present at all testing centers. These supervisory personnel, whether medics or not, should be trained to recognize symptoms of undue stress in individuals taking the test. Next, control by the Surgeon General’s office should facilitate raising the passing standard to the more realistic Category IV. Support for this standard could be advanced by the improved educational program.

Monitoring. These changes in testing actually set the stage for the more important reason for Surgeon General control, the monitoring of specific individuals. Monitoring of cardiovascular fitness involves close evaluation of the physiological responses of individuals who exhibit substandard capability. Two progressive methods of accomplishing this type of monitoring are increased exercise stress testing and the development of coronary profiles. Let us look at each of these methods in more detail.

In an earlier discussion of exercise stress testing, it was established that this approach provides an excellent safety check and evaluation mechanism for the field of cardiovascular fitness testing. Although it is not feasible to use this test on all military personnel, exercise testing should be more widely used within the Air Force. A combination of the following two factors could be used to determine its increased use: one, if an individual had over ten years' service or was beyond age 35; two, if his medically supervised aerobics test showed Category III or lower.

The age/length-of-service requirement is important in that it places a cost-effectiveness control into the program. Essentially, it does this by predicting coronary problems in personnel who have indicated that they will be in the Air Force during the high-coronary-risk period and upper-level-management years. Thus, the proposal developed here would read: All personnel over age 35 or with more than ten years service who score Category III or lower on their annual aerobics test will be required to complete a maximal exercise test.

Immediate questions might include: What is the cost to develop this capability? can we get enough medical personnel? and why a maximal test? Each question deserves a lengthy response, which cannot be included within the purview of this article. However, a short reply is provided to indicate that the problems have been considered.

The cost of developing a maximal exercise testing capability should not be great since portable bicycle ergometers are available for approximately $500. Many military hospitals already have the preferable motor-driven treadmill. The remaining required medical equipment is routinely used in administering annual physicals.

Availability of medical personnel is obviously a problem in the military today, but specialized training could alleviate this situation. The American College of Sports Medicine guidelines mentioned earlier outline specific procedures for using allied medical professions in combination with physicians to increase the availability of safe exercise stress testing. Although this would assist in collecting data, the problem of providing cardiologists to interpret the results must be considered.

One approach to utilizing available cardiologists effectively would be to develop a centralized ECG computer center similar to that of the Seattle Heart Watch Program.¹⁹ This group emphasizes the need for exercise testing for early detection of coronary artery disease and has established a network of 15 test centers which are "all linked by dataphones to a computer for analysis of electrocardiographic responses to maximal exercise…"²⁰ Program leaders believe this project proves the feasibility of developing a working network of exercise test centers tied to a centralized computer. Expansion of this concept by the Air Force would allow a central agency to read all electrocardiograms, thus limiting the number of specialists required at base level. However, proper methods of counseling and exercise prescription would have to be developed congruent with the centralized computer concept.

Dr. Victor Froelicher and associates from the Clinical Sciences Division, USAF School of Aerospace Medicine at Brooks Air Force Base, have demonstrated a tremendous interest and capability in the detection of latent coronary artery disease through exercise testing. A recent report completed for NATO summarizes their work in this area.²¹ In discussing computer analysis of electrocardiograms, they conclude, "The present study demonstrates both the feasibility and the desirability of automated analysis of the electrocardiographic response to exercise testing."²² Thus, it is evident that the capability for centralized analysis of exercise ECG’s is already present in the Air Force Aerospace Medical Division. Development of this centralized processing concept is certainly an area where the Air Force could show innovation and provide national leadership in an emerging aspect of group health care

The third question is why do we need a maximal exercise test? Maximal exercise tests are presently preferred over the easier submaximal tests because of their ability to show a significantly greater number of cardiac arrhythmias; Dr. Froelicher and his associates also dealt with this aspect of exercise testing.²³ Thus, the capability is already present in the Aerospace Medical Division to investigate which type of stress test would best suit Air Force needs.

The second major proposal within the concept of medical monitoring is the development of a coronary profile. This profile would include the major coronary heart disease factors of cholesterol levels, percent body fat, and smoking habits, as well as a fitness level and other medical inputs. The profile would become part of an individual's record and could be used in evaluating that person's chances of providing high-quality service in the crucial supervisory or management portions of his or her career. It seems logical that a coronary profile would be a reliable tool in helping provide a high-quality force.

Education. Medical supervision and monitoring of aerobics, like any large program change, would require preliminary and follow-on education. However, the mere placement of cardiovascular fitness in the medical environment establishes an inherent credibility base not presently enjoyed. This advantage should be maximized in overcoming present biases against the program. The role of exercise in preventive medicine must be stressed, not separately but entwined with other factors of coronary heart disease. Doctors W. V. R. Vieweg and D.A. Lee have written an excellent article in the Naval Institute Proceedings emphasizing the necessity for increased military education regarding heart disease,²⁴ and more such articles should be appearing in military and professional journals.

Despite the value of publications of this type, the emphasis must be more personal and far reaching. This approach could include briefing teams, pamphlets, movies, and seminars. The role of' exercise in preventive medicine should be discussed at intermediate and senior staff schools as well as at noncommissioned officer academies. The media should approach aerobics from its physiological base and as a major contribution to prevention of coronary heart disease.

In conclusion, it is my opinion that placing the aerobics program under the Air Force Surgeon General, with the suggested improvements, will greatly enhance the contributions of this program to the Air Force community.

1. Frank Vitale, Individualized Fitness Programs (Englewood Cliffs, New Jersey: Prentice-Hall, 1973), p. 4.

2. Kenneth Cooper, "Flying Status Insurance," Aerospace Safety, March 1966, pp. 8-10.

3. Jere Mitchell and Gunnar Blomquist, "Maximal Oxygen Uptake," New England Journal of Medicine, May 6, 1971, pp. 1018-22.

4. Kenneth Cooper, "A Means of Assessing Maximal Oxygen Intake," Journal of the American Medical Association, April 1968, pp. 134-38. (Hereafter refereed to as Cooper, "A Means.")

5. Bruno Balke and Ray Ware, "An Experimental Study of Air Force Personnel," U. S. Armed Forces Medical Journal, 1959, pp. 675-88; Edward Fox, et al., "Fitness Standards for Male College Students, "International zeitschrift für angerwandt physiologie einschliesslich arbeitsphysiologie (Berlin), 1973, pp. 231-36; Cooper, "A Means."

6. "Staying Trim, Productive . . . and Alive," Nation’s Business, December 1974, pp. 26-28.

7. Ibid., p. 26.

8. Susan Margetts, "Executives and Heart Attacks," Dun’s Review, October 1972, p. 95.

9. "Keeping Fit in the Company Gym," Fortune, October 1975, pp. 136-43.

10. "The New Rx for Better Health," Business Week, January 5, 1974, pp. 69-71.

11. Ibid.

12. John Judge, "Business Moves . . . Government Lags," Government Executive, April 1974, pp. 32-33, 36.

13. American College of Sports Medicine, Guidelines for Graded Exercise Testing and Exercise Prescription (Philadelphia: Lea & Febiger, 1975), p. 7.

14. Arlene and Howard Eisenberg, "The Heart Test That Could Save Your Life," Reader’s Digest, September 1974, pp. 115-17.

15. Ibid., p. 116.

16.Parker Hodges, "Joggers Get Physically Fit for a Fatal Coronary," Moneysworth, April 18, 1975, p. 21.

17. Eisenberg, p.117.

19. Robert A. Bruce, et al., "Seattle Heart Watch: Initial Clinical, Circulatory and Electrocardiographic Responses to Maximal Exercise," Responses to Maximal Exercise," American Journal of Cardiology, April 1974, pp. 459-69.

20. Ibid., p. 467.

21. Victor Froelicher, et al., "Treadmill Exercise Testing at the USAF School of Aerospace Medicine: Physiological Responses in Aircrewmen and the Detection of Latent Coronary Artery Disease," North Atlantic Treaty Organization, AGARDograph No. 210, 1975.

22. Ibid., p. 35.

23. Ibid., pp. 4-10.

24. W. V. R. Vieweg and D. A. Lee, "CHD--The Heart of Military Readiness," U. S. Naval Institute Proceedings, June 1973, pp. 49-55.